Abstract
Background: Despite a growing demand for skilled teachers and administrators in graduate medical education, clinician-educator tracks for residents are rare and though some institutions offer ‘resident-as-teacher’ programs to assist residents in developing teaching skills, the need exists to expand training opportunities in this area.
Methods: The authors conducted a workshop at a national meeting to develop a description of essential components of a training pathway for internal medicine residents. Through open discussion and small group work, participants defined the various roles of clinician-educators and described goals, training opportunities, assessment and resource needs for such a program.
Results: Workshop participants posited that the clinician-educator has several roles to fulfill beyond that of clinician, including those of teacher, curriculum developer, administrator and scholar. A pathway for residents aspiring to become clinician educators must offer structured training in each of these four areas to empower residents to effectively practice clinical education. In addition, the creation of such a track requires securing time and resources to support resident learning experiences and formal faculty development programs to support institutional mentors and leaders.
Conclusion: This article provides a framework by which leaders in medical education can begin to prepare current trainees interested in careers as clinician-educators.
Introduction
The role of clinician-educators in post-graduate medical education has evolved rapidly over the last decade. In part, this change has been driven by the growth of medical education research and a body of evidence to support specific methods for teaching and training. Concurrently, the emphasis of residency training has expanded from a focus on medical knowledge and clinical performance to include other core competencies that impact patient care and the profession. In addition, the training experience has become more challenging for residents with diverse educational needs as they manage patients with complex illnesses in an era of increasing regulation and attention to quality of care and safety. Clinician-educators, in leading these reforms, have forged a new career pathway for residents to consider. Increasing numbers of residents express interest in becoming leaders in medical education and, as a result, education leaders are faced with the challenge of answering the question ‘What is it that we do as educators?’.
Academia has traditionally been the home of the so-called ‘triple threat’ physician, who provides excellent clinical care, inspired teaching, and innovative research. However, the pace of development of modern medicine in all three domains has demanded that faculty focus their efforts to maintain quality and retain their effectiveness. Nonetheless, the clinician-educator has several key roles to fulfill beyond that of skilled clinician, including those of teacher, researcher and administrator. The role of clinician-educator remains complex and rather indistinct at most academic medical centers. In response, a growing number of medical schools have introduced clinician-educator promotion tracks for faculty (Fleming et al. Citation2005). Nonetheless, most programs still lack educational skill development programs to support clinician-educators. Clinician-educator tracks for residents are almost non-existent (James Citation1998) and though some institutions offer resident-as-teacher programs to assist residents in developing teaching skills, program directors acknowledge the need for more training in this area (Morrison et al. Citation2001). At Duke University Medical Center with the opportunity to participate in the Educational Innovations Project (EIP) from the Accreditation Council for Graduate Medical Education (ACGME), a group of clinician-educators in the Department of Medicine have begun to develop an educator training track for residents. The group aims to develop not simply a resident-as-teacher program but to create a career path for residents who are interested in becoming clinician-educators. In an effort to open this discussion and gain greater understanding from a broader group of stakeholders, the authors conducted a workshop at the 2006 fall meeting of the Association for Program Directors in Internal Medicine (APDIM) to further define the various roles of clinician-educators and, with this information, craft a description of a specific training track.
Methods
The workshop's central aim was to assist participants in the development of a description of a training program for internal medicine residents interested in careers in clinical education. To achieve this goal, the following explicit objectives were established for the session:
Define clinician-educator.
Delineate training goals for residents on a clinician-educator track.
Identify opportunities for skill development for residents.
Describe methods for resident assessment.
Identify resource needs and potential barriers.
Workshop participants included 23 internal medicine program training directors from a variety of academic medical centers and community-based residency programs interested in developing a clinician-educator track for residents. Participants were self-selected for the experience based on a description of the workshop in the meeting program.
After a brief introduction summarizing the challenges and opportunities in graduate medical education, the session leaders asked the group to respond in an open discussion format to the following question: ‘What, in your opinion, are the specific roles of a clinician-educator?’. A list of roles was captured and consensus created about the major domains or headers for these jobs. Next, attendees were divided into working groups and charged with designing a plan for training residents in each of the major clinician-educator roles. As per the objectives listed above, these small groups took 30 min to complete the following tasks: (1) list 2–3 key learning goals, (2) identify 1–2 venues/opportunities for residents to achieve the goals, (3) describe specific assessment measures and (4) identify resource needs and potential barriers for implementation. Each group recorded their responses on paper and then presented their findings back to the large group. The authors facilitated this discussion and, following the session, summarized each group's ideas in a tabular format. The authors then reviewed these tables for prevailing themes and searched available literature for supporting evidence and existing resources. From this work, they created the curriculum descriptions explained in the following text and the tables.
Results
Workshop participants identified four major roles to describe clinician-educators, including: (1) clinical teacher, (2) curriculum developer, (3) administrator and (4) education scholar. First and most fundamentally, participants felt that the resident must acquire and master clinical teaching skills. Participants repeatedly referred to existing evidence that informs the creation of effective programs to instruct residents as highly skilled teachers in varied learning environments. Second, they stated that resident must acquire and practice skills in curriculum development and evaluation. They cited the complexity of both modern medicine and the contemporary learner as reasons that the clinician-educator in training must acquire a methodical approach to the design and delivery of medical education programs. Third, the group acknowledged that effective education requires the development of high level administrative and leadership skills to organize and manage tasks, negotiate change, inspire learners and compel stakeholders. Fourth, the resident must have access to specific means to become a scholar and gain the ability to disseminate products and ‘survive’ in academia. Overall, a pathway for clinician-educators, they contended, must offer structured training and meaningful evaluation in each of these four areas to prepare residents effectively for their chosen career.
Small groups were then assigned to develop lists of learning goals, training opportunities, assessment methods and resource needs for each of the roles. The results of small group work are summarized in Tables .
Table 1. Clinical teaching: Summary of key components
Table 2. Curriculum development: Summary of key components
Table 3. Administration: Summary of key components
Table 4. Educational scholarship: Summary of key concepts
Discussion
The results of the workshop highlighted not only the complexity of the professional life of clinician-educators, but more so the rich array of resources and opportunities available to the next generation of medical teachers. Here, we offer a synthesis of the issues for each role grounded in available evidence and experience.
Clinical teacher
The most fundamental role of the clinician-educator is that of clinical teacher. Effective teaching requires a combination of meticulous planning and organization, creativity, patience and self-evaluation. For many years, internal medicine training programs have graduated residents with the expectation that they become competent teachers, yet have not provided them with the knowledge, skills and mentoring to do so (Ludmerer Citation1999). Among all education related roles, clinical teaching has the most well defined set of competencies and structured curricula for skill acquisition and assessment. Residents must first grasp the fundamental principles of learning theory as well as their own learning style and account for these in a variety of teaching situations. They must also create a climate that is comfortable and conducive to learning and to control the pace and timing of their teaching. In discrete teaching sessions or interactions, they will develop skills at establishing appropriate goals and objectives, utilize a variety of interactive strategies, and evaluate the learners’ achievement of desired outcomes. They will also need to master skills at teaching in specific situations and settings–including large group and small group sessions, as well as inpatient and outpatient venues. See for a listing of these competencies.
Fortunately, structured curricula exist for instructing residents to become teachers. For almost 20 years, the Stanford Faculty Development Program has offered a month long course, designed to train participating medical faculty to teach colleagues and trainees how to teach (http://www.stanford.edu/group/SFDP/). The course has graduated 117 teachers from 87 different institutions across the country. Other programs have developed more detailed curricula, specifically designed to train residents as teachers. Faculty at the University of California at Irvine, through the BEST program (Bringing Education and Service Together) promotes the development of residents as self-directed learners and teachers (http://www.residentteachers.com/best.htm).
Of course, development of teaching skills requires practical application and repetition with a plan for structured feedback. Didactic opportunities include noon conferences (journal clubs, M&M, gallops) and inpatient and outpatient morning reports. These sessions may be observed or filmed with a formal checklist of items to be evaluated by both faculty and peers. Clinical teaching, likewise, is a prime opportunity for observation. Again, attendees and fellow residents in both of these settings may provide feedback via completion of a skills checklist (DaRosa Citation2002). In addition to these ‘opportunities’ for assessment, programs have also used a structured assessment of teaching skills. Through the BEST program at UC-Irvine, residents participated in a randomized trial of a structured curriculum and were ultimately evaluated using an Observed Structured Teaching Examination (OSTE). Like its clinical counterpart, the OSTE asks residents to teach a ‘standardized’ learner using specific methods introduced in the course of a teaching skills curriculum (Morrison et al. Citation2004). They are evaluated based on explicit criteria and provided with feedback on their performance. Other programs have utilized videotaping or observation by a trained rater in much the same manner.
Successful implementation of a teaching skills curriculum requires significant investment on the part of the training program and the sponsoring institution. Residents need blocks of time away from clinical duties to participate in workshops or seminars on clinical teaching skills. In addition, effective conduct of the workshops requires faculty training and time as well as appropriate food and facilities. Faculty will also need time to invest in mentoring individual residents in the various stages of teaching, including preparation, delivery, and, most importantly, provision of timely, well delivered feedback. While less structured than the workshops, this process is extremely important for the development of individual residents and requires dedicated faculty time.
Curriculum developer
In the modern era, clinician-educators need more than the ability and inclination to teach. They must also possess specific knowledge and skills in curriculum design and evaluation in order to effect growth and change in individual learners, entire educational systems and communities. Kern et al. (Citation1998) specifies key components for effective educational programs, including: problem definition; needs assessment of targeted learners; written goals and objectives; development of instructional content and strategies; implementation of programs; and evaluation and feedback for both learners and programs. Clinician-educators must understand and be able to manage the development of each of these components of the curriculum design process in order to address actual problems and to design effective educational programs. Residents must, for instance, learn to identify gaps in learners’ knowledge, skills or values and be able to answer these deficits with educational interventions. They should master the ability to write clear goals and objectives that address targeted outcomes. With the overwhelming amount of information now available in the field of medicine, clinician-educators must also be able to carefully determine the appropriate quantity and quality of content, keeping in mind the nature of the audience, venue, timeframe and desired outcomes. Through exposure to learning theories, residents must learn to select the most appropriate strategies for teaching specific material. The process requires the resident to identify teaching methods that are theoretically sound and practically effective. Assessment skills are essential for the clinician-educator. These skills allow the resident to measure his or her impact on learners and effectiveness as a teacher. Both formative and summative evaluation methods must be applied in order to measure learning as well as program success. Finally, residents must recognize institutional context and anticipate its impact on implementation of educational interventions. Indeed, knowledge of human and fiscal resources, physical space and facilities for teaching, technology and library resources, and time for educational endeavours is essential to the success of educational programs.
A variety of venues and opportunities exist in which residents can develop curriculum design skills. One is through the resident-as-teacher programs discussed previously. Such programs expose participants to fundamental principles of curriculum design. The concepts learned in these programs can and should be complemented by opportunities for residents to apply skills in practice. At Duke for instance, residents: (a) develop and deliver curriculum for the medical student clinical clerkship lecture series; (b) develop, coordinate and teach in the outpatient clinic conference; (c) develop and facilitate teaching sessions on palliative care and (d) design and teach small group sessions in the Ambulatory Rotation. For each of these, faculty mentors provide guidance at each stage, observe implementation, review evaluation findings with the resident and guide the resident in seeking opportunities to disseminate his or her work.
As with the other clinician-educator roles, barriers to implementing this type of training curriculum include lack of adequate money, space and time. Administrative support, space, technologic resources and faculty development are often basic needs of many curricula. Securing a fraction of the residents’ restricted work-week to participate in curriculum development presents a significant challenge. Securing funding for these resources, while difficult, can often resolve many of the above barriers. Collaboration, effective marketing and supportive data can assist as well.
Administrator
Traditionally, administrative duties have constituted a necessary but tedious part of the work of education leaders at academic medical centers. Now, with greater accountability for the well-being and competency of learners at all levels, the role of clinician-educator requires high level administrative and communication skills to lead successful educational programs. Currently, clinician-educators acquire many of these skills through trial and error or by self education. For residents in training to develop and grow as clinician-educators, they need formal instruction and training in a number of different areas, including the administrative and regulatory issues impacting undergraduate, graduate and continuing medical education. In addition, they need to develop an appreciation for the complex organizational and financial issues involved in oversight of medical education programs and foster skills in identifying funding sources and managing budgets. Trainees should also learn effective administrative and leadership skills, including communication, delegation, negotiation, conflict resolution and feedback. In this process, they will acquire skills in advocating for improvement and change in academia.
Few published models exist for creating a curriculum in education leadership and administration. Retreat style programs prepare residents for clinical leadership roles, particularly those required as junior and senior residents leading teams on the wards or in clinics. Other examples focus on the preparation of chief residents for their duties. These programs use case-based approaches to focus on key interpersonal and communication skills that promote team-building and effective collaboration (Wipf et al. Citation1995; Stoller et al. Citation2004). Clinically oriented leadership training clearly needs augmentation to better prepare future educators for the programmatic and institutional aspects of their careers. While some knowledge and skills may be provided through didactics, practical experiences will provide residents with exposure to key issues and challenges in educational program administration. For example, residents may serve on a variety of institutional committees, including undergraduate and graduate curriculum committees, graduate medical education councils and review committees and residency advocacy bodies. They should also seek out active membership on regional or national committees, for which specific positions exist for post-graduate trainees. Finally, and perhaps most importantly, residents need close mentoring relationships with faculty clinician-educators. Evidence suggests that effective mentoring increases career satisfaction and achievement and that residents may connect with mentors less often than necessary during training (Paice et al. Citation2002). Program leaders need to facilitate linking trainees interested in clinical education with faculty role models.
Assessing the success of both individual residents and programs will require careful review of portfolios for key outcomes. Specifically, active participation in curriculum planning and on a variety of committees with achievement of leadership roles, such as subcommittee work or policy development, will provide important evidence of accomplishment. Faculty, peer and administrative staff reviews in a 360-degree format will offer documentation of success as will receipt of awards for teaching and leadership. Ultimately, programs should track fulfillment of trainee's career goals in service as chief residents, participation in education fellowships and promotion to faculty rank.
The most important resource for development of administrative and leadership skills among residents is faculty mentoring. To promote the positive impact of effective role modelling and guidance, the faculty members themselves must receive development, guidance and support from the institution. Peer groups of faculty educators participating in academies have found an important source of support (Irby et al. Citation2004). Of course, buy-in from leaders across the institution from Department Chairs to Deans to Designated Institutional Officials (DIO's) is essential as well. As with other career development for residents, the program must also provide resources and time for dedicated training, skill development, and project completion and dissemination.
Education scholar
The most challenging role for many clinician-educators is that of scholar. Like the researcher, the educator must consider how to document and disseminate their day-to-day work in a manner that allows for comprehension, critique, replication and growth. A primary question, however, is ‘What should constitute scholarship for clinician-educators?’. Academic Medical Centers (AMCs), have traditionally defined scholarship narrowly as the products of basic and clinical research. In many institutions, this view of scholarship still guides the faculty promotion process. Fincher et al. (Citation2001) argued that descriptions of innovative educational methods that are well defined and supported by evidence of impact on relevant learner and patient-oriented outcomes satisfy the traditional definition of scholarship. Faculty whose work fulfills these criteria should be recognized as scholars and rewarded with promotion.
To facilitate the recognition and growth of educational scholarship in academia, Glassick et al. (Citation1997) defined specific criteria for assessment of descriptions of teaching programs, including clear goals, adequate preparation, appropriate methods, significant results, effective presentation and reflective critique. The curriculum design process described above promotes a rigorous approach to satisfying several criteria in its requirement of meticulous attention to needs assessment, objective identification and selection of content and teaching and evaluation strategies. In addition, the scholar must develop self reflection and assessment skills to evaluate their performance as clinician-educators. They also need to acquire research skills including designing a research study, collecting, analysing and reporting evaluation data about their educational (teaching, curriculum design, educational leadership and administration) practices. Residents must also disseminate results from their educational practices using appropriate methods and venues, which requires familiarity with the variety of regional and national venues (meetings, conferences) and online and print publications where they can make their work public, available for peer review, and available to be reproduced and built upon by other scholars (Simpson et al. Citation2007). Finally, as critical thinkers, successful scholars continually strive to search for and apply best practices in the design, implementation, administration and evaluation of educational activities.
Residents’ achievement as education scholars must be promoted through a combination of role modelling and requirement. Programs need to identify, develop and promote clinician-educator faculty to serve as role models for residents. These faculty members, through their experience, should offer examples of scholarship and seek to collaborate with residents on specific educational research projects. Program leaders should also promote scholarship through specific requirements for presentation and publication. This can be achieved through establishment of local peer review processes and opportunities for project exposition such as a ‘Resident Research Day.’ Ultimately, these efforts and events can demonstrate evidence of the impact of resident clinician-educators’ educational practices on organizational and administrative processes, learning and curriculum and evaluation systems enhancement. Residents’ achievements can also be evidenced by number of presentations in regional and national conferences, and submission of materials/products as well as articles to web-based education repositories (e.g. Med Ed Portal) and academic journals. Finally, residents should develop and maintain an educator's portfolio to capture evidence of effectiveness of their work in each of the clinician-educator's roles (Holmboe et al. Citation2006).
Institutions’ traditional perspective on what constitutes scholarship, lack of protected time for clinician-educators to enact their roles as educators, and lack of training on educational principles are just a few of the barriers that residents will face in their clinician-educator scholar role. Institutions committed to clinician-educator success will have to rethink their definition of scholarship and create an infrastructure to assist scholars’ professional development, and creation and dissemination of their work (Lubitz Citation1997; Fleming et al. Citation2005; Simpson et al. Citation2007). To succeed in this role, resident clinician-educators will need mentoring, education resources (books/journals), access to statistical expertise and clinician-educator development programs mentioned in previous sections.
This study describes a comprehensive training model for residents interested in clinical education. This plan would indeed benefit from further refinement through formal feedback from a larger group of stakeholders, principally program directors and residents. Such an analysis will provide a more complete listing of existing resources and potential barriers. In addition, this description would be enhanced evaluation data from actual implementation of the pathway. It is certainly our intention to follow through with such analysis as time and resources allow. Nonetheless, we believe that this article provides a key step forward in construction of a basic framework for a clinician-educator pathway and will greatly facilitate future work in this area.
Conclusion
With the advent of the EIP and the interest of the ACGME in innovation, a new era has dawned in graduate medical education. The initiatives demand the attention and expertise of a new generation of physicians possessing not only traditional skills in clinical care and teaching, but the ability to create and evaluate curricula, to lead organizations and orchestrate change, to mentor and advise physicians in training, and to thrive in academia through the dissemination of descriptions of their work and its impact. The development of specific promotion and tenure tracks demonstrates recognition on the part of major academic institutions of the essential contributions of clinician-educators to the missions of the medical community. Leaders, therefore, need to prepare current trainees for the challenging and complex nature of this job through the establishment of pathways using the framework outlined in this article.
Acknowledgments
The authors would like to acknowledge the editorial and administrative support of Leigh Burgess in the production of this manuscript.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Additional information
Notes on contributors
Mitchell T. Heflin
MITCHELL T. HEFLIN, MD, is an Assistant Professor in Medicine and an Associate Program Director in the Internal Medicine Residency Training Program and Program Director for the Geriatric Medicine Fellowship Program at Duke University.
Sandro Pinheiro
SANDRO O. PINHEIRO, PhD, is an Assistant Professor in Medicine and Education Director of the Donald W. Reynolds Faculty Development Program for the Advancement of Geriatrics Education at Duke University.
Catherine p. Kaminetzky
CATHERINE KAMINETZKY, MD, Associate Chief of Education at the Durham VA Medical Center and an Associate Program Director for the Department of Medicine at Duke University.
Diana Mcneill
DIANA MCNEILL, MD, is an Associate Professor and Principal Investigator of the Educational Innovations Project and Program Director of the Internal Medicine Residency Training Program at Duke University.
Related Research Data
References
- DaRosa DA. Forms for evaluation of resident teaching-skills programs and resident performance. Residents’ teaching skills, Edwards JC, Friedland JA, Bing-You R. Springer Publishing Co, New York 2002; 100–114
- Fincher RM, Simpson DE, Mennin SP, et al. Scholarship of teaching: An imperative for the 21st century. Acad Med. 2001; 75: 887–894
- Fleming VM, Schindler GJ, Martin DA. Separate and equitable promotion tracks for clinician-educators. JAMA 2005; 294: 1101–1104
- Glassick CE, Huber MT, Maeroff G. Scholarship assessed: Evaluation of the professoriate. Jossey-Bass, San Francisco, CA 1997
- Holmboe ES, Rodak W, Mills G, McFarlane M, Schalt H. Outcomes-based evaluation in resident education: Creating systems and structured portfolios. Am J Med 2006; 119: 708–714
- Irby DM, Cooke M, Lowenstein D, Richards B. The academy movement: A structural approach to reinvigorating the educational mission. Acad Med 2004; 79: 729–736
- James WD. On the importance of the clinician-educator: Dermatology fellowship for academic clinician-teachers. Arch Dermatol 1998; 134: 151–153
- Kern D, Thomas P, Howard D, Bass E. Curriculum development for medical education: A six-step approach. Johns Hopkins University Press, Baltimore 1998
- Lubitz RM. Guidelines for promotion of clinician-educators. J Gen Intern Med 1997; 12: S71–S78
- Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. Oxford Press, New York 1999
- Morrison EH, Friedland JA, Boker JR, Rucker L, Hollingshead J, Murata P. Residents-as-teachers training in US residency programs and offices of graduate medical education. Acad Med 2001; 76: S1–S4
- Morrison EH, Rucker L, Boker JR, Gabbert CG, Hubbell FA, Hitchcock MA, Prislin MD. The effect of a 13-hour curriculum to improve residents’ teaching skills: A randomized trial. Ann Intern Med 2004; 141: 257–263
- Paice E, Heard S, Moss F. How important are role models in making good doctors. BMJ 2002; 325: 707–710
- Simpson D, Fincher RM, Hafler JP, Irby DM, Richards BF, Rosenfeld GC, Viggiano TR. Advancing educators and education by defining the components and evidence associated with educational scholarship. Med Educ 2007; 41: 1002–1009
- Stoller JK, Rose M, Lee R, Dolgan C, Hoogwerf BJ. Teambuilding and leadership training in an internal medicine residency training program. J Gen Intern Med 2004; 19: 692–697
- Wipf JE, Pinsky LE, Burke W. Turning interns into senior residents: Preparing residents for their teaching and leadership roles. Acad Med 1995; 70: 591–596