Correspondence
Clinician-Educators in Academic Medical Centers
N Engl J Med 2000; 342:138-139January 13, 2000
- Article
To the Editor:
In describing the failure to integrate clinician-educators into the traditional academic milieu, Levinson and Rubenstein (Sept. 9 issue)1 have focused on the symptom, an outmoded promotions process, and not the underlying disease, the fact that excellence in teaching is undervalued and not the primary mission of most academic medical centers. Our data from one institution with a long-standing non-tenure track showed that winners of a “Teacher of the Year” award left the department sooner than nonwinners, even after adjustment for age, rank, and career track.2
Although medical education is the mission that sets academic medical centers and medical schools apart from other health care and research entities, the primacy of research is too much ingrained to be repaired by modification of the promotions process alone. Most, if not all, academic medical centers would point to their mission statements citing the importance of all three missions. The reality, however, is quite different, particularly at institutions whose deans and department chairs measure their quality according to the center's ranking in terms of funding by the National Institutes of Health. Members of medical-school faculties are socialized into a value system in which scholarship, narrowly defined as research, especially if it is funded by the National Institutes of Health, is more highly valued than teaching or clinical work. Moreover, the costs of both research and medical education have been subsidized by clinical income; much teaching consists of unreimbursed contributions of time and effort by those who will not receive recognition in the current system.
Establishing organizational systems that support clinical care and teaching, as suggested by Levinson and Rubenstein, would require a major change in both the financial underpinnings and the value system of academic medicine. We question whether those who have benefited from the current system and continue to have a stake in its preservation are willing to cede its perquisites, much less provide the leadership necessary for the transformation of academic culture.
2 ReferencesDavid C. Aron, M.D.
Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH 44106John N. Aucott, M.D.
Park Medical Group, Lutherville, MD 210931
Levinson W ,Rubenstein A . Mission critical -- integrating clinician-educators into academic medical centers. N Engl J Med 1999;341:840-843
Full Text | Web of Science | Medline2
Aucott JC ,Como J ,Aron DC . Teaching awards and departmental longevity: is award-winning teaching the “kiss of death“ in an academic department of medicine? Perspect Biol Med 1999;42:280-287
Web of Science | Medline
To the Editor:
The recommendations of Levinson and Rubenstein regarding integrating clinician-educators into academic medical centers fail to address the changing role of tenure in academic medical centers. Eliminating requirements for a regional or national reputation and publication in peer-reviewed journals for clinical-track promotion will send the not-so-subtle message that nontenured clinicians have less value than their tenured research-track colleagues, despite the observation that the degree of financial risk to an institution is probably less with respect to clinicians than to scientists.
Although expectations for clinician-educators and investigators may reasonably be different, a two-tiered system with different rewards promotes elitism and conflict. Clinicians as well as investigators may be intimidated by the lack of academic security. It is time to level the playing field: either tenure should be available to clinicians, or investigators should share the same risks of continued performance on a nontenured basis as their clinical colleagues.
Paul D. King, M.D.
University of Missouri–Columbia, Columbia, MO 65212To the Editor:
Levinson and Rubenstein make a plea for strengthening the clinician-educator track by eliminating the need for a regional or national reputation and the need to publish. My own institution was one of the first to be founded on the premise of training doctors who “not only sail by the old charts, but who can make new and better ones for the use of others.”1 To do so, one ideally should submit written evidence that bears up under public scrutiny and trial. To do so by local oral tradition may inadvertently perpetuate outdated parochial landmarks. Students find important validation in knowledge derived from clinician-educators who can profess not only at the bedside, but also to the world at large.
Levinson and Rubenstein, however, rightly decry the overemphasis on the making of charts that increasingly seem to be designed more for self-promotion than for the use of others. For it is in the clinical use of knowledge that its effectiveness and accuracy can be tested, mid-course corrections made, and once again another newer and better way found. Moreover, only appropriately charted care can lead to the relief of human suffering, which should be a major goal of all academic medical centers. Ultimately, institutions that promote the science and not the teaching of the art of medicine will train doctors who care little about the use of charts by others. Therefore, a resolution to the current economic pressure to deliver more care is not to relax high academic standards, but rather to strengthen our commitment to clinical scholars, who test the current charts so that new and better ones can be made.
1 ReferencesPhilip L. Smith, M.D.
Johns Hopkins University, Baltimore, MD 21224To the Editor:
Traditionally, promotion has been the reward for excellence in whatever one does at an academic institution. Because research has tangible results, in the form of papers, it has always been easy to document the progress and evaluate the excellence of those involved in research. Though it is harder to do this for teaching, it can and should be done. Teaching portfolios and teaching awards definitely have their place in documenting activity and, one hopes, excellence. Developing new and innovative ways of teaching are clearly important, but these methods must be disseminated. It is here that I disagree with Levinson and Rubenstein that a national reputation should be unnecessary. Going to meetings and presenting ideas is the only valid way of discerning whether or not new methods can actually have useful, long-term effects. Writing book chapters, books, and articles and speaking at meetings are all ways to teach. Even presenting old ideas in new ways is a form of teaching. To look at it from a researcher's point of view, what good is discovering something new if no others hear about it or try to use it themselves?
Saundra E. Curry, M.D.
Columbia–Presbyterian Medical Center, New York, NY 10032Author/Editor Response
The authors reply:
To the Editor: We agree with the correspondents that the clinical and teaching missions of academic medical centers should be valued equally with the research mission. Changing promotion criteria for clinician-educators is necessary to evaluate the contributions of these faculty members properly. The result will be two sets of expectations, each tailored to the job descriptions of different and complementary faculty members — investigators and clinician-educators. We believe that two tracks for promotion can be equally valued rather than present a situation in which one track is less prestigious than the other. Alternatively, these two sets of clearly defined expectations can be incorporated into a single-track system. Commitment on the part of leaders will be necessary to make this happen.
Dr. Curry raises the important point that scholars should develop new teaching methods and study their effectiveness. She suggests that these scholars should disseminate their work nationally. We agree that rigorous scholarship pertaining to medical education is needed to advance the science of the field. However, faculty members conducting research on medical education will need to devote the majority of their time to this research and will not be able to spend 80 percent of their time on clinical care and teaching, as clinician-educators do. Innovative science in any field, including medical education, requires a major commitment of time and effort.
Wendy Levinson, M.D.
University of Chicago, Chicago, IL 60637Arthur Rubenstein, M.B., B.Ch.
Mt. Sinai School of Medicine, New York, NY 10029- Citing Articles (1)
Citing Articles
1
Robert R. Kempainen, Edward F. McKone, Gordon D. Rubenfeld, Craig S. Scott, Mark R. Tonelli. (2004) Comparison of Scholarly Productivity of General and Subspecialty Clinician-Educators in Internal Medicine. Teaching and Learning in Medicine 16:4, 323-328
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