Expectations of and for Clerkship Directors 2.0: A Collaborative Statement from the Alliance for Clinical Education

Abstract

This article presents an update of the collaborative statement on clerkship directors (CDs), first published in 2003, from the national undergraduate medical education organizations that comprise the Alliance for Clinical Education (ACE). The clerkship director remains an essential leader in the education of medical students on core clinical rotations, and the role of the CD has and continues to evolve. The selection of a CD should be an explicit contract between the CD, their department, and the medical school, with each party fulfilling their obligations to ensure the success of the students, the clerkship and of the CD. Educational innovations and accreditation requirements have evolved in the last two decades and therefore this article updates the 2003 standards for what is expected of a CD and provides guidelines for the resources and support to be provided.

In their roles as CDs, medical student educators engage in several critical activities: administration, education/teaching, coaching, advising, and mentoring, faculty development, compliance with accreditation standards, and scholarly activity. This article describes (a) the work products that are the primary responsibility of the CD; (b) the qualifications for the CD; (c) the support structure, resources, and personnel that are necessary for the CD to accomplish their responsibilities; (d) incentives and career development for the CD; and (e) the dedicated time that should be provided for the clerkship and the CD to succeed. Given all that should rightfully be expected of a CD, a minimum of 50% of a full-time equivalent is recognized as appropriate. The complexity and needs of the clerkship now require that at least one full-time clerkship administrator (CA) be a part of the CD’s team.

To better reflect the current circumstances, ACE has updated its recommendations for institutions and departments to have clear standards for what is expected of the director of a clinical clerkship and have correspondingly clear guidelines as to what should be expected for CDs in the support they are provided. This work has been endorsed by each of the eight ACE member organizations.

Keywords:

• Clerkship
• clerkship director
• clinical undergraduate medical education
• job description/scope

Introduction

The clerkship director (CD) is an essential, and perhaps the most important, academic leader in the education of medical students on core clinical rotations. These “core clerkships” remain the foundation of undergraduate clinical training, whether in traditional, departmental/specialty-based, or in newer formats, such as the longitudinal integrated clerkship (LIC). In the past several decades, professional organizations for CDs and clinical undergraduate medical education (UME) in general have nurtured a group of academic clinician-educator leaders specifically tasked with preparing students in the clinical stages of their training before receiving their medical degree. This article represents an update of the collaborative effort of the Alliance for Clinical Education (ACE) published in 2003, ¹ endorsed by the leadership of its eight member organizations and reflecting the evolution in theory, curricula, assessment, and accreditation that has and will continue to impact UME.

The educational organizations comprising ACE (listed at the end of this article) are committed to promoting excellence in the clinical education of medical students through collaboration across specialties. ACE represents the commitment of its member organizations to work across departmental lines to ensure medical students acquire the fundamental clinical skills that are the foundation of their professional careers. The guidelines presented in this article are designed to be used by chairs, deans, CDs themselves, and all other leaders in undergraduate clinical medical education (i.e., in the Dean’s office or departmental leadership) to establish and communicate expectations of and for CDs within the institution. For the sake of brevity, the term clerkship director, is used in this article to include the leadership faculty team of these core experiences (e.g., Associate CD, Assistant CD, site director). The full-time equivalent (FTE) allocation described is, however, specific to the CD role only, not all the leadership; other roles (e.g., for associates and assistants) and their FTE should be negotiated by the CD and made explicit. The term clerkship administrator (CA) is used to identify administrative support for the CD. They/their are used, rather than he/she or his/her. “Assessment” is used to apply to students, in specific when a grade is to be attached to that assessment. “Evaluation” is used when the evaluation is performed on programs or processes, and it applies to faculty and trainees, as typically, no grade is attached to such evaluations.

This article describes the following:

• The frameworks upon which the enumerations of expectations are based

• Recent trends fueling the evolution of the CD’s roles and responsibilities, and (in some cases) the expansion of the clerkship leadership team

• Work products that are the primary responsibility of the CD

• Qualifications expected of the CD

• Resources in time, training, and personnel that are necessary for the clerkship leadership to accomplish their responsibilities

• Incentives and career development for the CD

• Time allotted to the CD for the clerkship and the CD to succeed

This article provides an appropriate time estimate for the full-time equivalent (FTE) support of both the “official” CD and the CA positions, supported by the breadth of the tasks articulated. In the first position statement, ¹ expectations were articulated as either essential or desirable. Since the majority of the desired elements have now become required, we no longer list “desirable” items. The remaining desired expectations/skills from that first statement may provide a guideline for the continued professional development of all CDs.

Educational frameworks

Many potential frameworks can be used to inform the generation of the lists of expectations “of and for” that follow. As noted, the CD is typically a clinician educator who also is a leader and a manager—an academic director. ² It follows, then, that the CD’s roles and responsibilities should be based firmly on the educational elements, since the CD is already a clinician. One framework that informs the current recommendations identifies four principles that all educators should value, endorse, and practice: learner engagement, learner-centeredness, adaptability, and self-reflection. ³ Although the attributes in this paper were ascribed to the ideal “educator,” they clearly apply to the CD as a key subset. Srinivasan et al. ³ also identified three “specialized” skills for all educators: content knowledge, process knowledge (how to be an effective communicator/teacher within that content area), and assessment knowledge. More specific to other roles of the CD, those authors further enumerated knowledge and skills expectations for those who develop educational programs (a role of the CD). These are reflected in the lists of responsibilities and qualifications which we provide below: understanding educational theory; knowledge of techniques for assessing programs, educators, and learners; proficiency in conducting educational research; using advanced technology; and faculty development, including remediation of faculty.

In another paper using the ACGME competency framework, ⁴ Srinivasan et al. identified six parallel competencies for educators:

• Medical knowledge (in this context, how educators use their content expertise to tailor instruction and to assess individual learner progress)

• Learner-centeredness, based upon the ACGME patient care competency, which would manifest as a personal commitment to meet a learner’s unique needs while treating them with respect

• Interpersonal and communication skills, emphasizing problem-solving and being able to adapt to all teaching/learning environments

• Professionalism and role modeling in all fields

• Practice-based reflection, which must be accurate and, in this context, focused on improvement as an educator

• Systems-based practice, which entails understanding the educational macro- and microsystems, and understanding how and when to advocate for change ³

Others have taken this further and identified traits that a CD should possess, ^{3 , 5} separating them into competencies and temperamental features. The former, in addition to those listed above, include: administrative/organizational skills, skill at giving and receiving feedback, and willingness to change and try new ideas. Identified temperamental attributes include positivity, good interpersonal and communication skills, adaptability, drive, passion, and a talent for collaboration. A CD with these traits may be better positioned to address the complexities of this evolving role.

Evolving roles and responsibilities of a clerkship director

An evaluation of what has changed in the breadth of the CD’s roles and responsibilities since the original ACE paper was in part initiated at an ACE-sponsored session during the 2016 Association of American Medical Colleges’ (AAMC) annual Learn Serve Lead meeting. ⁶ The session was built based on work by ACE member organizations and others that addressed these issues. ^7–18 Responsibilities of the CD role that were added included those associated with clerkships in Emergency Medicine (whose organization, CDEM, joined ACE after the 2003 publication), acting internships, LICs, early and advanced clinical courses, increased class sizes over multiple sites and settings, student (and faculty) wellness ¹⁹ and competency-based medical education. ²⁰ The impact of the SARS-CoV-2 pandemic has given prominence to the need for CDs to have skills in educational technology, including the theory and techniques of distance learning, for both instruction and assessment.

Recent imperatives for the clerkship director

Further evidence of the evolution of the CD role is the increased scope in The Guidebook for Clerkship Directors, 5th Edition, ²¹ an ACE publication, which added seven new chapters (and divided another) to the 24 chapters in the 4th edition. Recent publications have also added new or enhanced roles and responsibilities. For example, a survey of Internal Medicine CDs in 2017 identified the following as new responsibilities since the 2003 ACE recommendations: recruitment of new faculty and sites, faculty development, addressing student mistreatment reports, ²² attending departmental and medical school curriculum meetings, ensuring compliance with LCME standards, training and managing additional faculty leaders such as site clerkship faculty and co-directors, and navigating the increasingly complex and centralized administrative structure of the institution. ²³ These responsibilities were also raised at the 2016 AAMC session described above. ⁶

Diversity, equity and inclusion

The CD should follow national, school, and specialty-specific guidance on the critical inclusion of materials that address societal factors and the social determinants of health (SDoH) as a component of clerkship education. Surveys of CDs across the country have acknowledged the need to incorporate education about health disparities ²⁴ and cultural competence ^{25 , 26} [perhaps best referred to as cultural humility] into clinical clerkships. Curricula and structured guidelines have been developed ^26–29 to improve learner understanding of cultural practices and beliefs that impact the health outcomes of patients. Given acts against members of minoritized communities in the United States, and the disparate impact of the SARS-CoV-2 pandemic, clerkship objectives should address the impact of social injustice and disparities on health care outcomes. This type of curriculum requires increased faculty development on the part of the CD for effective design and implementation.

CDs must promote a diverse, inclusive, and healthy environment in their clerkships. Guidelines on the inclusion of students with physical disabilities have been designed ³⁰ and are included in LCME accreditation criteria. ³¹ In light of the identification of medical students with learning disabilities ³² and mental health concerns among medical students, ^{33 , 34} CDs must have the knowledge and skills to intervene when needed ensuring that these students successfully complete required activities without inadvertent disclosure of such issues. In addition, microaggressions, overt acts of discrimination, and other manifestations of bias and/or discrimination still occur in clinical settings against students from marginalized groups. ^{35 , 36} The CD, with support from departmental and medical school education leadership, is crucial in implementing strategies to maintain equitable, fair clerkship experiences for all students. Of particular note, CDs should also work to promote diversity, equity, and inclusion by reviewing and ensuring diverse representation (without stereotypes) in teaching and assessment materials. ³⁷

Health systems science

CDs have important roles in UME curricular integration and the successful transition of graduates to residency. Health disparities and inequities are just a few of the concepts increasingly included in explicit longitudinal health systems science (HSS) curricula, now a third pillar of medical education (complementing basic and clinical science) to help ensure graduates are prepared to advance the Triple Aim (or Quadruple Aim) believed to represent optimal healthcare delivery in the 21st century. ^38–40 HSS curricula include, but are not limited to:

• Healthcare structures and processes

• Health system improvement

• Healthcare value

• Population, public, and social determinants of health

• Clinical informatics and health technology

• Healthcare policy and economics

• Leadership

• Teaming

• Change agency, management, and advocacy

• Ethics

• Medical jurisprudence ³⁸

HSS must be integrated into core clinical rotations (much like basic science) so students can see the relevance and application of HSS concepts and skills in their future roles. ⁴¹ CDs must therefore develop the necessary knowledge, skills, and attitudes to incorporate these topics.

CDs should advance HSS education by working with local curriculum leaders to determine school-wide HSS gaps in learning and assessment as well existing HSS-related content in pre-clerkship courses and other clerkships. CDs can then plan, implement, and evaluate early clerkship ‘wins’ in direct and indirect clinical activities. ⁴² CDs (and faculty/residents) should assume more explicit HSS roles ⁴³ as they emphasize, model, and directly observe learner application of HSS concepts in authentic clinical experiences. ^44–46 For assessment purposes, HSS skills can be woven into, for example OSCEs, ⁴⁷ documented histories and physicals, or as reflection exercises. ⁴⁸ CDs and their faculty should explicitly emphasize (‘label’) the intrinsic HSS concepts/skills if students are to meaningfully embrace HSS as part of a new professionalism, ^{49 , 50} and to observe that HSS aligns with their (the students’) professional identity formation, including advocacy and community engagement.

Performance and productivity of a clerkship director

Rationale

The CD’s performance should be evaluated based on the degree to which the CD meets the responsibilities noted below. The CD should implement a comprehensive educational program in the clerkship and evaluate the program, its faculty (including trainees at the GME level) and assess the students. The scholarly activities of CDs may derive from these responsibilities, but they are not detailed in this section.

NOTE: The lists in this article are not intended to be exhaustive. They represent a minimum. Individual schools and departments may have other specific expectations of and/or for the CD. For consistency, these lists are organized according to the following rubric: administration of the clerkship, curricular development/assessment, student education/assessment, and faculty development/assessment. The order of bulleted items does not represent any prioritization. ACE members feel that they are all required for the CD to succeed.

Responsibilities of a CD include:

Administration of the Clerkship

• Development and management of the budget for all the experiences under the CD’s control (these may extend beyond the clerkship) ⁵¹

• Overall programmatic evaluation—both as an independent effort and as a part of the school’s quality improvement programs

• Recruitment of clinical training sites for student experience

• Ensuring comparable experiences among training sites

• Oversight of the performance of the clerkship administrator

• Ensuring non-paid faculty have departmental appointments

Curricular development/assessment

• Curriculum development, within the clerkship and across the school’s programs, including optimal learning strategies and alternate learning experiences

• Documentation and evaluation of the process and the products of the educational experience as part of ongoing improvement activities

• Implementation of school-wide educational initiatives/priorities (e.g., health systems science, opioid education, interprofessional education, health disparities)

• Evaluation of patient care learning environments to ensure sites are conducive for learning and patient care opportunities

Student education/assessment

• Ensuring students are meeting course objectives and participating in required clinical experiences

• Assessment, feedback, and grading for individual students, within the school’s and the LCME’s established timeframes

• Oversight of students’ remediation programs and progress should any students need remediation

• Provision of, as determined by curricular and student needs, direct clinical and in-class instruction, small group facilitation, and/or asynchronous educational platforms

Faculty development/assessment

• Recruitment, in conjunction with the department leadership, of a diverse faculty to execute the educational experiences, and provide the faculty development for those recruited to prepare them for teaching and assessing medical students

• Evaluation and feedback for individual faculty (and trainees) relevant to their clerkship roles, including their attention to issues of diversity and equity

Essential products for which the CD is responsible: the CD must produce or provide the following:

Administration of the Clerkship

• Annual proposed budget and periodic reports that reflect the clerkship’s performance relative to the approved budget

• All schedules (both production and distribution)

• Materials that support the goals and objectives, such as didactics, readings, and virtual resources

• Reports on the sufficiency and comparability of clerkship experiences at all teaching sites, as well as the equivalency of student assessments

• Reports on student performance, faculty development and performance, needs and available resources, and program effectiveness

• Oversight of, or at a minimum knowledge of and input into, other clinical observers to minimize interference with the medical students’ experiences and to ensure that the observers have the appropriate clearance to be in a clinical setting

• Regular (e.g., quarterly) review and validation that required data from clerkship evaluations (overall clerkship and site), learning environment evaluations, student clinical experience log fulfillment, and mid-clerkship feedback delivery have been entered into a central monitoring database as required by LCME

• Any documents and data required by the school for the internal review of the specific clerkship and the overall clerkship experience

• Attendance at and participation in UME educational meetings at the departmental, clerkship, and medical school levels, and during relevant LCME survey visit meetings

Curricular development/assessment

• Written set of core educational goals and objectives for the clerkship, informed by national specialty organization clerkship objectives, reflective of overall competencies and objectives of the school, and the approved by the school’s curriculum committee, with a plan for periodic review

• A full-time clinical experience that meets course and medical school learning objectives for the clerkship for every student

• Recommendations for changes in clerkship design or methods based on outcome measurements, resource availability, and/or current trends in education

• Participation in LCME compliance committees as needed, relative to clerkship curriculum

Student education/assessment

• Clear and specific expectations and standards for student participation in patient care at clinical sites

• A description of assessments comprising the final clerkship grade that aligns with clerkship goals and objectives and aligns with school policies that is provided to students, and all who teach them.

• Examinations, if used, that address core learning objectives and that are current, valid, and reliable

• Final grades for each student, with a written narrative noting goals met, strengths, and areas for continued improvement, delivered in a timely manner in accordance with LCME and school standards

• A summary of students with academic difficulty and a clear strategy for remediation for each clerkship cycle for the office of Student Affairs.

• Advice and assistance to students applying to residency programs, such as letters of recommendation

• Mentorship (at minimum the point of contact) for students interested in learning more about the specialty

Faculty development/assessment

• Clear and specific expectations and standards for residents, fellows, and faculty in promoting and maintaining a safe and effective learning environment that is distributed to all these parties.

• A written performance evaluation of the CA and any assistant CD or site directors under the supervision of the CD (or provision of feedback to their supervisors), with clear goals and metrics for the performance of these associates

• Documentation of the CD’s role in educational scholarship

• Summaries to the chair on the teaching contributions of faculty, along with their evaluations by students; summaries to the chair and/or program directors on the teaching contributions of residents/fellows, with their evaluations by students

Qualifications of a clerkship director

Rationale

Aligned with the educational framework outlined above, the CD should be able to manage a complex educational program and also be able to adapt quickly to a changing clinical and learning environment. The CD must have demonstrated effectiveness as a teacher, with both knowledge of the discipline and an understanding of curricular design, pedagogy, and methods and effectiveness in assessment and providing feedback. A CD must be an effective administrative and academic leader and that leadership role needs to be supported by both departmental and school administrations. The CD must also have the skill to manage the fiscal aspects of the course(s). These qualifications describe a person who is typically experienced as a clinician, educator, and leader who has the potential (if not already there) of being promoted to associate or full professor. ACE regards the selection of a CD as a contract among the CD, department chair, and the school, and expects each will take the appropriate steps to ensure the success of the clerkship (and all other courses) and of the CD. ACE recommends that the parties generate a document of some form to memorialize this compact with the CD.

The knowledge, skills, and attributes of the CD reflect the school’s and the department’s commitment to UME. The CD is also a role model, whose sense of duty to learners, patients, families, colleagues, and coworkers should be essential to being selected for the position.

Essential qualifications for a CD

The CD, ideally clinically experienced and (for physicians) board prepared/certified in their field, and/or possess a terminal degree, must:

Administration of the Clerkship

• Hold a faculty appointment at the medical school

• Have demonstrated administrative and management skills

• Have demonstrated adaptability/flexibility in response to frequent/unexpected changes

• Have demonstrated the ability to lead clinicians

• Recognize the fundamentals of strategic planning

Curricular development/assessment

• Explain the need to integrate the school’s objectives, curricular structure and its administrative structure and processes.

• Recognize the need to incorporate basic science, HSS, interdisciplinary and interprofessional themes

Student education/assessment

• Be able to provide formative assessment and feedback to learners and educators

• Have demonstrated skill in learner assessment

• Be enthusiastic about and for students

• Regard medical education as a central focus of their career development

• Have demonstrated skill as advisor, coach, and/or mentor

Faculty development/assessment

• Have demonstrated excellence in the clinical supervision and instruction of learners

• Have demonstrated effective interpersonal skills to work with colleagues, leaders, and administrators

• Be able to motivate colleagues to teach and assess medical students

Resources for support of the clerkship

Rationale

The complexity and the need for timeliness in the cyclic and often repetitive tasks of the clerkship mandate that resources associated with a specific budget, such as administrative support, and protected time, be given to the director. The CD should not be burdened with routine clerical tasks. CDs typically are skilled teachers and role models for students and often spend a major amount of their time teaching. A CD’s success often depends on support from their supervisor, and ACE again emphasizes the implied contract (when selecting the CD) ensuring sufficient resources to successfully meet the job requirements listed in this document.

Essential resources for the CD must include:

Administration of the Clerkship

• A defined budget with control over educational resources for personnel, materials, and travel that is sufficient to meet the requirements of the clerkship

• A clear reporting chain of command (for both the department and the school)

• A full-time CA to serve, among other roles, as the “first contact” liaison with students (See the ACE Guidebook ²¹ for the roles and responsibilities of this position, which are beyond the scope of this paper)

• Sufficient material resources (furnished office space, telephones, computers, copiers, etc.) to support clerkship requirements

• Access to new technologies (hardware and software) and technology support (including for students and all clerkship faculty) as needed

• Sufficient dedicated time and resources for (but not limited to) the following responsibilities:

• Orienting students

• Assessing students and preparing grades with associated narrative assessments

• Providing feedback to students at minimum as mandated by LCME standards

• Meeting students as needs arise to discuss performance

• Addressing student correspondence promptly

• Evaluating the curriculum

• Orienting faculty and residents to their role as educators

• Maintaining clerkship integrity, including recruiting and developing new faculty and sites ⁵² (e.g., ambulatory experiences)

• Making real-time adjustments to any and all exigencies that arise during any given rotation

• Advising/coaching/mentoring students ⁵³

• Writing letters of recommendation

• Visiting all sites at which clerkship experiences occur

• Conducting research and development in curricular evaluation and planning

• Evaluating and providing formative feedback to educators

• Preparing for LCME surveys and site visits

• Additional time, FTE, and administrative support for each additional course (e.g., elective, acting internship) under the CD’s direction

Curricular development/assessment

• Access to and protected time to participate in departmental education committee and school curriculum committee meetings to discuss course updates/initiatives, review curricular goals and strategies, and review students with academic difficulty

• Access to statistical and informatics consultants to aid in curricular and assessment development and research

Faculty development/assessment

• Sufficient time available to participate in departmental and institutional committee work/events that will lead to personal development (discussed subsequently)

Incentives and career development for the clerkship director

Rationale

The medical school curriculum cannot succeed, nor can the school maintain accreditation, unless the clerkships thrive. Successful clerkships in turn contribute toward successful recruitment of residency candidates, and national recognition for departmental and school programs. The roles of the CD and residency program director are comparable and complementary positions, and one should not be seen as a steppingstone to the other. The CD answers to both the department and the school, and input from both entities should be a formal aspect of the promotion process. The school and department also must recognize that a CD has two specialties in which to maintain currency: medical education and the CD’s clinical discipline; therefore, professional development in both must be supported. Finally, CDs should be expected to serve for some minimal period of time to allow both clerkship stability and their own development in educational scholarship.

The value of the CD to the academic community must be explicitly and formally recognized in the promotion and tenure system. Academic promotion beyond assistant professor typically requires more than “time-in-grade” in a departmental role. To be eligible for the rank of associate professor, time for school-wide, extra-departmental service in curriculum and other committees should be planned with supervisors. Clerical and administrative support for analyzing and synthesizing educational observations into reportable data are needed. Financial support for travel to present at academic meetings is important. Within the school, mentoring should be made available. Externally, the CD should belong to a clerkship director organization in their own specialty, and regularly attend national and international meetings for medical education.

Essential support for the career development: the CD must receive

• A transparent system of communication between the school and the department regarding the CD’s responsibilities, with clear departmental support for the CD’s leadership role in innovation, equity, and inclusivity

• An annual review of roles, responsibilities and the time required/allotted to meet them

• Within the overall clerkship, a transparent identification of funding for the CD and their team’s salary support ⁵⁴

• Assurance there will be no negative impact on total compensation in performing the role of the CD, as they support the mission of the school and the department

• Modified clinical productivity expectations based upon time allocated for educational activities

• Reassurance that educational productivity will be accepted as a qualification for promotion and, if applicable, tenure (ideally, promotion and tenure guidelines will detail professional and academic advancement expectations)

• Time and funding to attend a course for new CDs early in their experience to become familiar with the basic concepts, terminology, and application of educational practice

• Time and funding to regularly participate in faculty development programs to build and enhance their personal skill set, including training on how to become a master faculty developer

• A supported system for reporting faculty who require remediation in their roles with students and access to mechanisms for that remediation to occur

• Time and funding to attend at least one national meeting for medical education annually

• Time and funding for discipline-based continuing medical education and Maintenance of Certification activities to maintain credibility as clinician

• Mentoring to acquire greater departmental responsibility and authority, including skills as a manager of budgets and resources

• Leadership positions within the department, e.g., chair of an education committee

• Consideration for, and encouragement to seek, advancement to positions such as vice-chair for education, director of division of medical education within the department, or an assistant/associate dean

• Time and funding to develop skills in educational research and allocation of resources to participate in educational innovation, including participation in national educational associations

• Appointment to positions on relevant institutional education committees

• Encouragement and support to serve on education committees in national organizations

Time allocation for the clerkship director to fulfill responsibilities

A minimum of 0.5 of a full-time equivalent (FTE) should be allocated for the CD position. It is our opinion that the funding for the FTE should be borne by the school, as the clerkship is a core medical school entity. The CD’s time should be explicitly included in the medical school budget and not be subsidized by income from patient care or from research. Each school and department dyad would need to develop a process for the accounting and control of the monies. We recognize that institutional contexts may dictate sharing of the cost between the school and the department. However, support from the medical school should carry assurances the clerkship director is provided allocated time for their work. Departmental and school leadership should meet routinely with the CD to assess changes in roles/responsibilities that may warrant further increases in this support. The outcomes of these meetings must be documented.

The total FTE assigned to manage the clerkship, and hence appearing in a specific budget for the clerkship, including associate/assistant CDs, site directors, and clerkship administrators, may well depend upon the class size and the geography of the experience. In addition, more time and resources will be necessary if the CD also manages other courses/experiences, such as a longitudinal integrated clerkship, acting internship, elective, or student interest group. The CD should be supported by at least one full-time CA, given all the administrative responsibilities of the CD.

While the lists above are not exhaustive (as noted earlier) they enumerate an extensive set of necessary knowledge, skills, and attitudes that CDs must possess or master. In addition, the CD must be a master adaptive learner, ⁵⁵ as the healthcare and medical education worlds are in a state of semi-constant change. At the core, most CDs contribute to the clerkship by engaging in three principal activities: administering the clerkship, teaching, and conducting scholarly work. Scholarly activity is often a principal measure of productivity toward academic promotion and, so, is necessary for fostering both longevity in the CD position and the educational expertise necessary for a successful clerkship. Since there are few external funding sources, this should be supported internally, at the least to provide seed money for preliminary data collection.

How well do these recommendations reflect the current realities?

Since the initial publication of the ACE expectations paper, many of the member organizations have begun formal processes of surveying their memberships. ^{7 , 9 , 23 , 56–64} This provides the ability to see how well schools measure up to what was outlined in 2003. Several trends are apparent:

• CDs rarely have overt control over the development and administration of the budgets to which they are held accountable.

• CDs are often not part of the leadership teams of departments (a reality which may subtly undermine the CD’s authority to manage the faculty and residents to execute the education mission).

• Administrative support for all the roles of the CD is often suboptimal.

• CDs may not receive explicit job descriptions, nor any other demonstration of the commitment of the department and school with respect to CD expectations (both of and for).

• Diversity is suboptimal among CDs. ⁶⁴

• FTE commitments are not uniformly at the recommended 0.5; in fact, some are significantly lower.

Summary

This article represents a collaborative effort of ACE, and the recommendations included in the article have been endorsed by the leadership of its constituent organizations. The evolution of medical education and the clinical practice of medicine have accelerated over the 17+ years since the first ACE paper was drafted. The role of the CD has expanded to accommodate all these changes. It is proper to revisit these expectations in light of current trends.

ACE member organizations have not assessed the impact of recommendations such as those outlined in this paper in a systematic fashion, save for one effort. ⁸ As noted, many of the organizations individually have endeavored to capture some data in their surveys. If these recommendations are to assist in the evolution of the CD role, they must be studied prospectively. Additionally, LCME Standard 2 states “A medical school has a sufficient number of faculty in leadership roles and of senior administrative staff with the skills, time, and administrative support necessary to achieve the goals of the medical education program and to ensure the functional integration of all programmatic components.” ³¹ ACE encourages the LCME to assess this sufficiency at the level of clerkship education for a consistent and transparent approach to this critical issue.

On behalf of its eight constituent organizations, with this paper ACE has updated its expectations of and for the Clerkship Director. This update aims to help secure the necessary talent and resources to ensure that medical students have the clinical fundamentals necessary for lifelong practice and learning. Above all, ACE wishes to set a high standard for the supervision and delivery of clinical education in our medical schools. As we noted in the original paper, “a great deal should be expected from our CDs. We believe that these expectations can be met with an investment in CDs as essential agents for curriculum, assessment, and innovation in clinical education.” ¹

Member organizations of ACE endorsing these revised recommendations are:

• Association for Surgical Education

• Association of Directors of Medical Student Education in Psychiatry

• Association of Professors of Gynecology and Obstetrics

• Clerkship Directors in Emergency Medicine

• Clerkship Directors in Internal Medicine

• Consortium of Neurology Clerkship Directors (American Academy of Neurology)

• Council on Medical Student Education in Pediatrics

• Society of Teachers of Family Medicine

Acknowledgements

The authors would like to thank Dr. Gary L. Beck Dallaghan for his assistance in coordinating and driving the writing process of this work.