Leaders in medical education recognize the need for continuous improvement in medical curricula, in methods of instruction and evaluation, and in institutional culture in response to the changing needs of students and society. In addition, guidelines promulgated by accrediting bodies such as the Accreditation Council for Graduate Medical Education and the Liaison Committee for Medical Education continuously mandate educational change. National reports on the state of medical education regularly stimulate discussion of problems and solutions for better preparing physicians for a lifetime of practice.1 Another pressure for change in medical education is the movement from a hospital-based to an ambulatory/community-based teaching venue for clinical training.
Changes in the practice of medicine, in the health care needs of the population, in what is known about medical science, in health care finance, and in accreditation standards create the need for medical education programs that are capable of constant revision and renewal with the flexibility to include new topics such as improving communication skills and assuring professionalism. New methods of teaching and evaluation continue to emerge as research in education, psychology, and the neurosciences advances our understanding of how people learn.2 As a result, there is increasing interest among faculty members in using more active learning techniques (eg, small-group activities, team-based learning, individualized instruction using technology) as methods of instruction and assessing competency attainment. The use of medical simulation, virtual reality, standardized patients, and computer-based simulations are becoming increasingly necessary to train and certify physicians. Teaching in this environment requires an expansion of the educator’s toolbox, including new teaching skills and expertise in new topics.
Faced with these educational challenges, many medical schools have implemented or enhanced their faculty development programs with more frequent workshops on teaching skills or seminars on teaching approaches for new topic areas such as geriatrics or evidence based medicine.3,4 These efforts have been coupled with increasing attention to the ways in which teaching is funded and rewarded, such as mission-based management5 or the growth of academies of excellent educators.6 Traditionally, intellect and productivity in research and clinical duties have been valued far above a faculty member’s humanistic and educational qualities in terms of academic advancement.7 However, since 1990, there has been a growing interest among medical schools in broadening the definition of academic scholarship to include creative acts of teaching and the development of innovative educational strategies and materials.8–10 Changes in the system of academic advancement and increased attention to teaching excellence have been especially important as the ranks of clinical educators and clinical track faculty have grown to meet clinical productivity demands.11,12
In this article and nine others in this issue of Academic Medicine, we and our colleagues address a unique approach to faculty development designed to prepare faculty members as excellent teachers and educational leaders while strengthening their skills for academic advancement and increasing attention to the educational mission of the institution. This approach has been called by numerous names—faculty scholars programs, faculty fellowships, educational fellowships, medical education fellowships, master teacher programs—but all share the same features: a cohort of faculty members selected to participate in a longitudinal set of faculty development activities with the goals of improving the participants’ teaching skills and of building a cadre of educational leaders for the institution. Participants in these programs are usually called “fellows” or “scholars.” Both of those terms have been used in the ten articles that follow this introductory one.
The idea of fellowship programs in medical education for faculty members grew out of the need in the 1980s to develop a cadre of skilled teachers for emerging departments in Family Medicine, stimulated by funding from Health Resources and Services Administration grants.13–19 These early fellowship programs targeted graduating residents bound for faculty positions or experimented with innovative multicampus approaches for existing faculty. Over the past 25 years, the idea of educational fellowships has matured into a tool for stimulating reflective practice as a basis for individual teaching improvement and for developing educational leaders prepared to guide larger departmental or institutional change activities.
While traditionally faculty development in higher education has been carried out during a faculty member’s sabbatical leave, educational fellowships provide extensive training without having scholars take a sabbatical or be away from other professional responsibilities for an extended period of time. A fellowship typically lasts from one to two years with a cohort size as small as three or as large as twenty participants. Most educational fellowships include only medical faculty in their programs, but some also include residents, fellows, dentists, and other health professions faculty. Many programs require that participants complete and present an education project or an educational research study.
In the rest of this article, we describe the common features of educational fellowship programs and the prevalence and focus of such programs in North American medical schools, based on findings from a recent survey of those schools. We also give a brief overview of the nine fellowship programs discussed fully in later articles in this issue of Academic Medicine.
The Development of Educational Fellowships
Are educational faculty development programs, and fellowships in particular, an appropriate tool to cultivate continuous improvement and develop change agents? The definition of faculty development has changed over the last 15 years.3,20–24 Wilkerson and Irby3 define faculty development as “a tool for improving the educational vitality of academic institutions through attention to the competencies needed by individual teachers, and to the institutional policies required to promote academic excellence.” Steinert24 recommended in 2005 that “faculty development initiatives are to bring about change at the individual and the organizational level.” Several have suggested that changes in curricula as well as changes in teaching and evaluation methods cannot be made at the institutional level without faculty development.23,25–29
Clinical educators have specific educational needs that must be met for them to be successful. Jolly and Macdonald30,31 suggest that effective clinical teachers need expertise in clinical teaching, learning theory, and educational evaluation. Irby32,33 added that clinical teachers benefit from learning about a variety of teaching methods, the modeling of experienced teachers, and the development of content-specific teaching examples that can be incorporated into faculty development activities. Drawing upon the skills derived from the practice experience of clinical educators provides an essential perspective in educational faculty development. Physicians improve more than just their educational skills when they learn to teach. Hatem34 hypothesizes “that teaching and doctoring are fundamentally the same process and that caring for the learner and caring for the patient reflect identically parallel professional skills. Both endeavors require eliciting the learner/patient’s needs, stating the teacher/doctor’s agenda, use of appropriate diagnostic approaches, ongoing feedback/communication, and evaluation of outcomes.”
Strong leaders are needed to implement and support change.35 In addition to improving teaching skills, some educational fellowships have been created explicitly to develop educational leaders from an institution’s education faculty,36–39 and most fellowships include significant elements of leadership training in their curricula. In interviews conducted by Baldwin et al.40 to determine the faculty development needs of generalists to become educational leaders, they found that generalists felt undervalued by their specialist colleagues. They also identified, as a global need, a better understanding of and rewards for generalists’ academic activities as well as better networking with others and with nongeneralists. This may be one reason why more pediatricians and internal and family medicine generalists participate in faculty development activities—including educational fellowships—than do physicians in other disciplines.
In a survey of all dental schools in Canada, Harrison and Forgay41 found that those who had participated in educational faculty development activities to improve teaching had much more interest in learning more about teaching. They proposed that “there is a threshold of knowledge about a topic which, when traversed, unlocks awareness of the need for more successful or rewarding teaching methods.” This can be a two-edged sword when evaluating faculty development programs. Since many programs depend upon self-ratings, many faculty do not evaluate their new skills accurately because they are more aware of their deficiencies.42
Developing Positive Change Agents
Which faculty development strategies work best to develop faculty capable of improving the educational system? In particular, activities designed to train the trainer are an effective and efficient way to improve faculty members’ teaching and change-agent skills. Such activities are based on the diffusion theory of innovation,43 which suggests that the most effective change agents have characteristics similar to those of the target audience. Wilkerson’s and Irby’s3 comprehensive review in 1998 of strategies used in faculty development to improve teaching identified the following strategies as having a positive effect on a teacher’s knowledge, skills and attitudes about teaching:
- Longer (more than two days) rather than shorter workshops
- The use of student ratings and peer evaluation
- Educational fellowships
They found that fellowships usually involve activities designed to improve teaching and evaluation skills, to teach the principles of curriculum development and learning theories, and to provide training in educational leadership and scholarship. In addition to inculcating strong educational principles, educational fellowships develop a core of educators who know each other and can work together across departments for improvement of the educational program.
Educational Fellowship Programs Across North America
In 2005, we developed an online survey to determine both the prevalence and focus of educational fellowship programs in medical schools. We administered it to 140 public and private medical schools across North America. A total of 81 (58%) responded; of these, 42 (52%) reported having educational fellowships; of those, 4 reported they had begun their programs during academic year 2005–06. Of those that did not have a program, five were interested in beginning one. Participants were asked to describe the focus of their programs indicating whether specific topics were a primary, secondary, or tertiary focus or not a focus at all (see Table 1).
The finding that four of the 42 schools reported that they were just beginning a fellowship program, and five schools were interested in beginning one, shows an increasing interest in educational fellowships. Perhaps this interest is in response to some of the educational changes required in medical schools as reported earlier in this article.
Although there are trends across programs, it is obvious from our survey findings that educational fellowships vary widely in scope and mission. The range in length from two to 36 months and the range of total contact from 10 to 400 hours illustrate how different these programs are. It appears that successful programs must meet the needs and live within the resources of their institutions.
As is common in many faculty development activities, our findings indicate that satisfaction and self-assessment questionnaires continue to be the most common form of program evaluation for educational fellowships. Because of the detail and complexity required to describe and evaluate faculty development programs, including educational fellowships, it is difficult to attribute quality improvement or change directly to a particular program. As eloquently explained by Jolly in the International Handbook of Research in Medical Education, although many studies on faculty development programs attempt evaluation,
few have looked at replicable cause-effect linkages. This is understandable; as such investigations would be difficult. Faculty development is as much ad-hoc as programmatic and usually of finite length but with the potential to deliver infinite effects. Institutions generally do not fund faculty development to provide subjects for inevitably lengthy and costly research projects. Much of the scant research in this area was done in the 1980s, when resources were more generous.7, p. 960
We contend that one way to evaluate the effectiveness of faculty development fellowships is to look at what educational improvements have been instigated by program graduates and adopted by their institutions.
The Value of Educational Fellowships
The next nine articles in this issue report on educational fellowships at Harvard Medical School; McGill University Faculty of Medicine; the Medical College of Wisconsin; the David Geffen School of Medicine at UCLA; the University of California, San Francisco, School of Medicine; the University of Iowa Roy J. and Lucille A. Carver College of Medicine; the University of Michigan Medical School; the University of Washington School of Medicine; and a joint program carried out by Baylor College of Medicine, The University of Texas Medical School at Houston, and The University of Texas Dental Branch. All of these programs have produced a core of change agents in education. The programs described in these nine articles share core features but otherwise are quite different from one another. We hope this variety will be useful to readers as they compare these programs with their own, or perhaps pick and choose components to create new programs that may be useful in their specific medical school environments. Many of the programs described in this issue of the journal have been documented in the literature,3,36–39,44–48 but the authors did not describe their programs in those articles at the level of detail necessary for replication as suggested by Jolly.7 Details about costs and staffing needs will be found in the nine articles that follow. By comparing and contrasting these various programs, characteristics of success can be identified as well as directions for the future. These topics are discussed further by Gruppen et al. in the final article in this issue.
Why invest in an educational fellowship? Modern medical education is a professional enterprise. As we speak of medical schools and teaching hospitals, it is necessary that our faculty charged with teaching learners at all levels and overseeing our educational programs achieve the same high level of competence as that expected of clinical and research faculty members.49,50 Educational fellowships such as those described in this issue serve two important purposes: they can teach individual faculty members the expertise necessary to train physicians to meet contemporary practice and research needs, and can provide institutions a core of faculty members with the leadership skills to facilitate educational change and improvement in the academic medical environment of the 21st century.
Those who direct educational fellowships or are interested in learning more about educational fellowships are invited to attend a meeting of directors of medical education fellowships on Saturday, October 28th, in Room 210 at the Seattle Convention Center from 2–4 pm.
The authors thank Britta M. Thompson, PhD, Baylor College of Medicine, for her assistance with both the development of the survey and the statistical analysis of the survey data.
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