Clinical department chairs of U.S. medical schools manage activities across the realms of education, research, and patient care.1 Their responsibility for educational programs can be similarly broad, encompassing undergraduate medical education (UME), graduate medical education (GME), and continuing medical education (CME).
A monograph about the clinical education of medical students from the Association of American Medical Colleges (AAMC) states that “… as a general rule, the chairmen of the clinical departments are uninvolved in the clinical education of medical students,” and that “many [chairmen] have only sporadic contact with students.”2 Because departments of medicine assume the largest responsibility for the education of medical students at U.S. medical schools,3,4 we sought to ascertain the degree and type of involvement of chairs in the core, third-year internal medicine clerkship, and whether their participation is at all associated with the clerkship's or the clerkship director's characteristics.
Each year, the Clerkship Directors in Internal Medicine (CDIM), the national organization of individuals responsible for teaching internal medicine to medical students, conducts a survey of its membership. For the 2003 survey, members of the CDIM submitted topics and questions, and the CDIM's Publications Committee drafted and revised the questionnaire. The CDIM's Council approved the survey. After discussions with the IRB at the Uniformed Services University of Health Sciences, IRB approval was deemed unnecessary.
The questionnaires were mailed in May 2003. A total of 113 questionnaires were sent to CDIM Institutional members (typically, the medical school's internal medicine clerkship director), and 144 questionnaires were sent to CDIM Individual members (may be the clerkship director, a clerkship site director, the director of the internal medicine fourth-year rotation, or other individual involved in teaching) at all U.S. and Canadian medical schools with CDIM members (not all medical schools have a representative to CDIM). Respondents had the option of completing the questionnaire by hand or online using the CDIM server. All responses were confidential and identifiers removed. Nonresponders were contacted up to three times by e-mail and/or telephone.
The first section of the questionnaire asked demographic questions about age, gender, part-time or full-time status, academic rank, clinical promotion track, tenure status, the respondent′s role in the clerkship, percentage of time spent in role of clerkship director, outpatient and inpatient clinical responsibilities, and the number of years as clerkship director. With regard to the department's chair, we asked the number of hours per month the clerkship director spent with the chair or vice chair for education discussing issues related to the clerkship; the number of hours per month the clerkship director thought they should spend discussing such issues; and whether the clerkship director had explicitly discussed published expectations of and for the clerkship director with the chair or vice chair for education.5 We also asked the number of hours per month spent discussing clerkship-related issues with a representative from the dean's office.
With regard to the role of the chair in the clerkship, we asked if the chair taught medical students during the internal medicine clerkship and, if yes, whether it was in the capacity as a ward attending physician, a clinic attending physician, a teaching attending physician, or “other,” with a space for written comments. Respondents could choose any or all of the responses. (Other sections of the questionnaire, not reported on here, sought feedback about medical students’ clinical skills, a subinternship curriculum, introduction to clinical medicine courses, and use of electronic resources in the clerkship.)
Descriptive statistics (e.g., frequencies, means, medians, standard deviations, range) were performed using a standard statistical software package. To determine if any of the clerkship's or clerkship director's demographic variables were associated with whether the chair taught in the clerkship, we compared variables from respondents who reported their chair taught with those who reported their chair did not teach using Mann-Whitney, chi-square, or Fisher exact test as appropriate. All p values are two-tailed, with statistical significance set at the .05 level.
The overall response rate was 62% (158/254): 77% (87/113) of the Institutional members responded and 51% (71/144) of the Individual members responded. Of the responses, 103 were from a unique medical school, and these formed the basis of the analysis. Because both Institutional and Individual members may have responded from the same institution, the response of the clerkship director was used for the analysis. If no clerkship director responded from an institution, an individual respondent′s information from a unique institution was used. The roles of these 103 respondents were clerkship directors (89), medical school's dean's office (4), departmental vice chair for education (2), ambulatory block director (2), faculty member involved in the clerkship (2), deputy clerkship director (1), clerkship site director (1), director of student teaching programs for the department (1), and unidentified (1).
The demographics of the entire group of respondents (103) were essentially identical to the demographics of the clerkship directors (89) alone. Most of the clerkship directors who responded were men (62%), with a mean age of 44.5 years (SD ± 7.5). They spent 3.3 (SD ± 2.1) half days per week in ambulatory clinical activities, 69% identified themselves as clinician–educators, and they devoted 29.5% (SD ± 11.7) of their time to the clerkship. Most clerkship directors held senior academic rank: 5% were instructor, 33% were assistant professors, 46% were associate professors, and 17% were professors. The mean time as a clerkship director was 6.5 years; 18% (16/89) had been clerkship director for less than two years, but their demographic information was similar to the overall group of clerkship directors (data not shown). Of the responding clerkship directors, 36% had discussed published job expectations with their department chair.5
The clerkship directors reported they spent 1.7 hours per month (SD ± 2.2, median = 1.0, range = 0–15) with the department chair or vice chair for education discussing clerkship related issues; they believed they should spend 2.5 hours per month (SD ± 2.9, median = 2.0, range = 0–20) discussing these issues. Clerkship directors reported they spent 1.4 hours per month (SD ± 2.4, median = 1.0, range = 0–15) with a dean's office representative discussing clerkship related issues, and that they should spend 2.0 hours per month (SD ± 2.9, median = 1.0, range = 0–20) discussing these issues. A total of 17% (15/89) of the clerkship directors reported spending zero hours per month with their department chair or vice chair for education, and 29% (25/89) reported spending zero hours per month with a dean′s office representative.
Chairs taught in the internal medicine clerkship in 82% (84/103) of the responding medical schools. Their teaching roles included: teaching attending physician (54%, 56/103), inpatient ward attending physician (53%, 55/103), ambulatory attending physician (14%, 14/103), and other (22%, 22/103). The “other” roles included leading teaching or chair's rounds with students (8/22), lecturing in core clerkship lecture series (6/22), leading physical diagnosis rounds (4/22), attending teaching conferences (3/22), meeting with students to discuss career choices (2/22), leading professionalism intersession (1/22), and serving as a consult service attending (1/22).
A total of 45% (40/84) of the chairs participated in one of the activities; 36% performed two activities (ward attending and teaching attending, ward attending and other, ward attending and ambulatory attending, teaching attending and other, and ambulatory attending and teaching attending); and 14% participated in three activities (ward, ambulatory, and teaching attending; ambulatory and teaching attending and lecturing; and ward and teaching attending and physical diagnosis). Only 2% (2/103) performed all four activities.
Table 1 depicts whether a clerkship director's demographics were associated with whether a chair taught in the internal medicine clerkship. Clerkship directors reported spending significantly more time each month (approximately one hour more) with the chairs who taught in the clerkship compared with the time spent with those who did not teach in the clerkship. Academic rank approached statistical significance, as more of the clerkship directors were instructors for those clerkships in which the chair did not teach. Otherwise, there was no association between the chair's teaching with the clerkship director's age, gender, percentage of time the clerkship director devoted to the clerkship, the clerkship's length, the number of half days per week the clerkship director spent in clinical activities, or whether the clerkship director and chair had discussed expectations. The length of time as clerkship director was not associated with a chair's participation in the clerkship, whether analyzed as a continuous variable or as a dichotomous variable (≤ two years as clerkship director, or > two years).
Chairs of medical schools’ clinical departments are faced with managing a broad range of educational missions, as well as patient care and research missions. In its report on the clinical education of medical students, the AAMC called on department chairs to place a priority on medical students’ education and, essentially, to lead and set an example for their departmental faculty by being involved in teaching medical students.2 Our findings demonstrate that chairs of internal medicine are already leading their faculty on this issue.
An overwhelming majority of the 103 responding medical schools′ clerkship directors or similar educational leaders (82%) noted that the internal medicine department's chair participated in teaching during the core third-year internal medicine clerkship. Most often, this teaching took place when the chair served as a teaching attending physician for the students (54%) or as an inpatient ward attending physician (53%), and less so as an ambulatory attending physician (14%). Of note, though, is that more than half of the respondents noted that the chair was involved in more than just one of these activities, reflecting a deep personal commitment to teaching students. As further evidence, a notable number of department chairs took time to conduct rounds just with the students, met with students to discuss career goals, and participated in the clerkship's core lecture series.
The chair's participation in all of these activities is in keeping with a recent report from one medical school that summarized the following features that medical students viewed as the most important characteristics of a clinical department chair: be an advocate for teaching by participating in lectures and being visible in ambulatory and inpatient settings; meet with students, often as a group, at some time during the clerkship to make clear the department's commitment to teaching; participate in teaching; and be available to the students.6
Chairs who taught in the clerkship also spent significantly more time each month, over one hour more, with their clerkship director discussing clerkship-related issues compared with chairs who did not teach. We believe this finding is related to the chair′s interest and investment in medical students’ education. In fact, the amount of time the teaching chairs spent with the clerkship director (1.9 hours per month) is very close to the time per month clerkship directors felt they should spend with their chair (2.5 hours per month).
Our findings also highlight two areas that can be readily addressed in support of the UME mission. First, clerkship directors believed they needed only a few hours each month (2.5 hours) to meet with the department chair to discuss clerkship-related issues. Such a relatively small commitment of time will send a clear message to a department's faculty about the importance of UME. Thus, it is encouraging that the amount of time per month with the department chair has increased from 1.2 hours in 20017 to 1.7 hours currently, more closely approximating the goal of 2.5 hours. Although the percentage of clerkship directors who reported they spend zero hours per month has decreased (27% in 20017), the fact that 17% of clerkship directors reported they spend no time each month with their department chair discussing clerkship issues is of some concern. Because we phrased the question in terms of “hours per month,” there may have been some respondents who meet less often (e.g., quarterly) with their chairs who would have answered they spend no time each month, such that the 17% is an overestimate. Even though this is a clear minority of respondents, we believe that neither the clerkship director nor the chair should be in a position to decide not to meet. Furthermore, the clerkship director and the chair are best positioned to decide the amount of time needed each month to discuss clerkship-related issues, and our findings provide an important consensus among clerkship directors.
Second, we believe all clerkship directors and chairs should discuss the expectations that have been published by clerkship directors’ organizations5,8 and endorsed by the Association of Professors of Medicine.5 We acknowledge that clerkship directors and chairs may discuss expectations without using these specific, published expectations,5,8 and our survey was not designed to determine whether specific recommendations about these expectations may already be in place; nevertheless, these guidelines provide an important national norm to frame such discussions. The percentage of clerkship directors discussing these expectations has increased from 22% in 19999 to 36% in the current survey. Yet, it is disappointing that relatively few internal medicine clerkship directors have discussed these expectations since they were first published because it is clear that those who do have demonstrable scholarship and job satisfaction.7,9
We also acknowledge that support of the clerkship need not take the form of direct teaching participation by the chair. Administrative support, providing time for the clerkship director to devote to the clerkship, and financial support of personnel and professional society membership are all critical to ensuring high-quality UME, and internal medicine chairs have consistently demonstrated their commitment.7,9,10
Finally, in the analysis of whether any clerkship director's demographics were associated with the chair's participation in the clerkship, there was a statistically nonsignificant trend that chairs did not teach in those clerkships in which the clerkship director was an instructor. Because the absolute number of clerkship directors who were instructors was small (only 4/89), it was difficult to judge the educational significance of this finding. Even if the association is real, it is noteworthy that this represents the vast minority of clerkship directors. Nevertheless, we see such a circumstance as a tremendous opportunity for the chair's participation in teaching to be a visible vote of confidence in their clerkship director.
This study has limitations. It represents the views of internal medicine clerkship directors, and thus does not represent the extent to which chairs across other clerkship disciplines are teaching in those clerkships. We did not quantify the frequency of noted teaching activities. We also did not ask about participation of the chair in other medical student courses often overseen by the department of medicine, such as introduction to clinical medicine courses,11 the fourth-year medicine clerkship, mentorship relationships, or other preclinical or interdisciplinary clinical courses. As a result, we have likely underreported the extent to which internal medicine chairs are involved in teaching medical students.
We believe our study has several strengths. We have responses from 103 unique medical schools, which enhances the generalizability of our findings across internal medicine clerkships. We asked the internal medicine clerkship director, the person charged with directly overseeing the educational program for the medical students, to report whether the chair was teaching. We believe this likely minimized any response bias that might have been introduced if we had asked the chairs themselves. However, surveying the chairs is an important next step to understand the reasons behind their decisions to teach or not to teach in the clerkship.
In conclusion, our findings demonstrate that, as a general rule, internal medicine chairs are deeply invested in and committed to the education of medical students. Internal medicine chairs not only invest significant time in the direct teaching of medical students, they are also involved in the administrative aspects of the clerkship. As such, the characterization of chairs being “uninvolved” or superficially involved in the clinical education of medical students does not apply to internal medicine chairs. Our findings are reassuring given the extent to which departments of medicine oversee medical education.3,4 Although direct involvement of the chair in the medicine clerkship is certainly desirable, such direct participation is not the sole measure for ensuring a successful clinical education program. Furthermore, policy discussions regarding overseeing and administering the internal medicine, or any other, clerkship should not presume that chairs are disinterested or unwilling to commit to high-quality UME. We believe that the activities and participation of internal medicine department chairs in the clinical clerkship can serve as a model for successful departmental responsibility for clerkship education, and similar surveys from other clerkship disciplines are needed. We should trust the clerkship directors, working collaboratively with their chairs and deans, to create high-quality educational experiences. Such a contract requires a discussion and monitoring of expectations and an ongoing time commitment, preferably monthly, to discuss the clerkship, both of which are readily achievable goals.
The authors wish to acknowledge the Alliance for Academic Internal Medicine staff, particularly Tom Crist, for their help in creating an online survey, as well as survey distribution, collection, and data entry.
The data used in this survey are the property of the Clerkship Directors in Internal Medicine and are used with permission.
The opinions expressed in this article are solely those of the authors and do not reflect the official policies of the Department of Defense, the United States Air Force, or other federal agencies.
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