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INTRODUCT ION

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The Clinician-Educator—Present and Future Roles

illiam Osler was not the first clinician-educator,

but he established the tradition in North America.

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Interestingly, his students worked in the outpatient de-partment at Johns Hopkins University.

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They were ex-pected to evaluate and present their patients to Osler,and to follow them longitudinally. Osler appears to haveplaced great weight on the students getting to know theirpatients. Each student had a handful of patients andmade housecalls. On the inpatient services, a team of res-idents and students worked under Osler or a member ofhis staff. Residents were semipermanently employed, andwere more like junior faculty than the residents of today.Each resident had an assignment, such as work in thebacteriology or chemistry laboratory, or interpreting pa-thology specimens.

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If present-day generalists feel stretched,so it seems were their colleagues of a century ago, whowere expected to master fields now considered to be farseparated from internal medicine.

The system of learning from cases under the director-ship of a professor and his staff apparently replaced aloose apprenticeship system, and was consistent with theFlexner report. Osler’s system still remains in place, influ-enced by the pressures of modern practice. But the re-markable strength of this system reflects its core virtues.We postulate that these core virtues are principles ofadult learning, which is collaborative, involves activelysolving problems, and is readily applicable to the futurework of physicians. While medical learning over the fol-lowing decades became firmly hospital-based, shortenedlengths of stay with rapid turnover of patients in hospitalsare beginning to truncate this learning. New trends, how-ever, promise a new horizon, shifting the focus of learningto the outpatient setting. The trends, which seem inexora-bly in place, include treating the majority of everydaymedical problems cost-effectively within outpatient set-tings, the consequent expansion of outpatient practicesaffiliated with academic centers, and the availability oflarge numbers of clinical faculty as teachers. These arethe new clinician-educators, recruited to staff outpatientpractices. The trend toward generalism is also clearly inplace.

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Because the new practices are built around com-prehensive primary care delivered by generalists, themost pressing need is to train future generalists, not onlyin larger numbers, but also more comprehensively.

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Clearly, there are magnificent opportunities now to bringthe finest traditions of clinical teaching to the outpatientsetting. There are also formidable obstacles that must be

overcome. To a large extent, success depends on develop-ing faculty as clinician-educators to carry out this task.

WHAT IS A CLINICIAN-EDUCATOR?

We solicited definitions of the clinician-educator or“clinician-teacher” (we use the two interchangeably here,although “clinician-educator” could also have a broadermeaning, suggesting expertise in educational theory andpractice, in addition to hands–on teaching) from manysources. Although no consensus exists, the essence of alldefinitions includes the concept of a superior clinician,who is also a dedicated teacher. A clinician-educatormust be a superior clinician for several reasons. Impart-ing knowledge is a key attribute of teaching, so the clini-cian-educator must keep up with the literature. Clinicalskills are particularly important in the outpatient setting,and perhaps neglected in our current educational system.The clinician-educator must master skills that can betransmitted to students. Being a role model, setting agood example, is vital. To be less than knowledgeable orskillful undermines example setting. Humanistic qualitiesalso are important. The attitude of the teacher toward pa-tients, colleagues, and work profoundly influences stu-dents. On reflection, all agree that being a superior clini-cian is essential for clinician-educators.

Dedication to teaching is the second trait included inthe consensus definition. Here, there is disagreement be-tween those who would require substantial commitment toteaching time and those who accept any reasonable amountof participation in teaching. A common joke at some medicalschools, when the administration is asked to designate fac-ulty for teaching roles, is to “line up the usual suspects.” Weall recognize that until now a small number of dedicated in-dividuals have provided the bulk of teaching in many pro-grams. These individuals we call “old-style clinician-educa-tors.” They were clinicians part-time, perhaps only one dayper week, and leaders and organizers of educational pro-grams, as well as the principal teachers. Many new-styleclinician-educators spend the majority of their time inpractice, and might teach only 5% or 10% of the time. Thekey concept is dedication, taking teaching seriously. Wethink the clinician-educator of the future, whether spend-ing the majority or only a small component of time inmedical education, will need to work purposefully to ac-quire teaching skills, and especially to be mindful of thecomplex elements involved when interacting with learners.

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BARRIERS AND OPPORTUNITIES

Today, we appear to stand at a crucial point in thedevelopment of academic medical centers. Many aca-demic institutions are affiliating with or developing net-works of primary care physicians. The large number ofprimary care physicians being appointed to medicalschool faculties will help to fill the critical need for outpa-tient teaching. However, currently, the principal goal ofaffiliated networks is to serve as a base of patients for ac-ademic clinical programs. There may be synergies or in-consistencies between the goals of providing a patientbase, and of providing more outpatient teaching.

To learn the perceptions of those involved in these ef-forts, the Society of General Internal Medicine (SGIM)Council interviewed a sample of 52 clinician-educators,selected by convenience. This survey was designed to gainan understanding of the issues identified as important byclinician-educators. In fact, one important issue was theneed to clarify and define the role of the clinician-educator.Clinician-educators whom we interviewed felt that theirrole is poorly, if at all, defined—hence, the beginning effortsat suggesting a definition, as outlined above. Other issuesof importance include keeping clinically up-to-date, devel-oping teaching skills, getting academic recognition, beingpromoted, sustaining career satisfaction, working in themanaged care environment, and attaining economic goals.

The timeliness of these issues led to our creating thissupplement. Generalist teachers have been a core con-stituency of SGIM since its inception in 1978.

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Indeed,the earliest supplements of the journal were devoted ex-clusively to educational issues.

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A 1994 supplement onreaddressing the specialist/generalist imbalance againconsidered many training and curricular issues but alsobegan to examine the organizational, policy, and clinicalchanges occurring in academic health centers.

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Our sup-plement is interdisciplinary, as the issues currently af-fecting general internal medicine are also facing familymedicine, general pediatrics, and the primary care as-pects of gynecology. We aim this present supplement atclinician-educators, and at the physician leaders who em-ploy and support clinician-educators. It is meant to be apractical and useful summary addressing current issues.We hope it will lay the groundwork for future researchand analysis.

SUPPLEMENT SECTIONS

Keeping Clinically Up-to-Date

The movement toward

evidence-based medicine

is en-twined with the

primary care movement

. Generalists, whobroke ground to establish academic primary care, beganby studying the epidemiology of clinical problems, theusefulness of laboratory tests, and the effectiveness oftreatments. In fact, in the late 1960s when academic pri-mary care was born, there was little

evidence

behind theapproach to the preponderance of commonly encountered

outpatient clinical problems. Thus, it is fitting that Robertand Suzanne Fletcher begin this supplement with theirarticle on keeping up-to-date with the medical literature,stressing an evidence-based approach. Both the Fletchersand Frank Davidoff, who follows with his article on con-tinuing medical education, acknowledge the difficultiesfaced by practicing physicians, who are busy, need practi-cal input, and demand a high yield for investing their hard-won time and money in continuing education or readingjournals. The discussion by these three highly-knowl-edgeable authors brings some coherence to the surfeit ofcourses and literature available, and provides guidance tothe busy clinician. The evidence-based theme is contin-ued by Eric Larson, addressing how clinicians translaterelevant new research findings into practice, and by AlBerg, David Atkins, and Bill Tierney, who analyze practiceguidelines and discuss how to evaluate and keep up withthem. Thus, we move from the beginnings of primary careresearch in clinical epidemiology to the most current is-sues. Practice guidelines might not have been conceivable30 years ago when the evidence to support most practicewas minimal. Today’s clinician is fortunate to have themany research advances that permit a more rational wayof practice, but today’s clinician is challenged to be moreknowledgeable and more skillful in critical appraisal of re-search results and recommendations. This supplement’sfirst section aims at providing help for clinicians strug-gling with these challenges.

Teaching Skills

Teaching skills distinguish a clinician-educator fromother types of faculty. This section begins with practicaladvice from Steve McGee and David Irby, who combinetheir experience in teaching and educational research toprovide concrete suggestions for outpatient teaching.Readers of their article will become familiar with outpa-tient case presentations, teaching scripts, priming, mod-eling, delivering feedback, and teaching on rounds beforeor after clinic sessions. This article is followed by JackEnde’s article on inpatient teaching. Dr. Ende begins, asdid we, with Osler’s classic teaching rounds, and then ad-dresses the issues of the modern world—the purpose andfunction of teaching rounds, combining teaching with pa-tient care responsibilities, and essentially, how to be aneffective teacher in our time-pressured world. Craig Kaplan,Benjamin Siegel, Janet Madill, and Ronald Epstein ad-dress the teaching of communication skills. These au-thors discuss what skills are important, and where to goto improve one’s communication skills. Dr. Kaplan andcoauthors make the case for placing communication skillsat the center of one’s teaching and practice.

Faculty Development

Whether addressing outpatient, inpatient, or commu-nication teaching skills, faculty development lies at the

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Volume 12, April (supplement 2) 1997

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heart of all efforts to develop the clinician-educator’s role.It is the solution to the problems created by employing verylarge numbers of teachers in diverse settings with less timefor teaching. Otherwise, we would be in danger of reinsti-tuting an apprenticeship system with poor quality controls,rather than implementing the best traditions of clinicalteaching in the outpatient world. Kelly Skeff and coauthorspresent the rationale for faculty development and provide acompendium of effective programs available to generalists.

As care becomes more efficient and cost-effective, italso becomes more comprehensive. Generalists are chal-lenged to expand the scope of their practices. Tom Norrisand coauthors address the practical question of how weshould teach procedural skills to students, residents, andourselves, and which skills we should master and teach.Procedural skills pose a particular challenge for clinician-educators, who coordinate residency and medical studentteaching. Our programs need to be upgraded regardingthese skills, to prepare our students and residents for mod-ern outpatient practice.

Promotion and Recognition

SGIM has pioneered the development of guidelines forpromotion and tenure for clinician-educators. In the firstarticle in this section, Robert Lubitz reviews these guide-lines, which were developed by the SGIM Education Com-mittee. The Committee articulated guidelines and setstandards to reward clinician-educators for their scholar-ship, which is not limited to peer-reviewed publications,and for their multiple contributions to teaching. The arti-cle includes practical suggestions for developing a curric-ulum vitae for clinician-educators. No academic centercan afford to neglect the work of its teachers; they are thelifeblood of a medical school, and will determine thecourse of the next generation of physicians, who are fac-ing the most arduous challenges experienced by any gen-eration of physicians in modern memory. Academic recog-nition for generalist physicians continues to requirestrong advocacy. For example, a recently completed na-tional survey found that biases against primary care werestill pervasive among many faculty and leaders in aca-demic health centers.

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The articles by Holly Humphrey and colleagues andLucy Osborn et al. on institutional change and recruitingand retaining clinician-educators are meant to tap into theexperience of these authors at their institutions, whichmay be helpful to others in a changing time. The authorspresent case studies that highlight “lessons learned” fromfive institutions.

Career Satisfaction

The satisfaction of clinician-educators has seldombeen studied. Martha Gerrity and colleagues provide a con-ceptual model derived from the literature on career satis-faction among physicians in general, and postulate which

factors are particularly salient to clinician-educators. Thisarticle, focusing on the relation between teaching and sat-isfaction, will provide background for future studies, suchas the national survey being conducted by the SGIM Ca-reer Satisfaction Study Group to determine teaching andnonteaching issues that affect satisfaction. Interviews ofclinician-educators by the SGIM Council reveal satisfac-tion and dissatisfaction existing side by side, as clinician-teachers grapple with lack of recognition, difficult promo-tions, time pressure to practice and teach simulta-neously, an impossible amount of literature to read, andill-defined roles; while at the same time they benefit fromthe rewards of teaching and practicing in an era of pri-mary care expansion.

Managed Care

Jan Shorey, Andrew Epstein, and Gordon Moore arepioneers in developing a residency program within thecontext of managed care. These authors have the advan-tage of working within an old-line health maintenance or-ganization with well-established services and a large, sta-ble patient population. Their program is also affiliatedwith a highly esteemed teaching hospital. Many new pro-grams for teaching in the managed care setting may existwithin less stable, discounted, fee-for-service or point-of-service systems, which will pose added challenges. Les-sons learned by Drs. Shorey, Epstein, and Moore will be auseful contribution to the evolving literature on teachingin these new practice settings.

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Economics

Finally, we come to economics. Michael Adams andJohn Eisenberg address the cost of ambulatory educa-tion. They show a real and measurable cost of outpatientteaching. The bad news is that physicians who teach inthe office currently work longer days to offset expected in-come losses resulting from time spent teaching. These au-thors’ surprising conclusion that teaching residents costsmore than teaching students in an office practice iscounter to conventional wisdom, and to some of the litera-ture.

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The economics of teaching is crucial because,unlike research, which provides funding to institutionsfrom indirect costs, and unlike patient care, teaching gen-erates no income. Yet, teaching is the central mission ofevery medical school and residency program.

CONCLUDING COMMENTS

We have outlined many challenges, but we believe in abright future. The new millennium carries in a tide of sub-stantial changes for medical education.

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Academic cen-ters are assuming the responsibility to provide integrated,population-based care for large numbers of individuals inthe context of their families and communities. The general-ist clinician-educators qualified to do so are already arriv-

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ing in large numbers. Medical education has changed bythe very nature of moving to the outpatient setting. A qual-itatively improved curriculum for medical student and resi-dency training, capable of teaching more comprehensive,better coordinated, longitudinal care is needed.

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Faculty-development programs are essential. Teaching institutionscannot afford to fail to support their educational pro-grams, both spiritually and financially. This supplement ispublished early in this process. We have seen our taskmore as identifying obstacles and challenges, rather thansolving most of them. We have pointed out some obvioussolutions such as more stable funding for medical educa-tion. Yet, most of these articles reflect the practical experi-ence and wisdom of their authors, just as the practice ofgeneralists 30 years ago reflected the wisdom of previouspractitioners. We look forward to the next generation of cli-nician-educators, who will provide an evidence base for thefield and, we expect, will joyfully overcome its obstacles andchallenges.—

W

ILLIAM

T. B

RANCH

, J

R

., MD,

Department ofMedicine, Emory University School of Medicine, Atlanta, Ga.;

K

URT

K

ROENKE

, MD,

General Medicine Division, UniformedServices University of Health Sciences, Bethesda, Md.; and

W

ENDY

L

EVINSON

, MD,

Section of General Internal Medicine,University of Chicago (Ill.) School of Medicine.

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