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Abstract
Background Residents in internal medicine programmes lack formal training in leadership, curriculum development and clinical teaching. Residency programmes created clinician-educator tracks (CETs) to formally teach residents to become effective educators and to involve them in the science of medical education. However, the curricula in these tracks are often locally developed and remain at the discretion of the individual programmes.
Methods This survey evaluates the frequency of CETs in internal medicine residency programmes in the USA and descriptively analyses their logistical and curricular content. During the academic year 2017–2018, directors of all Accreditation Council for Graduate Medical Education (ACGME) accredited internal medicine residency programmes in the USA were invited to participate in this survey (n=420). We developed a web-based 22-question survey to assess the logistics and curricular content of CET programmes.
Results A total of 150 programmes responded to the survey invitation (response rate=35.7%). Only 24% (n=36) of programmes offered a CET, the majority of which have been available for only 5 years or less. The track is most frequently offered to postgraduate year (PGY)-2 and PGY-3 residents. Only a minority of participating faculty (27.8%) have protected time to fulfil their CET role. Bedside teaching, feedback, small group teaching and curriculum development are the most commonly taught topics, and faculty mentorship and small group teaching methods are the most commonly used types of instruction.
Conclusions CETs are offered in only 24% of internal medicine residency programmes in the USA. The curricula of these tracks vary across programmes, and their success is often countered by logistic and financial challenges.
- medical education & training
- internal medicine
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Introduction
Many medical schools have clinician-educator promotion tracks for faculty, but often the criteria for these career tracks lack clarity, faculty receive little guidance or formal preparation for their professional responsibilities and may not understand how to achieve the promotion criteria. Over the past decade, some internal medicine residency programmes have developed clinician-educator tracks (CETs) for house staff interested in future careers as clinician-educators, a role that includes being a teacher, curriculum developer, administrator, mentor, coach, advocate and scholar. Despite the rising demand for clinician-educators, residents often lack any formal training in teaching, curriculum development or educational research.1–3 This created the unmet need to teach residents new skills related to medical education that have not been a part of their traditional clinical training. In internal medicine, CETs within residency programmes have been developed to address the shortage of resident teachers and to offer residents a systematic and dedicated approach to educational scholarship, curricular development, leadership and research in medical education.4 5
Over the past decade, CETs have proven to be successful and have therefore been increasingly popular.6 Nonetheless, these tracks vary substantially and are not standardised across residency programmes. CETs are incorporated at various times during residency and fluctuate in their focus, format and methods for instruction. Some programmes are highly focused on creating clinician-educators committed to medical education scholarship, while some are more focused on clinical and bedside teaching skills. Methods of information delivery are also variable and often include either small group discussions, webinars, journal clubs, lectures, bedside teaching or a combination.
While CETs are one of the most important trends emerging in graduate medical education, it remains unclear how many internal medicine residency programmes offer this type of track and how these tracks are being delivered to residents.7–9 We conducted a nationwide survey of all ACGME-accredited internal medicine residency programmes in the USA to better assess the types of programmes that offer a CET, as well as to evaluate the logistical and curricular content of these programmes.
Methods
Study participants
During the academic year 2017–2018, directors of all ACGME-accredited internal medicine residency programmes in the USA were invited to participate in this study via email (n=420). All participants were informed that their participation was voluntary. Consent was voluntary and considered to be implied on participation. All surveys were web-based and confidential. No individual subject identifiers were collected. The Institutional Review Board at Tufts Medical Center evaluated this study and exempted it from review.
Survey instrument
The authors developed a web-based 22-question survey that primarily focused on assessing the logistics and content of the CET pathway, namely, eligibility of participation, faculty roles and time allocation (online supplementary appendix 1). There were also questions regarding topics of instruction, types of delivery, scholarly activity offerings, and evaluation and outcome measurement methods. In addition, the survey addresses challenges pertaining to initiating or maintaining CET in residency programmes. We sent up to five reminder surveys to non-responders over the course of 5 weeks.
Supplemental material
Statistical analysis
Data were expressed as frequencies and percentages for categorical variables, means±SD for parametric continuous variables and median with IQR for non-parametric continuous variables. All tests were double-sided. A p value <0.05 was considered to be significant. All statistical analyses were performed using Stata V.13 (StataCorp LP, Texas, USA).
Results
Of the 420 US internal medicine residency programme directors who received the survey, a total of 150 responded (response rate=35.7%). The majority of respondents were from the Northeast region (36%), whereas only 17.3% were from the West. Eighty-five per cent of respondents were programme directors at a university hospital or a community hospital with university affiliation. The geographical distribution of the respondents and the hospital types were statistically similar to that of non-respondents (table 1). Compared with non-respondents, respondents generally belonged to larger programmes (72.5±43.0 residents among respondents vs 57.3±36.4 residents among non-respondents, p=0.001) and had significantly fewer international medical graduates (p=0.003).
Characteristics of the surveyed internal medicine programmes
CET eligibility and description of the track
Among all respondents, a CET was available in 24% (n=36) of the programmes. Table 2 shows the overall general characteristics of CET programmes across the USA. The majority (83.3%) of these programmes had been available for 5 years or less. Among the programmes that did not offer a CET (n=114), 19 (16.7%) were actively in the process of developing a track at the time of survey completion. One programme reported previously having a CET, but the track was no longer offered due to lack of interest among residents. In addition, 10 programmes did not offer a track because they thought their residents would not be interested in participating in this type of track. Among the remaining 84 programmes, the absence of a CET was attributed to either lack of available time among faculty or the programme being too small to accommodate the track.
General CET characteristics across the USA
The majority of CET programmes had an application process (69.4%), with 84% applying during intern year. In one programme, the track was offered only to PGY-3 residents, and in another programme, the track was offered after the completion of PGY-3. The number of residents per year was variable, ranging from 1 to 29 residents, and largely depended on the size of the residency programme. In almost all programmes (97.2%), the track was offered throughout residency over a period of 18–36 months. The majority of programmes (69.4%) provided residents with protected time to participate in the track either as protected hours during the week or as a protected elective block. Notably, one-fifth (19.4%) of these internal medicine CET programmes offered the track to non-internal medicine residents, such as paediatrics, medicine-paediatrics, neurology or even fellowship programmes, within the hospital.
CET faculty and methods of operation
The CET director was an associate programme director (27.8%) or core clinical faculty (30.6%) in the majority of programmes (table 2). In 69.4% of the programmes, the track directors had protected time to fulfil their role, and this often ranged widely from 5% to 25% protected time. The number of participating faculty also ranged from 1 to 20 members per programme, but only a minority of faculty members (27.8%) had protected time to fulfil their CET roles. CET faculty roles included career adviser (11.1%), scholarship mentor (38.9%) or teaching coach (41.7%), and the faculty performed all three roles in 58.3% of programme.
Logistical challenges, namely, space availability and technical support, were the most commonly reported challenge that countered maintaining CET pathways in programmes (55.6%). This was followed by the lack of protected time for faculty (52.8%), lack of protected time for residents (41.7%), lack of administrative support (41.7%) and finally lack of financial compensation for faculty (36.1%).
Topics and types of instruction
The frequencies for topics of instruction are shown in table 3. Overall, bedside teaching, feedback, small group teaching and curriculum development were the most commonly taught topics in CETs, whereas teaching with social media, time management and negotiation skills were rarely taught. Compared with qualitative and quantitative research designs, teaching of mixed methods research design was less frequent (27.8% and 19.4% vs 11.1%, respectively). Among the vast majority of programmes, faculty mentorship and small-group teaching methods were the most commonly used types of instruction (97.2% and 88.9%, respectively), whereas only rarely did programme use half-day retreats (13.9%), full-day retreats (5.6%) or webinars (5.6%) as types of instruction (table 3).
Frequency of the types of instruction and topics taught in the track
Resident evaluation
Evaluations by faculty observing residents were more common than peer-to-peer observations among residents (table 4). In particular, the frequency of faculty observing residents was higher than peer-to-peer observation for the following: bedside teaching, teaching and providing feedback to interns and medical students, providing feedback to peer residents and attending physicians, and leading morning report. When asked about either mandatory or optional scholarly activities offered to residents, 88.9% reported educational research as an option, 88.9% offered presenting at medical education professional meetings, 86.1% offered a capstone medical education project and 77.8% offered attendance to medical education professional meetings, whereas only 55.6% offered writing a review article and only 41.7% offered presenting at grand rounds.
Frequency of faculty versus peer observation of residents in clinical setting
With the exception of one programme, all CET programmes evaluated the participating residents. Faculty observation of residents with formative feedback was the most common method of evaluation (77.8%) followed by resident self-assessment after the track (75%), faculty evaluation of residents’ learnt knowledge, skills or attitudes after the track (47.2%), and educational portfolio (47.2%). Less commonly, residents were evaluated using peer-to-peer observation with formative feedback (27.8%), faculty observation without feedback (13.9%), peer-to-peer observation without feedback (11.1%) and objective structured teaching evaluations (8.3%).
Measured programme outcomes
The most commonly measured programme outcome was the development of educational resources, such as handouts, cases or curriculum development (66.7%) followed by coauthorship of medical education publications (52.8%), and scholarly presentations at professional meetings (41.7%). Long-term outcomes were also measured fairly frequently, such as evaluation of teaching performance by learners (41.7%) and educational leadership, such as becoming chief resident or clerkship director (41.7%)
Discussion
This nationwide survey about CET programmes in internal medicine residencies demonstrates that approximately one-fourth (24%, n=36) of responding programmes offers a CET, the majority of which are relatively new and have been available for only 5 years or less. Interestingly, 75% of residents have no access to CETs in their residency programmes, but the majority are still expected to be educators despite not being offered any formal training in education scholarship. The majority of programmes recognise the advantages of CET programmes during residency, but there continues to be a mismatch between acknowledging these potential benefits and developing an actual CET programme for residents. Realistically, however, it is challenging to ascertain the root cause for this mismatch. This survey suggests that logistic support, such as space availability or technical help (including availability of staff, classroom space, computer availability and information technology support), as well as the lack of protected faculty time and financial limitations, preclude the development and maintenance of these tracks and are often obstacles to developing more robust CET programmes. To date, however, there are insufficient data in the literature to suggest that increasing either institution-level or federal-level financial and logistic support truly changes outcomes.
This survey also highlighted the substantial variability in CET regarding the eligibility and timing of applications, topics and types of instruction, and methods of evaluation. This survey demonstrates that the application to CET programmes in internal medicine usually occurs during the PGY-1, and participating PGY-2 and PGY-3 residents have 2 years to complete their CET educational requirements. This, however, may be different from other programmes. For instance, in one radiology programme, their CET starts at the beginning of the second half of PGY-1, and participants then have one or two additional years during residency to finalise their educational and research requirements.10 Among psychiatry residents, one programme dedicates as much as 20% of resident time during PGY-4 for CET, including extensive medical student education, designing curricula, orientation and clinical teaching.8 11 Resident participation is often incentivised by having this experience culminating in the title of chief resident for medical education to further emphasise education as a commitment and career objective.8 11
The development of a successful CET programme across the nation remains an important unmet need for internal medicine residency programmes. Based on the results of this survey, we hypothesise that the development of a cost-effective, replicable and standardised, yet flexible, CET programme for internal medicine residency programmes may be a feasible strategy to grow CET nationwide. A standardised curriculum could overcome issues related to the planning of creating a CET programme. As financial limitations for running these programmes remain a cornerstone for their lack of development, a pre-existing standard curriculum may cut costs and time needed to fulfil this requirement.
This study was limited by its sample size due to the response rate of 35.7%. Although the respondents and non-respondents have statistically similar geographical distribution and frequency of hospital types (ie, community, university affiliation, university or military), they differ in the total number of residents and the number of international medical graduates within each programme. Also, this study has a survey design that may, at times, evaluate subjective and non-validated data solely based on the reported answers. Furthermore, the survey evaluates the availability of CET in internal medicine programmes but does not track progress within individual programmes over time or address how these programmes are evolving over time. Finally, although it evaluates the attitudes and nationwide trends for CET programmes, this survey does not address curricular or extracurricular outcomes following the introduction of these CET programmes.
Conclusions
Of the 150 internal medicine residency programmes that responded to our survey, only 24% of internal medicine residency programmes in the USA offer a CET. Bedside teaching, feedback, small group teaching and curriculum development are the most commonly taught topics, and faculty mentorship and small-group teaching methods are the most commonly used types of instruction. The curricula of these tracks vary substantially across programmes, and their development, as well as their maintenance, is often countered by logistic and financial challenges. Programmes like these are novel and are rapidly evolving. Although research on the effectiveness of these pathways is still limited, it is one of the most important trends emerging in graduate medical education.
Main messages
Only 24% (n=36) of internal medicine residency programmes offered a CET, the majority of which have been available for only 5 years or less.
Current research questions
Bedside teaching, feedback, small group teaching and curriculum development are the most commonly taught topics, and faculty mentorship and small group teaching methods are the most commonly used types of instruction.
What is already known on the subject
The frequency of CETs in internal medicine residency programmes in the USA is unknown.
The logistics and curricular content of CETs in residency programs are largely unknown.
Despite the rising demand for clinician-educators, residents often lack any formal training in teaching, curriculum development or educational research.
Internal medicine residency programmes have developed clinician-educator tracks (CETs) for house staff interested in future careers as clinician-educators.
Footnotes
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Contributors YD designed the study, communicated with the institutional board review, performed statistical analyses, revised the manuscript and submitted the study. AL conducted the survey, collected data and synthesised the first draft of the manuscript. KV conducted the survey, collected data and synthesised the first draft of the manuscript. LKS conceived the study hypothesis, created the survey, designed the study and revised the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request. Requests may be made to the corresponding author, Dr Laura K. Snydman via email: lsnydman@tuftsmedicalcenter.org.