The above scenario depicts some of the demands that clinician-educators face in today's academic medical centers. The increasing number of physicians who are joining college faculty as clinician-educators parallels the structural changes of contemporary health care organizations that have expanded delivery of care in primary care settings. Although the shift of patient care and education to outpatient settings makes the expanded role of clinician-educators necessary, it presents a dual challenge to the medical community. First, to serve their academic affiliates effectively, clinician-educators must meet the professional demands of both teacher and clinician in a changing care-delivery system. In turn, academic institutions must allocate sufficient resources to support clinician-educators in meeting the demands of their work. The challenge to institutions becomes particularly daunting in the face of current emphasis on "bottom-line" performance. In this article, we describe and propose solutions to some of the problems surrounding clinician-educators today.

Background

Because the American Association of Medical Colleges (AAMC) Faculty Roster does not collect specific information that differentiates clinician-educators from other faculty members, it is difficult to know exactly how many clinician-educators are now members of medical school faculties. In 1991, the AAMC estimated that 83 medical schools (74% of survey respondents) had instituted an advancement ladder that emphasized clinical and teaching contributions [1]. A recent survey of promotion-committee chairpersons of the 142 medical schools in Canada and the United States found that of the 115 responding schools, 45% had a separate promotion track for clinician-educators [2]. At the University of Chicago Medical School, the number of clinician-educators in the department of medicine alone increased from 20 in 1986 to 73 in 1996 while the number of faculty in other tracks remained relatively stable [3].

Although there is considerable variation among institutions, three predominant models of clinician-educators exist. These models differ in the proportion of time allocated to direct patient care, the amount of protected time available for research and teaching, and the extent of leadership responsibilities for educational activities (Table 1). The first model (C-E) characterizes full-time clinical faculty at academic medical centers. These faculty spend approximately 50% of their time seeing patients (often with students) and the rest of their time organizing and implementing teaching activities. The second model (C-e), an offshoot of the first, has developed because of pressure for teaching institutions to generate more clinical revenue. Physicians who fit this model spend most of their time (often 75%) seeing patients and the rest supervising students and residents. The third (clinical associate) model describes clinicians who spend almost all of their time seeing patients but commit some time to teaching. These physicians may have students or residents come to their offices or may teach history taking or physical examination skills. Some medical schools have used volunteer physicians in private practice to fill this role, and these persons have now become members of medical school faculties. The word "clinical" is often used in their title, distinguishing them from traditional full-time academic faculty.

Challenges to Clinician-Educators

Scope of Work

Clinician, administrator, educator-the very scope of these three disparate and changing roles challenges clinician-educators [4]. Many of the challenges are similar for primary care physicians and their subspecialty colleagues. Both groups are under intense pressure to maximize clinical revenues by seeing more patients. Financial incentives now encourage primary care providers to care for most of their patients' needs; as a consequence, many clinician-educators increasingly manage problems that previously fell within the domain of a specialist. In the inpatient setting, the clinician-educator plays a critical role in the judicious use of hospital resources by managing appropriate critical pathways and coordinating plans for outpatient care after discharge. Clinician-educators must efficiently coordinate a system of care that uses the hospital for a brief period but relies more heavily on the outpatient setting and home care than it has in the past. Furthermore, managed care delivery requires better data management, understanding of the requirements of various financial arrangements, and implementation of new systems for utilization management [5, 6]. To accomplish most of these tasks, physicians are often required to provide leadership to other faculty physicians, who are now being asked to change the way they conduct patient care [7].

Clinician-educators are the main supervisors for students and residents on the inpatient wards and during month-long ambulatory rotations and longitudinal ambulatory training. In addition to providing supervision, clinician-educators provide didactic teaching for students and residents. Typically, they organize and present lectures or teaching sessions on basic skills (for example, history taking, physical examination, and clinical reasoning) and ambulatory care topics. Clinician-educators also serve as mentors and advisors to students and residents. A growing number of graduates are pursuing careers as generalists, and students are seeking career advice from faculty who are practicing primary care [8].

Developing and Maintaining Skills

The Society of General Internal Medicine interviewed a convenience sample of 54 clinician-educators in general internal medicine to identify what they perceived to be the key attributes for fulfilling their role [9]. Respondents reported that they particularly needed to master skills in such areas as curriculum development and evaluation, time management, and managed care (for example, resource management and team management skills). In addition, they reported a need to develop teaching skills in various environments and to keep clinically up to date by evaluating new advances and incorporating them into their practice. Concerns about teaching skills and curricula are unique to physicians who define their role as teachers. The other needs are experienced by all practicing physicians but may be particularly important to physicians whose jobs include teaching students the most up-to-date information and modeling skills of life-long learning.

Teaching

Clinician-educators must adapt their teaching styles to several settings, including bedside rounds [10], the classroom, and the clinic or office. Particularly because of the implementation of recent Medicare regulations that require direct supervision of residents' work and careful documentation, clinician-educators need information about effective and efficient ways to teach in outpatient and inpatient settings [11]. Clinical associates who teach primarily in their offices need to know how to incorporate students into the flow of a busy practice. In the academic clinic, clinician-educators need to supervise residents while maintaining and encouraging the primary relationship between the resident and the patient.

Curriculum Development and Program Evaluation

Several monographs [12-14] have described the ways in which clinician-educators may be called upon to develop and implement various new curricula, including ambulatory rotations designed to teach the knowledge, skills, and attributes that are pertinent to office practice. Clinician-educators often lead newly developing courses in content areas that are not covered by subspecialists, such as adolescent medicine, evidence-based medicine, advanced interviewing skills, and diagnosis and management of common primary care problems. Often, this is the first time that a clinician-educator has developed the goals, content, materials, or evaluation strategies for an educational course. Some medical schools have departments of medical education that can offer assistance in this area, but many clinician-educators have to learn on their own.

Keeping Current

Clinician-educators need to learn efficient strategies for scanning the medical literature and judging the quality of the evidence it presents [15]. Although there are many opportunities for continuing medical education, busy clinicians need to be highly selective [16]. These teachers want to have current information when treating patients, but they also want to be able to teach students how to keep up to date in the future.

Skills in Medical Practice

Clinician-educators, particularly those who completed their training more than 5 years ago, are sometimes called on to teach various clinical and management skills that they never learned themselves. In the clinical setting, primary care physicians are more frequently caring for the needs of their patients in areas outside of internal medicine, such as gynecology, orthopedics, and dermatology. Clinician-educators may need to learn how to perform simple, specific office procedures in these areas in order to provide clinical services for their practice group and serve as the designated teachers of these skills [17, 18].

Besides teaching clinical skills, clinician-educators need to teach skills that are pertinent to managed care, including determining the most cost-effective treatment for common problems, working effectively with nurse practitioners or other members of the extended health care team, and developing systems to provide preventive care to patients served by their practice group [19].

Time Management Skills

Clinician-educators face intense, competing demands for the time they devote to curriculum development, direct teaching, and supervision. They are also see more patients in less time. As a result, they consult other medical teachers and business colleagues about time management strategies. For example, discussions on time management were incorporated into courses for clinician-educators at the 1997 annual meeting of the Society for General Internal Medicine.

Skeff and colleagues [20] recently reviewed the potential resources for faculty development, which encompass the skills described above. Possibilities include fellowships in general medicine, national and regional faculty development programs ranging from 1 week to 1 month, and programs provided by medical organizations at national meetings. A growing number of medical schools are developing local resources to provide faculty development for clinician-educators [21, 22].

Challenges to Institutions

Academic medical centers face fundamental questions. How do faculty members who see patients and teach but do not do research fit into the overall faculty environment? How should they be promoted and in what tracks? How can institutions incorporate a teaching mission into their new outpatient facilities and, at the same time, make these facilities financially viable? To answer these questions, academic institutions must examine longstanding values and make necessary changes in operating procedures.

Promotion

The promotion process is an important way for academic medical centers to demonstrate the worth of a faculty member. Many schools have developed new pathways with such titles as clinician-scholar or clinician-educator; other schools have not formally approved new promotion pathways [2]. Often, new promotion pathways are untested, particularly in the high ranks, and faculty on the promotion committees are inexperienced at evaluating the work of clinician-educators. Although it seems most appropriate to judge clinician-educators on the quality of their clinical work and teaching, many medical schools insist on research or publication. Thus, clinician-educators who are superb teachers must also contribute scholarly work, which may mean writing chapters, review articles, or other pieces that are related to teaching. A recent survey of chairpersons of medical school promotion committees found that these committees consider teaching skills and clinical skills to be the most important factors when evaluating a candidate for promotion but have few objective ways to measure the quality of these skills [2]. Most schools require C-E faculty members to publish a minimum number of articles (mean, 5.7) in peer-reviewed journals before they are promoted to the associate professor level. Rigid requirements may place unrealistic expectations on clinician-educators, who must devote significant time to meeting clinical responsibilities outside of the scheduled hours of patient care. Furthermore, many clinician-educators have neither the skill nor the mentorship that is necessary to write and publish papers.

Career Development

For many clinician-educators, promotion is not necessarily the most important show of support that an academic institution can offer. Clinician-educators often value protected time for their professional development more than advancement in academic rank. This is not to say that delayed promotion is a good idea. On the contrary, proper attention to career development facilitates promotion and creates a harmonious system. Career development should encompass a genuine effort on the part of departmental and divisional leadership to carefully nourish and encourage growth of the faculty as teachers, educators, clinicians, program leaders, and academicians current in knowledge and skills and grounded in the values and ethics of the medical profession. Institutions are challenged to support not only the faculty development process but also, more important, time away from patient care to participate in ongoing learning.

Culture

Although promotion and career development barriers may present the most tangible obstacles to academic recognition for clinician-educators, subtle yet pervasive attitudes may also foster division among traditional and newer types of faculty. A national survey showed that biases against primary care and generalist clinicians still prevail among most academic health center faculty and trainees [23]. In some institutions, generalist and subspecialist faculty in clinician-educator tracks do not have the same privileges or benefits (including financial compensation and eligibility to participate in governance) as do colleagues in the traditional research and scholarly tracks. These differences may lead to a sense of "second-class citizenship" for clinician-educators.

Financial Challenges

Academic institutions are also challenged to develop new financial arrangements to pay for faculty teaching in the outpatient setting. Although institutions hire faculty to provide primary care in facilities affiliated with the medical center, they also need these same faculty members to teach in these settings. Federal funding does not support the teaching costs of many of these community facilities. This leaves academic centers supporting the costs of training students or residents at sites both near and far from the main campus. "Relative value scales" for teaching time [24] and other creative financing systems are being explored in the United States [25, 26] and other countries [27, 28]. Overall, it seems that training residents is financially a "break-even" operation, whereas teaching students in the outpatient setting is costly [29].

Diversity

Because of sex and geographic diversity, institutions must explore alternatives to conventional methods of operation. A growing number of new clinician-educator faculty are women who serve as important role models and mentors to many female medical students. However, the increasing number of women faculty also challenges traditional faculty models [30]. For example, institutional investment in women's careers requires flexibility in scheduling because many women who are raising young children while developing their academic careers do not want to work full-time [31].

Because more academic medical centers are located in the community, many clinician-educators are based in off-campus sites. Placing faculty at settings that are distant from the main campus creates logistic constraints for institutions, educators, and students. Peers, colleagues, and teachers are no longer readily accessible for consultation or instruction, as they would be in a centrally located learning environment.

Solutions

To begin to find solutions, academic medical centers should develop a comprehensive plan for facilitating career development of their faculty members, especially clinician-educators, whose contributions have often been undervalued. Regular mentoring, assessment of individual faculty goals, assistance and encouragement in meeting these goals, and an outline for career development should form the foundation of these plans. For clinician-educators, faculty development efforts may focus on providing opportunities to improve teaching methods. The movement of medical education to the outpatient setting and the increasing number of new faculty present a need for faculty development programs that will "teach teachers how to teach" [32-35].

Institutions must demonstrate that they value teaching by assessing faculty efforts carefully and giving regular and detailed feedback. Ideally, that assessment would be coupled with an ongoing program to improve teaching skills. This program would create a cycle of opportunities to practice those skills, followed by intensive periods of reflection and feedback and the practice of more advanced skills.

The advancement of a faculty member from junior to mid-level status is a crucial time for faculty development. At this point, institutions may realize the fruits of their investment. Appropriate advances in skills, knowledge, and abilities should accompany a faculty member's advance to mid-level status. Too few institutions have invested sufficiently in the growth and development of junior faculty to realize the enormous gains for medical education and patient care that occur 5 to 7 years after these faculty members have completed their training.

Institutions should also focus on developing the patient care skills of their clinician-educator faculty. Again, such development should follow careful attention to the assessment of clinical work and provision of feedback and learning experiences. Awards may be given not only for excellence in teaching but also for excellence in clinical practice. Then, at the appropriate time, the institution should recognize the contributions of its clinician-educators through academic promotion.

Ultimately, institutions need to demonstrate that they value both the clinical and the educational work of faculty. Division chiefs, department chairs, and deans must give faculty members time to develop and implement high-quality educational programs for students and residents. These activities do not preclude the generation of clinical revenue but reinforce the broad mission of academic institutions. Because academic medical centers must compete in the academic as well as in the health care market, they must balance clinical productivity with the highest-quality educational effort.

New funding mechanisms for education are essential. Some of these mechanisms include shifting a proportion of Medicare graduate medical education funding to the teaching units, taxing for-profit health care organizations, and developing teaching consortia where many graduate medical education programs in a given community collaborate in residency training [36, 37]. Private foundations, such as The Pew Charitable Trusts in Philadelphia, Pennsylvania, are encouraging medical schools and insurers to work together and develop medical education programs that will better prepare graduates for work in the managed care environment. Clinician-educators will play a central role in this transformation.

Learning at a distance through technological methods, such as video conferencing and sophisticated computer networks (the latter not only for rapid communication by e-mail but also for sending radiographic images and laboratory data), offers links with off-campus teaching sites. At a certain point, however, there is no substitute for direct, face-to-face interaction to strengthen working relationships and support the development of professional skills. For example, at Emory University, site coordinators for primary care residency training in the network's larger internal medicine practices will spend half a day or more per week on the central campus, working with the curricular development group for the residency and participating in teaching activities [38]. Such simple reorganization requires the investment of time and funding in the career development of community faculty who are leaders of medical education at their sites. Hence, although it places logistic strains on the medical center, diversification of sites may ultimately strengthen educational programs if synergies between campus and community-based sites are fully explored [39, 40]. Community-based programs are themselves not immune from financial pressures, but the effort to overcome those pressures seems worth it because their perspective provides a unique opportunity for partnership [41].

Finally, professional associations should continue to serve as a resource to clinician-educators and institutions. Some already offer hands-on guidance in dealing with the challenges that clinician-educators and institutions confront. The American College of Physicians [42] and others [43-47] have developed tools for office-based teaching.

The Society of General Internal Medicine has published guidelines, which can be adapted to the needs of specific institutions, for the promotion of clinician-educators [48]. Individual schools have also reported innovative approaches to academic advancement [49, 50]. Professional organizations are ideally suited to disseminate such experiences through national meetings and local educational forums.

Conclusions

We anticipate that the changing medical environment, with its profound shift to outpatient care and ambulatory education, will lead to an increasing number of clinician-educators of all types on academic medical school faculties. As institutions and individual persons experience the growing pains associated with the development of these new jobs and systems, clinician-educators will gradually make up more of the faculty mainstream. There is a pressing need to create high-quality faculty development programs that will prepare clinician-educators to do their jobs well. Inclusion of these clinician-educators also offers institutions new opportunities, including a broadening of the patient population available for teaching purposes and an increase in the ability to do community-based research. Clinician-educators are likely to be the leaders in transforming academic medical centers into health care facilities that are prepared to provide high-quality, cost-effective clinical care and teaching.

Dr. Branch: The Emory Clinic, 1365 Clifton Road, Atlanta, GA 30322.

Dr. Kroenke: Regenstrief Institute for Health Care, 1001 West 10th Street, RGb, Indianapolis, IN 46202.