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Commentary

Commentary: The Work of Nonphysician Medical Educators: Why We Need Historical Context, Conceptual Models, Training Details, and Evidence

Shea, Judy A. PhD

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doi: 10.1097/ACM.0b013e3181ad1ac9

Abstract

I read “Nonphysician medical educators: A literature review and job description resource” by Riesenberg and colleagues1 with considerable interest. Within this highly informative piece were three topics that especially intrigued me. One was the history of medical education, one was nurses and allied health professionals as medical educators, and one was the growth of medical education programs—and more specifically, what graduates from such programs might do in their jobs. Each was enjoyable and interesting. Moreover, in applying a personal metric for assessing the impact of an article—how much it makes me think in the hours and days afterward—it scored high. I was left thinking about the individual topics on multiple occasions after the initial read. Each generated a distinct cluster of thoughts and questions about how these topics fit into the broader medical education literature that concerns defining history, linking to conceptual models, and cataloguing (and perhaps standardizing) master’s programs. And to this list I add a fourth category, establishing evidence for the value of nonphysician educators.

History of Medical Education

Riesenberg and colleagues present a succinct summary of the growth of medical education with—or by—nonphysicians. The authors are cautious in saying that “the U.S. nonphysician medical educator profession may [italics added] have had its beginnings in the 1920s at the University of Minnesota.” While medical education by nonphysicians might not have a singular sentinel event, Riesenberg and colleagues’ observations fit well with the historical account provided by historian and physician Ludmerer,2 where many of the same important and well-recognized names and institutions appear.

Moving beyond the detailed timeline populated by dates and names, it is useful to apply principles of historical analyses and ask why the early alliances between medical schools and medical educators and the nonphysicians were created. What was the impetus for involving nonphysician educators in the process of medical education, and, more pertinently, do those same reasons still apply today? The obvious motive for the physician-nonphysician alliance was to improve the quality of medical education, recognizing that those trained in methods of teaching and theories of learning could add to the educational enterprise. Recalling that the early associations came only a little more than a decade after the famed Flexner report,3 which called for widespread upgrading and standardization of admission requirements, curriculum, and evaluation practices, it is not so surprising that leaders in some medical schools reached out to their counterparts in education. However, the Flexner report also called for teaching by clinical faculty who were hired to teach. Flexner was responding to a situation in the early 20th century that remains the case today: Most teachers in medical education have been trained as scientists but not as educators. Indeed, in medicine as in most other professions, there is the widespread assumption—or at least practice—that once one earns an advanced degree, one is, by default, also qualified to teach novice learners. It in only in recent years that this assumption is being challenged, as evidenced by the proliferation of offices of faculty development and teaching academies, many of which include the goal of improving the quality of teaching.

So, if nonphysicians were not viewed at first-line teachers of medical trainees, what explains the rise in the prevalence of nonphysician educators and offices of medical education? I suspect a central reason was a need for evaluation services and expertise, a need that continues to grow. As suggested by Ludmerer, in the early 20th century, as the physician educators began to apply various methods of teaching, they recognized the need to evaluate the products, or outcomes, of their teaching—after all, most were trained in the scientific method. Since the earliest liaisons between clinicians and nonphysician educators, the need for evaluation of teachers, learners and curricula; processes, outcomes and recently, modalities (distance learning, small groups, teams, and computer-based teaching) has become nearly ubiquitous throughout UME and GME, and to a lesser extent CME, and in doing so virtually guaranteed a need for collaboration and partnering with nonphysicians who had the requisite expertise.

Finally, two recent developments that help explain the proliferation of nonphysicians involved in medical education are related to the broadening of curriculum content. As suggested by Riesenberg and colleagues, in most health systems physicians are under pressure to generate clinical revenue, thus reducing their time for and attention to teaching. But more importantly, when one moves beyond basic sciences and clinical medicine into domains such as physician-patient or physician-family communication, information management, teamwork, and ethics (to name a few), content expertise is required that is outside of both medicine and education.

Nurses and Allied Health Professionals as Medical Educators

My thoughts about Riesenberg and colleagues’ review of the literature about teaching by clinical nonphysicians stem from my attempts to retrofit that literature into existing literature. Where does the literature of nonphysician clinical teaching fit into the larger literature? What is it really about? Does it draw from, or lend itself to, broader teamwork and interprofessional education frameworks? A common critique of medical education literature is that experiments are done and aptly reported, but too much of the work lacks a conceptual model.4 And when we think about teaching by nonphysician clinicians—much of it done in partnership with physicians—there is a rich set of existing literatures that could provide the conceptual home for, as well as stimulate the development of, interesting hypotheses and broader discussions. For example, teaching shared by nonphysician clinical and physician teachers might be viewed through the lens of communication theory, shared decision making, or teamwork structure and function. For some of the cited studies, the history and theory of coteaching, prevalent in secondary and higher education, might be a comfortable home.5 Alternatively, a natural fit might be within the extensive literature about the complementary roles of content and process experts, found in the voluminous literature regarding problem-based learning, and the goal of teaching content.6 The choices are many. Reports of teaching by clinical nonphysicians would have a broader and lasting impact if they drew from or led to conceptual models and theories about teaching and learning. In education we are very good at developing a good idea, implementing it, and describing it, but we often fall short when it comes to placing the work within the larger literature.

Growth of Medical Education Programs

Who knew there were so many training programs? The methods used by Riesenberg and colleagues for arriving at the exact number were not specific, but they need not be. I suspect the real number is a moving target. What might be helpful in the next generation of reports about medical education training programs is to look deeper within the programs and try to define the target audience(s) and the breadth/pathways within the curricula. There are a certain number of programs that are designed to appeal to physicians who neither want nor intend to divert their primary work from patient care but who do wish to acquire a new set of knowledge and skills. Earning a master’s in medical education is a pretty cost-effective way to gain another degree while adding diversification and/or justification to one’s job description. And then there are other programs that are designed for nonphysicians. How do these curricula vary in scope and intensity?

I can think of several other questions to ask about the training programs. At the top of my list would be, “Why”? What exactly is offered in a medical education training program that is not available in a more traditional education program? Certainly, the content that makes up examples and discussion is specific, but are there unique research methods? Are there unique theories and conceptual models? And then there is a sizable set of questions about the trainees. What do they end up doing, and how are they different from all of the nonphysician medical educators who now populate the training settings? Indeed, given the recentness of most medical education training programs, it is certain that many (most?) nonphysician nonclinical educators working in medical settings today have master’s or doctoral degrees that are not in medical education per se but, rather, in disciplines such as education, psychology, and communications. Is one to be preferred over the other?

In some ways my thoughts about medical education training programs reminded me of the situation in medicine training a century ago, when programs varied greatly by site. Over time, training became standardized and regulated. I am not suggesting that is a desired pathway for medical education training programs. Indeed, the long list of activities presented in Riesenberg and colleagues’ Appendix 1 reflects the fact that the individuals hired into nonphysician roles have a diverse set of talents. It also probably reflects the reality that job descriptions fit peculiar local circumstances. Nevertheless, it would be interesting to debate the virtue—or lack thereof—of having a job title/profession that conveyed a shared understanding, such as that that comes with doctor, teacher, accountant, or astronaut. Likely, such social constructions only come after standardization of training and common job tasks.

Establishing Evidence for the Value of Nonphysician Educators

Finally, how might the observations in Riesenberg and colleagues’ report be informed with data? What types of data could serve as evidence to support claims for the value of nonphysician educators? One option is to use robust quantitative methods to count and categorize the nonphysicians who are working in UME and GME (CME is certainly more challenging). Leaving aside details such as funding of said work, imagine a survey to all (or a sample) of deans and/or residency program directors, asking them to list the nonphysician educators along with details such as titles, background/training, percent of effort, main responsibilities, and reporting structures. The feasibility of such a plan is likely limited, but it suggests a way to obtain a data-based, census-like view of the prevalence of nonphysician educators. Alternatively, one could draw on qualitative methods and create a rich story detailing the multitude of ways nonphysician educators are involved in education throughout the UME/ GME/CME continuum within a few institutions that are purposefully sampled. A few cases studies using methods such as observations and interviews with key informants would create new knowledge. In between these extremes, of course, are many alternatives that would ideally include important research questions derived from strong conceptual frameworks in, for example, leadership, communication, or team dynamics. And then there is the possibility of conducting most formal cost analyses evaluations. What is the value of the goods and products produced by nonphysician educators relative to their costs? The choices are many. The shared goal is to inform the vision with evidence.

Clearly, the article made me, a nonphysician educator, think. Why is there not more literature that documents the importance of and contributions by nonclinician, nonphysician educators? I think there are probably a few key reasons. First, as shown by the very long list of activities gleaned from job postings, nonphysician educators do a lot of different things. Indeed, the phrase “jack-of-all-trades, master of none” comes to mind. Second, they also come from a host of different backgrounds. There is not one central profession or program that stands to gain from documenting/counting our contributions, much as some medical schools do with the contributions of their graduates. Third, the nature of what we often, but not always, do is to support education programs, not deliver them. Fourth, although it is changing, at many medical schools it was/is hard for nonphysician educators to be appointed to faculty positions. It remains true that within and outside of medical schools, faculty have more leadership, prestige, and power than nonfaculty.

Overall, I learned a lot. I wholeheartedly applaud the “use” of nonphysicians in medical schools. However, rather than “fill roles that do not require a physician’s expertise,”1 I prefer to think we fill roles in which physicians do not have the necessary expertise!

References

1Riesenberg LA, Little BW, Wright V. Nonphysician medical educators: A literature review and job description resource. Acad Med. 2009;84:1078–1088.
2Ludmerer KM. Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press; 1999.
3Flexner A. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston, Mass: Updyke; 1910.
4Bordage G. Moving the field forward: Going beyond quantitative-qualitative. Acad Med. 2007;82(10 suppl):S126–S128.
5Villa RA, Thousand JS, Nevin AI. A Guide to Co-Teaching: Practical Tips for Facilitating Student Learning. Thousand Oaks, Calif: Corwin Press; 2008.
6Dolmans DH, Gijselaers WH, Moust JH, de Grave WS, Wolfhagen IH, van der Vleuten CP. Trends in research on the tutor in problem-based learning: Conclusions and implications for educational practice and research. Med Teach. 2002;24:173–180.
© 2009 Association of American Medical Colleges