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Commentary: When Much Is Promised, Much Is—and Should Be—Expected

Hafferty, Frederic W. PhD; Hafler, Janet EdD

doi: 10.1097/ACM.0b013e3181acf0a5
Commentary

There is much to be excited about in Riesenberg and colleagues' report—if all they promise can be delivered. But their endorsement of nonphysician medical educators' (NPMEs') remedial role in educating health professionals is excessive, even as they point out that NPMEs are only one solution to the problems facing such training, and even as they raise provocative ideas (having NPMEs function as role models for physicians in training) about the realignment of responsibilities for educating future physicians. Moreover, it is not clear how the core transformational skills for NPMEs identified in their report are tied to the broad array of educational experiences they outline. Furthermore, the venues for teaching NPMEs about education, particularly graduate schools of education, are, with some exceptions, not viewed as exemplars of educational excellence within the general university community.

Flooding classrooms, clinics, and hospital wards with NPMEs, however well trained and inexpensive, is not the way to best educate the next generation of health professionals. Medical practice and medical education constitute a complex system, and medicine's culture is tribal, and intolerant of generalists and outsiders (including “educationalists”). The real issue is not NPMEs' acquisition of theory, research methods, or teaching skills so much as it is whether NPMEs possess the disciplinary independence and identity necessary to make the kinds of contributions needed within a culture that can be so seductive, dominating, and dismissive of outsiders.

Dr. Hafferty is professor of behavioral sciences, University of Minnesota Medical School–Duluth, Duluth, Minnesota.

Dr. Hafler is a visiting scholar, Tufts University, Medford, Massachusetts.

Please see the end of this article for information about the authors.

Correspondence should be addressed to Dr. Hafferty, University of Minnesota Medical School–Duluth, Duluth, MN 55812; telephone: (218) 726-7144; e-mail: (fhaffert@d.umn.edu).

Editor's Note: This is a commentary on Riesenberg LA, Little BA, Wright V. Nonphysician medical educators: A literature review and job description resource. Acad Med. 2009;84:1078–1088.

Medical education is an educational rather than a professional problem … This distinction is an important one, for professional education, particularly in America, has suffered from the notion that to train a man for his profession, one must have the viewpoint of the practitioner only, and not the viewpoint of the teacher as well. The education of a physician is primarily an educational, not a medical question, just as the training of an engineer is primarily an educational question, not an engineering question … the methods employed in training physician and engineer involve educational procedures and educational skill. Each of these professions calls for a high order of reasoning, and for training in the observation of fact and in the proper marshaling of facts in order to reach a correct result; each finally involves the acquisition of a high order of skill. All this is education.

—Henry S. Pritchett, president, Carnegie

Foundation for the Advancement of

Teaching, in his Foreword to Abraham

Flexner's Medical Education in Europe,

Bulletin No. 6, 1912

As medical education reform inches forward, it appears we have luminosity at the end of our pedagogical tunnel—nonphysician medical educators (NPMEs). In their review of the literature about these unique and emerging pedagogical participants, Riesenberg, Little, and Wright1 define the concept, outline a history of NPMEs' involvement in medical education, link NPMEs' participation to other movements in medical education—for example, the rise of family medicine, standards of the Accreditation Council for Graduate Medical Education (ACGME), and outcome-based assessment—present studies documenting NPMEs' contributions to physicians' education, examine job postings for NPMEs, and offer a brief review of master's degree education programs specializing in medical education. There is much to be excited about in this report—if all that appears promised can be delivered.

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Background

Key to understanding the contributions and potentials of this “exponentially growing”* cadre in the training of physicians is to understand who are, and who are not, NPMEs. The authors introduce two general types: (1) individuals with advanced degrees in education (“or a related field”) who lend their skills and expertise to the particulars of medical education, and (2) individuals with various types of clinical training (e.g., nurse practitioners, clinical nurse specialists, physicians' assistants, nurse midwives, physical therapists) who have obtained “added training or experience in education” and/or “who [specialize] in medical education.” Those who have PhDs and teach basic sciences in the preclinical or clinical years, and physicians who have interest or expertise in education, are not a part of this designation. The bulk of Riesenberg and colleagues' report focuses on the contributions of those with a clinical background whose interest and/or expertise is the education of physicians.

The authors outline an extensive list of contributions that NPMEs can make to the training of medical students and residents, including (1) patient education, (2) a variety of clinical and physical exam skills, (3) history taking, (4) evaluation of humanistic behaviors, (5) physical diagnosis, (6) interviewing, (7) health maintenance, (8) growth and development, (9) general guidance and feedback to students, (10) student remediation, (11) student evaluation, (12) administrative monitoring of educational sites, (13) developing curricula and exams, (14) faculty development, and (15) faculty teaching skills. In addition, the authors analyze job-posting data for NPMEs and provide what they characterize as a “sample” of over 200 “distinctly different required duties” across 17 categories (e.g., accreditation, faculty development). Evidently, this breathtaking array of expertise is par for the course. For example, Stanford University's School of Education lists 12 different options for MA programs (alphabetically ordered from Curriculum Studies and Teacher Education to Social Sciences in Education), 17 for PhD programs (Administration and Policy Analysis to Teacher Education), three teacher certification programs, and an undergraduate honors program. The school's Web site (http://ed.stanford.edu/suse/programs-degrees/index.html) also lists 24 specialty areas (Assessment through Urban Education) along with 153 specific topics of faculty research interest (Academic Performance Standards to Youth Development and Organizations). There appears to be little that lies beyond the expertise of the education experts.

As might be expected, the authors cite the need for “major reforms” and a “major overhaul” of health professions education. They certainly have a chorus of supporters among medical education leaders in this regard, the majority of whom decry the diminishment of education within the tripartite (education, research, clinical services) mission of the medical school. Nonetheless, these leaders also have issued numerous calls for substantive change at the level of culture and/or underlying organizational structure, a theme we will return to in just a moment.2–4 Furthermore, the need for educators who have the requisite skills cited by Riesenberg and colleagues (“thorough understanding of adult education theory, valid needs assessment, writing objectives, curriculum development, competency-based education, evaluation, and medical education research”) appears self-evident and necessary. Finally, we note and concur with the authors' claims that physician educators are overwhelmed by their educational responsibilities, are directed to focus on competing (e.g., administrative, research, clinical) tasks, and have little training in their role as teachers. The authors portray NPMEs as ready, able, and willing to help in these necessary reforms. NPMEs are, in the words of the authors, “ideally suited to oversee and manage these new activities” with a presence and recognition of importance (within medicine) that is “grow[ing] exponentially.”

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Concerns

Our concerns begin with the essentially unbridled endorsement of NPMEs by the authors. NPMEs may be strangers in a culturally strange land, but like Robert Heinlein's Valentine Michael Smith, they appear here to possess almost messianic powers, and we find this portrayal disconcerting. NPMEs, according to the authors, have “unique training” and will “improve the quality of physicians' clinical education.” Moreover, they will do this “while controlling costs.” Even more enticing, and in a phrase guaranteed to quicken the pulse of any administrator, they do all this while bringing “added value.” Correspondingly, the authors call on medical education to “embrace the nonphysician medical educator,” to undertake future studies that will “seek ways to promote [their] success,” and they provide the above-cited study of job postings as a “resource for those interested in hiring nonphysician medical educators” (italics ours). In fairness, the authors do point out that NPMEs are “one solution” to the problems facing health professions' training, but no alternative players are identified. Finally, and in terms of what NPMEs need to know about medicine to provide all this expertise-driven and contextually appropriate help, the answer appears to be—not much. According to the authors, the “core skills of effective clinical teachers” such as “enthusiasm,” “clarity,” “organizational skills,” and others “are all characteristics that [NPMEs] can easily master.”

A related concern involves the training in education necessary to acquire the unique and cost-effective skills cited in the report. The authors refer to a broad array of educational venues and experiences stretching from doctoral (PhD and EdD) training to various master's, certificate, postgraduate diploma, and individual courses—including individuals who specialize in medical education without any formal training. However, we feel the authors fail to tie any of this training (or lack thereof) to the variety of benefits NPMEs are supposed to deliver. Thus, we remain confused as to who is qualified to do what. In this context, we also reject the age-old tacit assumption that those educated to a “higher level” (e.g., PhD, EdD, or even MDs who have acquired specialized education training) are therefore qualified to undertake just about any task placed before them. In short, we believe that Riesenberg and colleagues need to more explicitly link the types of training necessary to deliver the variety of workplace benefits that they outlined in their report.

Then there are the NPMEs themselves. The authors highlight the contributions of one specific type of NPME—those with preexisting clinical skills, and therefore a workforce category perhaps better labeled as nonphysician clinical medical educators (NPCMEs). The range of skills and benefits attributed to these clinical educators (e.g., physical diagnosis, student evaluation—see above) is extensive. The authors also claim that these workers can function as “role models” for physicians in training. This is a provocative extension of the role model concept, and one we hope the educational community will further explore. There is, nonetheless, one type of clinical educator missing in the report: physicians. Increasing numbers of MDs, particularly those who work as educators, are pursuing the same types of education training available to nurse practitioners and clinical nutritionists. Where do these physician medical educators (PMEs) fit into the picture? More important, how might PMEs work with NPCMEs and NPMEs to build a better education system, not just for physicians but for members of other health professionals as well?

Another set of issues targets the venues of training, particularly graduate schools of education. If NPMEs are a solution worth embracing, then should we not expect the education of educators (in all of its forms and levels) to be a paragon of educational excellence? If a thorough understanding of learning theory, skills in research, curriculum development, assessment, etc., is to be our vehicle of rescue, then should not the most evident site of effective and cost-efficient learning be the one place educators, in fact, control: schools of education? Moreover, and given this seat of expertise and excellence, should we not see other units within the university, from departments of English to schools of engineering, routinely bringing their local problems of pedagogy and practice to these schools of education? While neither of us has clear-cut answers to these empirical questions, the bottom line appears less affirming than one might hope, given the broad endorsement by Riesenberg and colleagues of NPMEs, and particularly NPCMEs, as agents of pedagogical change. Although there are some excellent programs (e.g., Stanford's STEP program and the University of Michigan's Center for Research on Learning and Teaching), schools of education, by and large, are not identified as exemplars of educational excellence, nor do they serve as first-line remedial resources within the general university community.5,6 Furthermore, there are large-scale investigations into education reform such as The Education Schools Project (http://www.edschools.org/index.htm) that characterize teacher education as “deeply flawed,” “unruly and chaotic,” in “disarray nationwide,” and (shades of the hidden curriculum) marked by “a chasm between what goes on in the university and what goes on in the classroom.” Of particular interest when evaluating Riesenberg and colleagues' comments is The Education Schools Project's characterization of teacher education as inferior to that in medicine and law.7 This is not a reassuring picture.

Finally, it is worth noting that NPMEs are not the only source of remedial support when considering the reform of medical education. Increasingly, problems within clinical medicine, medical research, and medical education are being framed from a complex systems perspective utilizing the language and methodological tools of network analysis and complexity science.8–10 Medical leaders such as Denis Cortese, Mayo Medical School's president and CEO, are aggressively promoting a systems-engineering approach to building a better health care system—and by (our) extension, a better system of health care education. Even “precursor” issues such as how best to teach science at the K–12 and college levels are being researched and debated outside the hallways of education schools, with individuals such as Harvard's Eric Mazur and Nobel Prize winner Carl Wieman taking the lead.11,12

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Closing Comments

Academic medical education, undergraduate through CME, is facing a number of challenges about how best to educate the next generation of physicians. These challenges are both cataclysmic and evolutionary. They include the variety of upheavals currently battering our current nonsystem of health care and the additional sources of chaos that are coursing through our broader economic and sociopolitical environment. Particular issues include how best to integrate the basic and clinical sciences, how to teach in the current workplace, the redesign of residency programs under duty hours restrictions, and the revamping of a CME enterprise whose main effectiveness has been to advance industry goals. Moreover, and echoing ACGME president Thomas Nasca,13 these problems are as much philosophic, conceptual, and value based as they are rooted in issues of assessment and evaluation.

As we look toward the horizon, one major problem we continue to face is medicine's own tribal nature. We are a culture dominated by specialists, a culture in which generalists are devalued and in which “outsiders” (including educationalists) are routinely (if invisibly to insiders) treated as second-class citizens. Nonetheless, we need to involve educators in the study and reform of our educational enterprise, and this remains as true today as it was when Henry Pritchett (as indicated in the quotation that opens this commentary) first hired Abraham Flexner to study medical education in the United States and Canada (Bulletin No. 414) and Europe (Bulletin No. 615) almost a hundred years ago. Furthermore, the education of physicians must become more multidisciplinary in scope and focus. Boundaries within medicine, between medicine and society, and those separating the various health occupations, should become more permeable and even facilitative in transporting new ideas and skills. Today, and nudged along by RO1 dollars, we have begun to embrace a transdisciplinary approach to research. Yet we have been slower to apply this reframing to our educational challenges. Medical practice and medical education constitute a complex system, and we need to be thinking and talking systematically. We believe education can help in this conversation. Nonetheless, the conversation that needs to take place right now is not so much between NPCMEs and residents or medical student learners but between nonphysician educators (be they medical or otherwise—and this would include systems engineers) and those in charge of training the next generation of health care providers. Flooding classrooms, clinics, and hospital wards with NPMEs, particularly NPCMEs, however well trained and inexpensive, is not the immediate challenge. Galvanizing conversations between physicians and others on the education of future practitioners, a discourse that then will be translated into both classroom and clinic, is.

Fifty-two years ago, sociologist and medical educator Robert Straus, who helped to establish medical sociology as an academic discipline and launched the first department of behavioral sciences within a medical school, drew a piercing distinction between a sociology of medicine and a sociology in medicine.16 He viewed these two types of sociology as “incompatible.” As new opportunities for employment in medical settings beckoned, Straus was concerned that sociologists might lose their disciplinary gaze and come to identify more with the educational, research, or clinical agendas of their employer (or setting). Straus was worried that any weakening of this parent identity would undercut sociology's ability to provide a unique contribution to issues of health and health care. NPMEs face a similar challenge today. Although Riesenberg and colleagues do a wonderful job of outlining the array of skills NPMEs can bring to medicine's pedagogical table, the real issue is not the application of education theory, research methods, or teaching skills so much as it is whether NPMEs, particularly NPCMEs, possess the disciplinary independence and identity necessary to make the kinds of contributions needed within a culture that can be so seductive, dominating, and dismissive of outsiders. We look forward to future discussions about how this can happen.

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Acknowledgments

The authors deeply appreciate the insights of David Stern, MD, PhD, who is in no way responsible for the arguments or conclusions presented in this essay.

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References

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13Nasca T. Shaping the future: Milestones, portfolios and the next accreditation system. Address presented at: ACGME Annual Medical Education Conference; March 6, 2009; Grapevine, Texas.
14Flexner 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.
15Flexner A. Medical Education in Europe. A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 6. New York, NY: Carnegie Foundation for the Advancement of Teaching; 1912.
16Straus R. 1957. The nature and status of medical sociology. Am Sociol Rev. 1957;22:200–204.

*All quotations in this commentary are from the Riesenberg et al report except the few that are clearly identified as being from other sources.
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