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The Responsibilities and Activities of Internal Medicine Clerkship Directors

Hemmer, Paul A. MD; Elnicki, D. Michael MD; Albritton, T. Andrew MD; Kovach, Regina MD; Udden, Mark M. MD; Wong, Raymond Y. MD; Battistone, Michael J. MD; Szauter, Karen MD

Educating Physicians: Research Reports

Purpose To characterize the responsibilities, activities, and scholarly productivity of internal medicine clerkship directors (CDs).

Methods In 1999, internal medicine CDs from 122 U.S. medical schools and one Canadian medical school were surveyed. The instrument asked about the CDs' demo-graphics, workloads, clerkship characteristics, and scholarly productivity.

Results The response rate was 89%; 72% of the respondents were men. Mean age was 45 years, mean time as CD was 6.5 years, and 58% of the CDs had completed fellowship training. The CDs spent 28% of their professional time on the clerkship, three half days weekly in clinic, and three months on inpatient services.

The CDs had published a mean of 2.2 (range 0-20) articles and received a mean of 0.7 (range 0-4) grants. Similar factors were associated with publishing articles and receiving grants; gender (men), ≤ three clinic half days weekly, fellowship training, having a faculty development program, teaching other courses, and discussing expectations with their department chairs. In a multivariate analysis, fellowship training, clinic half days, teaching other courses, and discussing expectations explained 22% of the variance for papers published. For grants received, a model with gender, clinic half days, a faculty development program, discussing expectations, and teaching other courses explained 35% of the variance.

Conclusions An internal medicine CD invests significant effort administering the clerkship and contributing to clinical and educational activities. The factors associated with successful scholarship may be useful for fostering CDs' academic careers.

Dr. Hemmer is assistant professor of medicine, The Uniformed Services University, Bethesda, MD. At the time the paper was written, Dr. Elnicki was associate professor of medicine, West Virginia University School of Medicine, Morgantown; he is now professor of medicine and chief, division of general internal medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Dr. Albritton is associate professor of medicine, Medical College of Georgia, Augusta. At the time the paper was written, Dr. Kovach was assistant professor of medicine, she is now associate professor of clinical medicine, Southern Illinois University School of Medicine, Springfield. Dr. Udden is associate professor of medicine, Baylor College of Medicine, Houston, Texas. Dr. Wong is associate professor of medicine, Loma Linda University School of Medicine, Loma Linda, California. At the time the paper was written, Dr. Battistone was instructor of medicine, he is now assistant professor of medicine, University of Utah School of Medicine, Salt Lake City. Dr. Szauter is assistant professor of medicine, University of Texas Medical Branch at Galveston. Dr. Hemmer is associate director and all others were directors of internal medicine clerkships. At the time of the study, the authors were the Evaluation and Research Committee of the Clerkship Directors in Internal Medicine.

Correspondence and requests for reprints should be addressed to Dr. Hemmer, USUHS—EDP, 4301 Jones Bridge Road, Bethesda, MD 20814; e-mail: 〈〉.

For information about the authors, see the end of the article.

The authors gratefully acknowledge the efforts of Ms. Yuhuku Yamada, who performed much of the data entry and follow-up with CDIM members, and the CDIM staff, particularly Ms. Trudie Bruner and Mr. Tod Ibrahim, for their supervision and administration of the survey process.

The opinions expressed in this paper are solely those of the authors and do not necessarily reflect the opinions of the Department of Defense, the United States Air Force, the Veterans Administration, or other federal agencies.

Clerkship directors (CDs) have a pivotal role in undergraduate medical education. Not only are they responsible for all aspects of clerkship administration, sometimes across vast distances and in varieties of clinical settings, they are also expected to provide faculty development for housestaff and faculty, participate in committees at their medical schools, and demonstrate scholarly activity, all while continuing their active roles in patient care.1 Changes in clinical clerkships, such as incorporating an ambulatory component, further complicate the CD's role. Prior surveys of CDs across disciplines have demonstrated that they find the CD role rewarding and challenging, yet they remain uncertain about whether their role and activities are recognized as a “legitimate” pathway toward academic promotion and tenure.2–6 Professional advancement is a particularly important issue for CDs because many are early in their academic careers.2–6 With the recent redefinition of scholarship at many medical schools,7 CDs are expected to lead as clinician-educators.1 In 1999, the Clerkship Directors in Internal Medicine (CDIM) conducted the first annual survey of its membership to characterize the role of the internal medicine CD and to achieve a better understanding of those factors contributing to their scholarly activities and growth as academicians.

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The CDIM's Research and Evaluation Committee developed the survey instrument during the winter of 1998-99. Suggestions for content were solicited from CDIM members and were refined into a series of themes. After consensus was achieved within the Committee, the CDIM Council reviewed, piloted, and approved the survey. The confidential questionnaire was mailed to the faculty member designated as the internal medicine CD, as of the fall of 1998, at each of the 122 medical schools in the United States and one medical school in Canada that had an institutional representative to CDIM. Each questionnaire was coded to conceal the respondent's identity. Telephone reminders were used and repeat mailings were sent to non-responders.

The questionnaire's content was designed to clarify issues about the CD's career and his or her clerkship. The first section focused on the CD [e.g., age, sex, academic rank, fellowship training, and American Board of Internal Medicine (ABIM) certification], and asked questions dealing with workload issues (i.e., the length of time in the position of CD, percentage of effort spent as clerkship director, inpatient and outpatient clinical duties, other educational responsibilities, and committee work). Questions about scholarly productivity followed, using the number of papers published in peer-reviewed journals and the number of grants awarded in the 48 months prior to the survey as the markers of scholarship. The next questions asked about the amounts of assistance the CD received from administrative coordinators and co-clerkship directors.

The second section of the questionnaire focused on the structure of the CD's clerkship, including the number of students and clerkship sites, the length of the clerkship, whether the clerkship contained an ambulatory component, and whether students were required to take inpatient call. Finally, the CD was asked whether the school or department had a formal faculty development program, and whether he or she had used the article, “Expectations of and for the Medicine Clerkship Director”1 in negotiations with his or her departmental chairs. This article, which was endorsed by the Executive Council of the Association of Professors of Medicine, sets forth clear expectations for the amounts of time and resources internal medicine CDs need to do their jobs, how that time should be allocated and protected, and what departmental chairpersons should expect in return from the CD. Our survey offered the first opportunity to assess whether the article had been used by CDs.

We performed descriptive analysis and a two-step comparative analysis using standard statistical software packages. In the first step of the comparative analysis, we selected variables that had significant (p ≤.05) associations with scholarly productivity. We used t-tests to compare means of continuous variables, and used the linear-fit model to assess associations between continuous variables. We compared nominal variables using chi square. All p values are two-tailed.

In the second step of the comparative analysis, we created models to explain the variance in scholarship using the variables selected in the first step. A forward, stepwise linear regression predicted the number of articles published and logistic regression was used to build the model for receiving grants. (Since the number of grants received was low, this was treated as a dichotomous variable, either “having received any grants” or “none.”)

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Of the 123 questionnaires mailed, 109 were returned, for a response rate of 89%. The CDs did not all answer every question. The demographic characteristics of respondents are summarized in Table 1. The ages of the responding CDs ranged from 30 to 60 years, with a median of 44 years. Virtually all CDs were ABIM certified in internal medicine, and a little more than half reported having received fellowship training [no subspecialty dominated the fellowships (range 2-16%), and general medicine accounted for 10% of fellowship training]. Most of these CDs were men (72%). They were essentially evenly distributed across academic ranks. The CDs reported spending approximately 25% of their professional time on clerkship-related activities and identified that approximately 25% of their salary support was specifically related to their job as CD. The CDs reported large time commitments to clinical activities, other educational duties, and committee work.

Table 1

Table 1

The results from the questions concerning clerkship administrative issues are summarized in Table 2. The median length of third-year internal medicine clerkships was 12 weeks, with students spending a significant proportion of that time in the ambulatory setting. However, 19 respondents (17%) indicated that their core internal medicine clerkships were entirely inpatient experiences. Ambulatory components often involved large numbers of teaching sites, and these were often administered by clerkship co-directors. While third-year students took inpatient call on a regular basis in virtually all clerkships, only half of the clerkships required the students to spend the night in the hospital. Fewer than half of the responding CDs reported required fourth-year internal medicine rotations at their institutions. Many third-year CDs also served as the fourth-year CDs.

Table 2

Table 2

With regard to faculty and professional development, few of the CDs reported having formal faculty development programs within their institutions or departments. A minority of CDs had discussed with their department chairs the accepted guidelines for and expectations of and their role as CD.1

The CDs reported publishing a mean of 2.2 (SD ± 1.0; range, 0-20) papers over the 48 months preceding the survey, and 47% of CDs had not published any paper. The mean number of grants received by CDs was 0.7 (SD ± 1.1; range = 0-4), and 62% of the CDs had not been awarded a grant in the 48 months preceding the survey. The medians for papers published and grants received were 1.0 and 0, respectively. Because the range of grants received was small, and most clerkship directors had not received any grant during the 48 months preceding the survey, the variable was dichotomized to “having received any grant” versus “none” for the remainder of the analysis. However, the number of papers published was treated as a continuous variable.

The variables describing demographic characteristics for workloads (both inside and outside the clerkship) and characteristics of the clerkships were examined for associations with the CDs' scholarly productivity. The significant predictors of publishing papers and receiving grants were identical and are shown in Table 3. Men CDs had published three times as many articles as had women CDs, and men were more than twice as likely than were women to have received grants during the study interval. A threshold effect on scholarly productivity was noted between three and four half days of outpatient clinic each week, so this variable was dichotomized accordingly throughout the remainder of the analysis. Outpatient clinic responsibility (> three half days per week) was the only variable negatively associated with scholarship. The others shown, including teaching in other courses, had positive associations. Teaching in, but not directing, other courses was the only continuous variable associated with scholarship. Having completed a fellowship was the variable most strongly associated with publishing papers, while the existence of an institutional faculty development program was most strongly associated with receiving grants. Clerkship directors who responded they had used the Pangaro article1 when negotiating with their chairs also reported publishing more than twice as many papers and being more than twice as likely to have received grants than did those who reported not using the article.

Table 3

Table 3

In the multivariate analysis, models were built to explain the variances in papers published and grants received using the results of the univariate analysis. The results are shown in Table 4. Gender and institutional faculty development programs were no longer associated with papers published at this level of analysis. Similarly, completing a fellowship was no longer associated with receiving grants. A model using fellowship training, weekly outpatient clinic half days, teaching other courses, and the Pangaro article1 explained 22% of the variance for papers published. The model for grants received incorporated gender, weekly outpatient clinic half days, institutional faculty development program, the expectations article and teaching other courses, and this model explained 35% of the variance in receipt of grants.

Table 4

Table 4

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This descriptive study demonstrates the breadth of activities in which internal medicine CDs engage. They spend about a fourth of their professional time as CD, they teach and direct other courses (including coordinating fourth-year medicine rotations), assume leadership and committee roles at their universities, have sizeable clinical responsibilities, and produce scholarly work. Much of the general demographic information about internal medicine CDs, such as age, gender, and time spent on the clerkship, has not changed dramatically in the past few years2; however, a slightly greater percentage of CDs achieved the rank of professor over those years (30% versus 21%).2 Finally, the general profile of the activities, roles, and responsibilities of the CDs in our study was similar to that reported for other core CDs.3–6

The findings from our survey also demonstrate the changing nature of clinical clerkships, with the majority of internal medicine clerkships now reporting that a substantial portion of training occurs in ambulatory settings. We could not determine why some clerkships remain entirely inpatient-based. Ambulatory components require multiple clerkship sites and co-clerkship directors, which complicates the administration and management of the clerkship. Faculty members, including CDs, who participate in such clerkships may be among the most likely to benefit from faculty development programs, especially with recent reports that competency deficiencies may be under-identified in the ambulatory setting.8 However, few respondents reported having such programs at their institutions or within their departments.

Beyond their many administrative and teaching roles, CDs are expected to produce measurable scholarly activity. We identified several factors associated with scholarly productivity reflected by traditional measures of peer-reviewed publication and receipt of grants. We found that men were more likely than were women to demonstrate scholarly productivity, and ours is not the first study to note such a difference. A previous report on the research activities in departments of internal medicine found women faculty members wrote fewer original articles and received fewer National Institutes of Health grants than did men.9 Adjusting for age or academic rank did not alter our findings. The explanation for the discrepancy may involve many factors such as child-rearing responsibilities, part-time faculty status, or differing views on academic careers,10 but with women increasingly represented in academic medicine, the finding deserves further investigation. Importantly, recent studies have noted that women faculty members were less likely to be promoted to the ranks of associate and full professor than were their men counterparts,11 and that women were given less time for traditional scholarly pursuits and were less likely than were their men counterparts to have the academic promotion and tenure process clearly explained to them.10 As a result, one cannot help but wonder about the roles that traditional measures of scholarship play in the differences in promotion between men and women.

Academic health centers increasingly require faculty to account for their time and to demonstrate that their activities reflect the missions of the institution.12 Clinical and research activities have been relatively easy to quantify and reward,13 but educational contributions have been difficult to quantify,14 although several recent publications have described methods for assessing and reimbursing teaching.15–17 Our study shows that CDs are represented on the spectrum of academic career levels, so it will be important to document their efforts adequately and ensure their timely career advancement.

We also found that time spent in several other activities affected scholarly productivity. First, there was a clear level of outpatient clinical activity (more than three half days of clinic responsibilities per week) beyond which scholarship suffered. This may be because these commitments are continuous and tend to extend beyond the allotted time (e.g., answering telephone messages) and thus have the potential to invade “protected time” for scholarship. In contrast, inpatient clinical activity had no effect on our markers of scholarship. Inpatient commitments are scheduled far in advance and consume finite amounts of time, which allows scholarship to be conducted around them. While this finding might be reassuring to those CDs who are hospitalists, it remains to be determined how the intensity and duration of their inpatient commitments affect their scholarship.

Second, teaching other courses had a weak, but positive, association with both grants and papers. It may be that successful individuals are more likely to be asked to teach or that this type of commitment does not take away time devoted to writing. Furthermore, participation in other courses may allow networking with other educators, who may be able to advise and collaborate on projects.

Finally, contrary to a survey of pediatrics CDs, which indicated that time spent administering the clerkship had a slight negative impact on publishing papers,3 we found that administering the clerkship had no influence on publishing among internal medicine CDs. The reasons for this are not clear, since the pediatrics and internal medicine CDs reported devoting similar amounts of time to their clerkships. The difference may be in the types of activities and time demands required of the different CDs, which was not captured in our survey.

Our findings also make evident that investing in career development seemed beneficial among this group of CDs. The presence of an institutional or departmental faculty development program was the strongest predictor of grants. Fellowship training emerged as the dominant predictor of publishing, as has been noted in earlier reports.18 A clear understanding of the role, responsibilities, and expectations of the CD, as evidenced by the CDs' use of Pangaro's article1 in their negotiations with department chairs, was independently associated with both markers of scholarship. Those responsible for helping faculty members' careers to flourish should be interested in these findings as a way to direct their efforts.

The overall level of scholarly productivity among the internal medicine CDs in this study was low. Many CDs had not published, and most had not received grants, yet these accomplishments remain the “gold standard” for academic promotion decisions. The professional activities of our respondents clearly suggest that most are clinician—educators, whose achievements may not be emphasized or deemed appropriate in traditional measures of scholarship. Although many schools still expect written scholarship from these individuals for career advancement, they also recognize that these individuals will need considerable institutional support to be successful in teaching and educational scholarship.19 As a result, recent efforts have sought to clearly define scholarly achievement among educators,20 promote the creation of a “teaching scholar” track where different scholarly achievements are valued,21 and suggest that an “educator's portfolio”21 be used as a method for categorizing these achievements.

Our study has several strengths, among which is the high response rate. The confidentiality of the survey allowed the CDs to freely answer sensitive questions about their work situations. Ours is also the first survey of CDs to determine the impact of responsibilities on scholarly productivity. Importantly, we found that several of the common CD activities explained a substantial amount of the variance between those who publish papers and receive grants and those who do not.

Some of the study's limitations deserve mention. First, our definition of scholarship was narrowly, albeit traditionally, framed as publishing in peer-reviewed journals or receiving grants. Future surveys by the CDIM will explore the relevant activities of CDs across the scholarship realms of teaching, discovery, application, and integration7 through the receipt of teaching awards, workshop and research presentations at national and international medical education conferences, and innovations in curriculum or evaluation. Second, given the breadth of topics covered in the survey, time constraints limited our ability to explore associations with outcomes of interest. For example, we were not able to differentiate educational scholarship from other types. Third, as with any survey, there is the potential for recall bias in responses. Finally, these results reflect the careers of only one individual from each medical school, so care must be taken in generalizing the conclusions to other internists or to CDs in other disciplines.

Despite these limitations, we believe that this study has helped to clarify the professional activities of internal medicine CDs and the clerkships they direct. In identifying factors associated with successful scholarship, we have provided ways for CDs and their supervisors to shape the growth and development of young academic physicians. The CD is an important position in a department of medicine and it should be valued and regarded as a legitimate pathway toward a successful academic career.

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