Author + information
- Matthew C. Konerman, MD∗ (, )
- Craig M. Alpert, MD and
- Shashank S. Sinha, MD
- Division of Cardiovascular Medicine, University of Michigan, Samuel and Jean Frankel Cardiovascular Center, Ann Arbor, Michigan
- ↵∗Reprint requests and correspondence:
Dr. Matthew C. Konerman, University of Michigan, Samuel and Jean Frankel Cardiovascular Center, 1500 East Medical Center Drive, SPC 5853, Ann Arbor, Michigan 48109-5853.
“Ideally, medical education should change as our knowledge base changes and as the needs, or the perceived needs, of patients, medical practitioners, and society change.”
—David Kern, MD, MPH (1)
Approximately 1 year ago, our fellowship program director posed the following questions to his fellows:
1. Who are we trying to train?
2. What does the ideal fellowship program look like?
In so doing, he empowered us to take charge of our educational experience. Indeed, fellow-driven quality improvement and curricular development are strongly encouraged in the recently released Core Cardiovascular Training Statement (COCATS) 4 recommendations (2,3). Specifically, COCATS 4 envisions fellows developing into “physician-learners” capable of assuming responsibility for personal education and achievement of competency-based milestones (2,3). The Accreditation Council for Graduate Medical Education, through its 6 core competencies including practice-based learning and systems-based practice, similarly urges fellows to play an active role in quality improvement within both the clinical and nonclinical domains at their home institution (4,5). In this context, we viewed our program director’s challenge as an opportunity to create a clinician-educator pathway within our fellowship.
From the beginning, the medical profession has always relied upon its experienced practitioners to educate the next generation of physicians. Yet, despite the standardization of undergraduate and graduate medical education, most physicians teach without any formal training in education. Given the current climate of increasing clinical demands and work-hour restrictions for trainees, such specialized preparation is arguably even more necessary as clinician-educators must now be as creative and efficient as ever before. Although academic medical centers attract intellectually curious physicians seeking to become lifelong learners, faculty development has only recently become a priority.
Fortunately, the culture of medicine is changing. Academic medical centers now recognize that a successful academic clinician must also be a successful educator. As a result, the career of a clinician-educator is now legitimized as an important scholarly pursuit with its own materials and methods. As aspiring clinician-educators, we desired a formal educational curriculum and, supported by our fellowship director, set out to create one ourselves. We share the key themes of our fellowship improvement initiative, which not only were integral in developing our clinician-educator pathway but also serve as an evolving blueprint for ongoing fellowship curricular reform (Table 1).
Creating a Culture of Continuous Improvement
In the months that followed those provocative questions, several novel ideas emerged intending to bridge a perceived gap between our current skillset and an idealized one—namely, those instrumental in the growth and development of a well-rounded cardiologist. Chief among these unmet needs was a shared commitment among fellows to become better educators.
From the outset, our program director recognized that such a transformative process would demand far more than just a call to action. He valued the importance of sustainability rooted in a culture of continuous improvement. He introduced a monthly hour-long meeting to serve as a forum for discussion of fellowship improvement projects and, in so doing, cultivated momentum, formalized our process, and supported our actions. Dedicated meetings fostered cooperative brainstorming, troubleshooting, and feedback. Fellows participated across a wide spectrum of engagement based on their intrinsic motivation and specific interests. Above all, these meetings introduced a regular rhythm and shared accountability into a training culture inevitably plagued by irregular periods of systoles and diastoles.
Building a Fellow-Faculty Coalition
Incorporating a new training pathway into an existing cardiology fellowship program presents several challenges. For centuries, the apprenticeship model has largely focused on clinical care and research. Learners simultaneously apprenticed as educators too, albeit primarily through emulating their best teachers and avoiding the pitfalls of those less effective. Yet, aspiring clinician-educators coveted formal structure and methods to parallel those well-established for aspiring clinician-scientists. Innovation expert Clay Christensen suggests that such a “disruptive change” be ushered in by a “heavyweight team” (6). Thus, we enlisted the help of a prominent professor of medical education within our university who, along with our program director, helped identify and then utilize all of the pre-existing resources to bring our vision to fruition. We assembled a core group of faculty across the health system that was energized by our proposal and eager to help.
Embracing Collaboration Across Institutions and Disciplines
Once we had built our coalition, we set out to study similar models that had already been implemented both inside and outside of our institution. We were pleasantly surprised that numerous other training programs in internal medicine already had established “medical education tracks.” We scrutinized curricula and their underlying framework, and in so doing, reshaped our own vision. We spoke with trainees that attended these programs and sought their insight into successes and failures. Along the way, we encountered the concept of the teaching portfolio to organize an individual’s clinician-educator experience, which would later become a key component of our proposed pathway (Table 2).
Around this time, we were also referred to a professor of urology that had designed a medical education seminar series for surgical fellows. We solicited her feedback on our proposed vision and attended some of her seminars to better visualize our own concept. We learned how best to solicit meaningful feedback following each session, therein allowing the pathway itself to exemplify a culture of continuous improvement.
Performing a Needs Assessment
Bolstered by a macroscopic vision and a team of builders, supporters, and enthusiasts, we began to outline the key areas of need. We recognized that training in medical education should: 1) be rooted in at least a rudimentary knowledge of learning theory and educational practice; 2) afford structured opportunities to teach and receive targeted feedback; and 3) introduce aspiring clinician-educators to the world of medical education scholarship. These needs ultimately served as the blueprint for our pathway design.
First, we recruited award-winning, distinguished clinician-educators from across the health system to lead medical education seminars (Table 3). During these workshops, fellows practiced their skills, engaged the faculty speakers in discussion, and shared experiences.
Second, we reshaped existing opportunities into “applied teaching labs” in which participants could hone teaching skills and experiment with new educational techniques. Such formalized teaching forums allowed fellows to teach and receive feedback from faculty, cofellows, residents, and medical students across a variety of settings from educational conferences to intensive care units to outpatient clinics.
Finally, we introduced the concept of an educational scholarly project to allow participants to apply their knowledge and skills to develop their own initiative within the fellowship. These projects also provided an opportunity for participants to become familiar with metrics and study design within educational scholarship and to navigate education-focused opportunities for conferences and publications.
Achieving “Short-Term Wins”
As outlined in the work of leadership expert John Kotter (7), many transformative efforts fail to set achievable short-term goals that can generate further momentum. If the magnitude of the project suggests that the transformation will be time-intensive, this becomes especially critical (7). Furthermore, agents of change can leverage such achievements to attract other interested parties to work toward the ultimate vision. In the case of our clinician-educator pathway, we decided to pilot an abridged seminar series over a 3-month period prior to the implementation of the full pathway during the subsequent academic year. Despite our fears that clinical and personal responsibilities would compete for this extracurricular time and energy, the sessions were very well-attended and well-received. At the same time, we have instituted a daily fellow-led resident teaching session in our intensive care unit that has allowed us to increase our teaching opportunities. With these 2 programs, we have seen additional interest in the pathway that is above and beyond those making an initial commitment. We have solicited feedback along the way to ensure that each subsequent iteration outperforms the one immediately preceding it. These “short-term wins” are now actively sustaining a culture of continuous improvement that was catalyzed by 2 very simple questions.
Through active fellow engagement and empowerment, our program has provided the resources necessary to foster our ongoing maturation into lifelong learners. Along the way, we have also developed an evolving blueprint for curricular reform, which like the projects themselves, is subject to a process of continuous improvement. In so doing, we have embraced a model for quality improvement of our fellowship experience that will undoubtedly serve us well throughout the remainder of fellowship and our future careers.
- Susan Francis Smith, PhD and
- Kim M. Fox, MD ()
RESPONSE: The Importance of Creating Infrastructure to Support Future Clinician-Educators
The definition of a “university” in the Oxford dictionary (1) is “an educational institution designed for instruction, examination or both, in many branches of advanced learning.” Curiously, in many medical schools, educators still lack a structured career development pathway, and much of the education is delivered by researchers whose primary interest lies elsewhere. Similarly, as discussed by Konerman and colleagues, university hospitals frequently expect clinicians, untrained in educational practice, to deliver teaching as an adjunct to increasingly high levels of service delivery.
It is therefore enormously encouraging to see fellows being empowered to define and create their own clinical-educator pathway within their fellowship, learning to become better clinician-educators through what an education specialist would describe as a “community of practice” (2). In their paper, Konerman and colleagues have analyzed the core elements that have made their endeavor a success, and in so doing, lay down a blueprint that can be translated into other settings. We absolutely agree with and applaud the model developed in this paper, which embraces a number of elements that would be recognized by an education specialist as excellent adult educational practice, including development of a learner-driven curriculum (3) and maintenance of a teaching portfolio (4).
The fundamental question is perhaps not what we should do, but how are we going to deliver it, both within the clinical and university contexts? At the National Heart and Lung Institute, Imperial College London (a department with approximately 75 full professors), we have very recently taken the step of setting up an education department in which we salary full-time educators (clinical and nonclinical) to deliver medical teaching. We intend to grow this department to develop a career structure so that our academics, who so choose, can major in education in the same way they can currently in research, and thus, contribute more meaningfully to the education of the next generation of doctors and specialists.
It is, perhaps, salutary to note that a supportive champion is integral to the success of both approaches. In the case of the clinician-educator pathway, it was the Fellowship Programme Director who created the supportive framework of dedicated education meetings essential to the sustainability of the venture, whilst in the case of the National Heart and Lung Institute it is the Educational Management Team empowered by the income derived by their teachers who are reinvesting in education specialists. We therefore close by encouraging all those readers who have the opportunity to support the growth and professionalization of medical education by whatever mechanisms suit their local environments.
- ↵Oxford dictionaries. Universities. Available at: http://www.oxforddictionaries.com/definition/american_english/university. Accessed November 28, 2015.
- Lave J.,
- Wenger E.
- Knowles M.S.
- Seldin P.,
- Miller J.E.,
- Seldin C.A.
The authors thank Dr. Peter Hagan for his extraordinary mentorship and the following faculty and colleagues for their contributions as project champions: Dr. Patricia Mullan, Dr. Cheryl Lee, Dr. Paul Fine, Dr. Sally Santen, Dr. Monica Lypson, Dr. Raj Mangrulkar, Dr. Prashanth Katrapati, Dr. Daniel Alyeshmerni, Dr. Michael Ghannam, Dr. Devraj Sukul, Chris Chapman, and the Harvard Macy Institute.
All of the authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Konerman and Alpert contributed equally to this work.
- American College of Cardiology Foundation
- Kern D.E.,
- Thomas P.A.,
- Hughes M.T.
- Halperin J.L.,
- Williams E.S.,
- Fuster V.,
- et al.
- Sinha S.S.,
- Julien H.M.,
- Krim S.R.,
- et al.
- Christensen C.M.
- Kotter J.P.