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Clinician–Educator Tracks for Trainees in Graduate Medical Education: A Scoping Review

Friedman, Karen MD, MS; Lester, Janice MLS; Young, John Q. MD, MPP, PhD

Author Information
doi: 10.1097/ACM.0000000000002814

Abstract

Health care has changed drastically since Abraham Flexner’s call for medical education reform over 100 years ago.1,2 In the 21st century, medicine has shifted from acute hospital-based care to a model of ambulatory care with population health management of complex chronic diseases. This transformation has changed the role of the physician,3–8 and current graduates of U.S. medical education programs may have difficulty successfully navigating this new role.

To produce the kind of doctors that are needed, numerous organizations have called for medical education reforms that align curricula and pedagogy with the competencies required of 21st-century physicians.3,9 For example, the 2010 Carnegie Foundation report Educating Physicians: A Call for Reform of Medical School and Residency recommended the redesign of medical education around 4 principles: standardize learning outcomes, integrate formal knowledge and clinical experience, develop habits of inquiry and improvement, and support the formation of professional identities.4–6 Undergraduate medical education (UME) and graduate medical education (GME) programs have responded to these calls with new curricula, pedagogy, and assessments.5

For these reforms to succeed, UME and GME need a pipeline of clinician–educators who possess the competencies necessary to develop new curricular content and deliver it via novel pedagogies. Sherbino and colleagues in 2014 defined the 21st-century clinician–educator as someone who participates in clinical practice, applies theory to education practice, and engages in education scholarship.10 Faculty development initiatives, such as workshops, longitudinal teaching scholars programs,11 and advanced degrees in health professions education,12–14 aim to “develop teachers, supervisors and educators of tomorrow’s health care practitioners.”15 At the time of this study, there were over 150 master of health professions education degree programs worldwide.12–14

In recent years, residency and fellowship programs have begun to offer clinician–educator tracks (CETs). These tracks seek to attract and develop a pipeline of future clinician–educators with the requisite competencies. In 2010, psychiatry was one of the first specialties to report on CETs for residents.16,17 The first report of a CET to train internal medicine residents was published in 2014.18 Since then, there have been more reports of CETs in the literature.

As CETs appear to be increasing in prevalence in GME and may play an important role in the development of the future medical education workforce, we set out to examine the CET literature. We conducted a scoping review to characterize the current state of knowledge about the structure, content, and outcomes of CETs in GME. The results of our review can inform future research and program development and highlight gaps in the literature.

Method

Given the varying methodological approaches and outcomes in the CET literature, as well as the broad nature of our research question, we chose to employ a scoping review methodology rather than conduct a systematic review.19 Following the framework developed by Arksey and O’Malley20 and advanced by Levac et al,21 we divided our scoping review into 5 stages: identifying the research question; identifying relevant studies; selecting the studies; charting the data; and collating, summarizing, and reporting the results.

Identifying the research question

In this scoping review, we set out to answer the following research question: What are the content, structure, and outcomes of CETs in GME? After an initial review of the literature, it became apparent that the definition of a clinician–educator has evolved over time.10 For the purpose of this review, we defined clinician–educator as someone who possesses the competencies of direct teaching, curriculum development, mentorship and advising, leadership, assessment, and educational scholarship.11,12,14,22

Identifying the relevant studies

A health science librarian (J.L.) conducted all literature searches in consultation with the researchers (K.F. and J.Y.) in January 2018. Six electronic databases that cover education and biomedical literatures were searched: Cochrane Library, Embase, ERIC, PubMed, Scopus, and Web of Science. The keywords used in the searches included derivations of the following keywords: track(s) or pathway(s) and resident, fellow, intern, house staff, resident as teacher, graduate medical education, educator, scholar, scholarship, teacher, “clinical and educator,”clinical educator, “clinician and educator,”clinician educator, medical educator, and “medical and educator.” In addition, we manually searched the bibliographies of included articles. The full search strategy for each database is shown in Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A687.

Selecting the studies

All records were imported into EndNote version X8.2 (Clarivate Analytics, Philadelphia, Pennsylvania), and duplicates were removed. We limited eligible articles to English-language articles published in peer-reviewed journals through December 2017. No other date limits were applied.

For an article to be included, the intervention (i.e., CET) described had to meet 3 criteria. First, the intervention had to target GME learners (i.e., residents or fellows) of any discipline in medicine. Studies focused on medical students or faculty were excluded. Second, the intervention had to be longitudinal in nature (i.e., a series of experiences over time). Third, the intervention had to have the primary aim of developing trainees into clinician–educators. Based on the literature,11,12,14,22 we decided that the intervention must address one or more of the following core competencies of a clinician–educator: direct teaching, curriculum development, mentorship and advising, leadership, assessment, and educational scholarship.

Articles were screened through an online application (Covidence, https://www.covidence.org/home). One reviewer (K.F.) did an initial, independent screen of all titles and abstracts to exclude any intervention that targeted a non-GME learner (e.g., faculty, medical students, allied professionals such as nursing, dentistry, pharmacy, or public health) or focused only on a research track. Both reviewers (K.F. and J.Y.) then independently screened the title and abstract of each remaining article. When the reviewers disagreed, both examined the full article and then reached a consensus. This process identified the articles that were eligible for full-text review (Figure 1). Abstracts were eligible for inclusion, but review articles and opinion pieces were excluded during the full-text review.

Figure 1
Figure 1:
Flowchart of the process by which articles were identified and selected for the scoping review on clinician–educator tracks in graduate medical education (adapted PRISMA flowchart52).

Charting the data

A data collection form was developed and piloted on 3 articles by 2 authors (K.F. and J.Y.). These authors made iterative revisions through discussion and consensus, and they used the final version to extract the data on all included articles. Both authors performed data extraction for each article independently and then compared results. Differences after independent extraction were resolved between the authors by discussion and consensus.

The following characteristics of CETs were extracted from each included article:

  • Track structure: Postgraduate year of entry into track, number of trainees per track cycle, protected time for trainees, time commitment, length of program, and resources for trainees (e.g., funding) and faculty (e.g., funding, protected time).
  • Admissions process components: Application, interview, curriculum vitae (CV), personal statement, and good standing in program or program director approval.
  • Track content: Evidence of a core curriculum with classroom-based and workplace-based sessions focused on direct teaching, curriculum development, mentorship and advising, leadership, educational scholarship, and assessment; expectation of an academic project and dissemination; a mentor; and a certificate.
  • Outcomes: Track outcomes and learner outcomes.

If an article did not mention (coded “N/M”) the information for the data point of extraction, it was counted as a “no” in our analysis.

Collating, summarizing, and reporting the results

For data synthesis purposes, the authors reached consensus on the following parameters. Time spent in the track was estimated both in terms of total hours and total years based on a 7-hour workday (i.e., daytime hours when conferences are held) and 48-week work year for trainees. Protected time was defined as whether residents/fellows were relieved from clinical duties to attend track functions. Resources for faculty included protected time and/or salary support. Resources for trainees included funding for projects, supplies, or travel.

To characterize the content of the CETs, we determined whether there was a core curriculum for all learners (i.e., classroom-based sessions and/or workplace-based opportunities to practice the skills covered in the curriculum) that addressed the following education activity categories typically included in teaching portfolios for faculty—direct teaching, learner assessment, curriculum development, mentoring and advising, and leadership11,12,14,22—as well as the addition of educational scholarship. Educational scholarship was defined using the Association of American Medical Colleges definition: “Any material, product or resource originally developed to fulfill a specific educational purpose that has been successfully peer-reviewed and is subsequently made public through appropriate dissemination for use by others.”23 We determined whether there were requirements for project completion and dissemination, defined as presentation or publication at a local, regional, or national level.

We coded outcomes using Kirkpatrick levels (KLs) per the Best Evidence in Medical Education (BEME) coding sheet.24 Based on that coding sheet, we designated KL-1 as learner reaction on end-of-program satisfaction surveys; KL-2a as modification of attitudes/perceptions; KL-2b as subjective (s) and objective (o) modification of knowledge/skills; KL-3 as behavioral change, including career tracking and project completion; KL-4a as change in organizational practice, including residency recruitment pattern and funding; and KL-4b as benefits to patients.

Results

Study selection

Our search yielded 2,438 English-language records, of which we excluded 1,004 as duplicates, leaving 1,434 records. The initial title and abstract screen by the lead author (K.F.) resulted in the removal of 1,196 records. Independent review by 2 authors (K.F. and J.Y.) of the remaining 238 records identified 32 articles eligible for full-text review. Upon full-text review, an additional 13 articles were excluded, resulting in 19 articles16–18,25–40 for data abstraction (Figure 1). Articles that pertained to the same track were combined in the analysis: articles by Celebi et al25 and Lin et al,26 by Jacobson et al16 and Penner et al,27 and by Kohlwes et al.35,36 Four articles were abstracts from academic conferences without corresponding published full text: Gorgas et al,28 Overland and Thronson,29 Farhat et al,30 and Mangold et al.31 The primary authors of these abstracts were contacted to provide additional information that was necessary to populate the data extraction form.

Characteristics of included CETs

The 19 articles, all published in 2010 or later, represented CETs at 18 separate departments or institutions. Of the 18 CETs, 2 (11%)32,33 were open to all GME specialties at those institutions. All others were specialty-specific, including CETs in 5 psychiatry residencies (28%),16,17,27,34 3 internal medicine residencies (17%),18,29,35,36 3 pediatric residencies (17%),30,31,37 2 internal medicine fellowships (11%),38,39 1 family medicine residency (6%),25,26 1 emergency medicine residency (6%),28 and 1 radiology residency (6%).40 All GME programs were university-based or -affiliated.16–18,25–40 Appendices 1 and 2 summarize the characteristics of the 18 CETs across 4 broad categories: track structure, admissions process components, track content, and outcomes.

The average length of the CETs was 2 years. Twelve tracks (67%)16,18,25–30,32–36,38,40 offered protected time, and 12 (67%)17,18,28–32,34–36,38 provided resources for trainees such as funding for projects, supplies, and travel (Appendix 1). Most of the tracks had an admissions process that required an application (n = 14; 78%),16–18,25–29,31–33,37,38,40 and many required a CV (n = 10; 56%)16–18,27,29,30,32,37,38,40 and/or good standing/program director approval (n = 9; 50%)17,18,25,26,28–32,40 (Appendix 1). For track content, the most common foci were direct teaching (n = 17; 94%)16–18,25–36,38,39 and educational scholarship (n = 13; 72%)16–18,25–27,29–34,38 (Appendix 2). Most CETs provided learners with a mentor (n = 13; 72%).16–18,27–32,34,38,40 The majority had a project requirement (n = 16; 89%),16–18,25–27,29,33,35,40 with the most common project category being curriculum development (13 of the 28 projects reported) (Appendix 1 and Table 1).

Table 1
Table 1:
Summary of Core Curriculum and Project-Based Curriculum Topics Across the 18 Clinician–Educator Tracks Included in the Scoping Review

All 18 CETs included required didactics, and 17 (94%)16–18,25–38,40 offered workplace-based opportunities to practice skills covered in the classroom (Appendix 2). Direct teaching was the most common topic (n = 17; 94%) covered in the core curriculum didactics (Table 1). The majority of CETs (n = 14; 78%) also had opportunities to practice the skill of direct teaching in the workplace (e.g., co-teaching a session with a faculty member). The most common outcomes reported were learner reactions on end-of-program satisfaction surveys (KL-1; n = 7; 39%)18,25,26,28,32,33,35,36,39 and career tracking of graduates (KL-3; n = 11; 61%)16,17,25–27,32–38 (Appendix 2). No benefits to patients (KL-4b) were reported.

The widest variations in the structure of CETs were in the number of trainees per track cycle (range from 1 to > 12) and total hours spent on track activities (Appendix 1). The median number of hours spent in the tracks was approximately 166 hours. However, one track39 had as few as 8 hours over a 4-month period, and another38 had as many as 1,288 hours over a 2-year period. Seven CETs (39%)16,18,27–29,32,35–37 reported faculty resources such as protected time and salary support. Four (22%)16,27,29,31,38 had an identified focus on mentoring and advising in the core curriculum (Appendix 2). While most CETs required a scholarly project, dissemination of scholarly work was only reported in 5 (28%).16,17,27,29,30,33 Most CETs (n = 13; 72%)16,17,25–27,30–33,35,36,38,39 did not mention awarding a certificate upon track completion (Appendix 2).

Discussion

This scoping review yields a composite picture of the current state of CETs in GME. Almost all CETs (16/18; 89%) included a core curriculum (classroom-based sessions plus opportunities to practice new skills in the workplace) and a required project. The combination of core knowledge with experiential opportunities is consistent with adult learning theory as described by Knowles.41 Direct teaching was the most common focus among the CETs throughout the classroom- and workplace-based sessions. Given the Liaison Committee on Medical Education42 and Accreditation Council for Graduate Medical Education43 requirements for residents to teach, most GME programs have had resident-as-teacher curricula for decades. Since direct teaching is the focus of most resident-as-teacher curricula, many programs already have in place the infrastructure and resources to focus on these skills, which may, in part, explain why direct teaching is the most common focus of the CETs.44

The variability in the CETs highlights areas for standardization and future research. For example, the time a trainee spent in the track varied greatly between programs. The right amount of time is currently unknown; however, one can extrapolate that more hours spent in the track will, up to a certain point, result in stronger skills acquisition. Also, more hours spent will increase the interactions of the learner with the community of practice of medical educators and may lead to stronger professional identity formation.45 Professional identity formation is critical to producing future clinician–educators who can mentor and guide junior trainees.46 Future research should focus on the amount and type of time necessary not just for adequate skills acquisition but also for the professional identity formation needed to sustain a career as a clinician–educator.

A second area for potential standardiza tion and research is dissemination of produced scholarship. Of the 18 CETs, only 5 tracks16,17,27,29,30,33 required dissemination. Many medical schools now recognize clinician–educator as a track for academic promotion.47 To be considered for academic promotion, clinician–educators need to show proof of dissemination of their ideas beyond the local level.23 Yet peer-reviewed publications are still a rate-limiting step.47,48 Future research should examine the importance of producing and disseminating scholarship in a CET to the likelihood of disseminating future scholarly contributions.

Third, mentoring and advising as a skill set appears not to be addressed by most CETs. This is concerning because the lack of a mentor–mentee relationship has been shown to have a negative impact on career trajectory in academic medicine.49 There is a need to mentor junior clinician–educators to reach their full potential. Training residents and fellows in these skills will help the academic medicine community address this need in the future. Future research should examine the association between teaching the skills of mentoring and advising in CETs and the success of track graduates in the roles of mentors and advisors.

Finally, this review highlights the paucity of CET outcomes data. The lack of data makes it impossible to draw conclusions from this review about best practices. For example, CETs are tracking the career positions obtained by CET graduates and reporting those positions as a behavioral change.32 Yet, the attainment of a faculty position post graduation is not an indicator of competence because clinician–educator competencies may or may not be factored into those hiring decisions. Future research should focus on more robust outcome measures in the areas of objective skills acquisition, transfer of skills to practice, longitudinal impact on career, changes in patient outcomes, and impact on society. Research using well-thought-out and objective measures will help identify the key features of effective CETs and then help secure needed resources for these tracks. These tracks need support to build the future workforce of clinician–educators because it is not feasible to expect all clinician–educators to obtain an advanced degree in health professions education.

Limitations

This review had several limitations. The included articles were mostly descriptive. Outcomes were largely limited to learner satisfaction, and the longitudinal data were sparse. It was not feasible to apply Medical Education Research Study Quality Instrument scores.50 Based on guidelines from the BEME Collaboration,24 the articles were a level 1—no clear conclusions can be drawn. Although we conducted a broad search of the peer-reviewed literature using multiple databases, as with all reviews there exists the chance of missing important innovations in the gray literature. It is well known that CETs exist in many GME programs that do not report findings in the peer-reviewed literature. For those articles that were abstracts, we contacted the primary authors for additional information. We did not, however, contact the authors of the published articles. It is possible, therefore, that some features of tracks were in place but not reported in the articles, and were coded as not mentioned. Finally, our methodology lacked a third reviewer, and we did not calculate a kappa statistic. However, there was a high degree of agreement between the authors, and most data points were not subjective in nature.

Conclusions

Medical educators must take heed of the Institute of Medicine’s finding that there exists “a gap between new physicians’ knowledge and skills and the competencies required for current medical practice.”51 Competency-based medical education is the response to this gap, but highly skilled clinician–educators are required to operationalize the competencies. Advanced health professions education degree programs and faculty development programs can begin to fill the void, but to ensure a sustainable pipeline of clinician–educators, we must continue to improve and expand CETs in GME as well as in UME. Research to address the gaps identified in this scoping review, with an emphasis on reporting reliable and valid outcome measures, will be an important first step.

Acknowledgments:

K. Friedman acknowledges the support of leadership and faculty in the Master of Science in Health Professions Pedagogy and Leadership program, Hofstra University.

References

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    Appendix 1 Summary of Track Structure and Admissions Process Components Among the 18 Clinician–Educator Tracks in Graduate Medical Education Described in 19 Articles Included in 2018 Scoping Review of the Literature

    Appendix 2 Summary of Core Curriculum and Outcomes Among the 18 Clinician–Educator Tracks in Graduate Medical Education Described in 19 Articles Included in 2018 Scoping Review of the Literature

    Supplemental Digital Content

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