Expanding the view of scholarship: introduction.

The Association of American Medical Colleges' Council of Academic Societies (CAS) has a long-standing interest in scholarship as it relates to research, education, and service, the traditional definition of the activities of medical school. The work of Ernest Boyer and Charles Glassick is highly respected for redefining scholarship and conceiving how scholarship as thus defined can be assessed. Because their ideas have been applied in other areas of the academy but not widely in medical faculties, the CAS Task Force on Scholarship collected a special set of papers on Boyer's four areas of scholarship as applied to medical school, including case studies and the perspective from the university. The four areas of scholarship defined by Boyer and Glassick are the scholarship of discovery, the scholarship of integration, the scholarship of application, and the scholarship of teaching. The scholarship of discovery-research-has for decades been the primary focus for promotion and tenure for medical school faculty, even though the faculty also had major and critical activities in the other areas of scholarship. The CAS hopes that the ideas put forth in this special theme issue will produce a continuing dialogue as faculty and administrators at medical schools reflect on the value of these different forms of scholarship, their application by medical school faculty, and their contributions to the individual missions of each medical school and teaching hospital. In addition, these articles will stimulate continuing discussions that will definite equitable methods for the continued assessment of the scholarly accomplishments of medical school faculty.     

Defining scholarship at the Uniformed Services University of the Health Sciences School of Medicine: A study in cultures.

Medical schools' long-awaited recognition of the varied contributions of their faculty has caused active dialogue and debate. The discourse centers on the best approach for incorporating a broader definition of scholarship, including professional service, into the traditional promotion and tenure processes. At the School of Medicine of the Uniformed Services University of the Health Sciences (USUHS), the majority of the clinical faculty also serve as active-duty uniformed medical officers, and the subject of how to appropriately recognize their varied contributions has long been contended. Concerns have been raised from all constituent groups that broadening the definition of scholarship at the USUHS has the potential to lower the standards of the academy and thus devalue faculty positions. The USUHS has viewed this challenge as a study in the integration of cultures. Institutional cultures include those of the academy, the military, government, basic science, and clinical science, and all the resulting permutations. A nine-year review of scholarship, promotion, and tenure at the USUHS has resulted in a document that supports the diverse missions of the university and appropriately rewards the accomplishments of its faculty. The dialogue continues, as the new document is subject to continuing review and ongoing critical analysis.     

Evolution of clinical ethics teaching at the University of Pittsburgh

The authors explain that several years of effort, by many faculty from a variety of disciplines, were required to expand medical ethics teaching at the University of Pittsburgh School of Medicine beyond the preclinical years. Since 1986, faculty associated with the school's Center for Medical Ethics have begun a comprehensive ethics teaching program for all four years and the residency period; they also are attempting to develop an ethics consultation service. The authors describe the program, its promise and plans, and the significant difficulties involved in establishing and maintaining it, not only problems of long-term funding but of the uninformed and negative attitudes of some students and faculty toward ethics teaching, especially in the clinical setting. Also discussed are the pros and cons of using cases in ethics teaching and the program's approaches to evaluation and to training clinical faculty in clinical ethics issues.     

Implementing a comprehensive relative-value-based incentive plan in an academic family medicine department.

The authors describe the implementation and first three years (1997-1999) of a department-wide incentive plan of the Department of Family Medicine at the State University of New York at Buffalo School of Medicine and Biomedical Sciences. By using a consensus approach, a representative elected committee designed a clinical relative value unit (explained in detail) that could be translated to equally value and reward faculty efforts in patient care, education, and research and which allowed the department to avoid the imposition of a model that could have undervalued scholarship and teaching. By 1999, the plan's goal of eight patient-care-equivalent points per four-hour session had been exceeded for pure clinical care. Clearly, only a small financial incentive was necessary (in 1999, an incentive pool of 4% of providers' gross salary) to motivate the faculty to be more productive and to self-report their efforts. Long-term productivity for pure clinical care rose from 9.8 points per session in 1997 to 10.4 in 1999. Of the mean total of 3,980 points for the year 1999, the contribution from teaching was 1,146, or 29%, compared with 25% in 1997. For scholarship, the number of points was 775, or 20%, in 1999, compared with 11% in 1997. The authors describe modifications to the original plan (e.g., integration of quality measures) that the department's experience has fostered. Problems encountered included the lack of accurate and timely billing information from the associated teaching hospitals, the inherent problems of self-reported information, difficulties of gaining buy-in from the faculty, and inherent risks of a pay-for-performance approach. But the authors conclude that the plan is fulfilling its goal of effectively and fairly quantifying all areas of faculty effort, and is also helping the department to more effectively demonstrate clinical productivity in negotiations with teaching hospitals.     

Medical Humanities at the University of Texas Medical Branch at Galveston.

The Institute for the Medical Humanities of the University of Texas Medical Branch at Galveston (UTMB) was established in June 1973 to ensure that humanities teaching and research became an integral part of the education of future scientists and health-care professionals at UTMB. The multidisciplinary faculty of the Institute-who currently represent the disciplines of art, drama, history, law, literature, philosophy, and religious studies-teach in all four years of the undergraduate medical curriculum as well as in various residency programs. In addition to its focus on students and residents in the School of Medicine, the Institute has a vibrant graduate program in medical humanities with several joint degree options, including an MD/MA and an MD/PhD program, and the Institute has always included the School of Nursing, the School of Allied Health Sciences, and the Graduate School of Biomedical Sciences in its activities. After 30 years, the Institute's commitment to health-professional education remains strong and enduring. Challenged by major curriculum reform in the School of Medicine and increasingly tight state budgets, Institute faculty members look forward to continued collaboration with their basic science and clinical colleagues to improve our evolving curriculum and to seek research funding from external sources.     

Scholarship in the medical faculty from the university perspective: retaining academic values.

Academic medicine and research universities have enjoyed a close relationship that has strengthened both, spawning an era of discovery and scholarship in medicine that has earned the U.S. academic medical enterprise a high level of public trust and a deserved leadership position in the world. However, changes in the financing of medical care and in the organization of health care delivery have dramatically affected the medical school-university partnership. The growing emphasis on delivery of clinical services and the concomitant decrease in time for tenured and clinician-educator faculty to teach and do scholarly work jeopardizes both the potential for continued discovery and the education of the next generation of medical scholars. The background of the medical school-university relationship and the factors leading to the development of clinician-educator faculty tracks are reviewed, and recent trends that impact faculty scholarship are discussed. Both tenure-track and clinician-educator medical faculty, as members of the broader university community, should expect from their university colleagues a continued demand for scholarship and educational activity that reflects the underlying philosophy of the parent university. As a corollary, the university, through its medical school, must provide these faculty the time and the financial support necessary to fulfill their academic mission. The size of the clinician-educator faculty should be determined by the academic needs of the medical school rather than by the service demands of its associated health care delivery system. To accomplish this, academic medical centers will have to develop cadres of associated or clinical faculty whose primary focus is on the practice of medicine.     

Promoting research in medical education at the University of California, San Francisco, School of Medicine.

Over the past seven years, educational innovations and scholarship have flourished at the University of California, San Francisco, (UCSF) School of Medicine. Prior to 1998, there was no infrastructure to support educational research and yet a few faculty members published in medical education journals and were active in national professional associations. With the initiation of curriculum reform in 1998, a great deal of excitement about education was generated and innovative new educational programs were envisioned. These changes became opportunities for educational scholarship. With the development of an Office of Medical Education in 1997 and the Haile T. Debas Academy of Medical Educators in 2001, the infrastructure was in place to expand educational research and the scholarship of teaching. The components of this support include educational leadership, faculty development, the Teaching Scholars Program, the Office of Educational Research and Development, the Academy, a Fellowship in Medical Education Research, collaborative research, and extramural grants. As a result of these investments, the number of UCSF faculty members who are involved in educational research has increased significantly. There has been a four-fold increase in peer-reviewed articles published in medical education journals and a greater increase in the publication of educational abstracts, editorials, chapters, and books, plus presentations at U.S. professional association meetings. In this article, the authors describe the changes that have occurred at UCSF to achieve these results.     

The Center for Clinical Epidemiology and Biostatistics of the Perelman School of Medicine at the University of Pennsylvania: an organizational model for clinical research in a school of medicine

A new model for the conduct of clinical research was established at the University of Pennsylvania (Penn) School of Medicine, now the Perelman School of Medicine, through the development of the interdepartmental Center for Clinical Epidemiology and Biostatistics in 1993 and the basic science Department of Biostatistics and Epidemiology in 1994. The authors describe the development and evolution of these novel structures.Five key objectives were achieved with these structures' creation: (1) Clinical faculty have the opportunity to be identified as both clinicians and epidemiologists, (2) nonclinical faculty have an academic "home," (3) clinical trainees are now educated in population medicine, which promotes its incorporation into their clinical practice, (4) population medicine and clinical medicine have become fully integrated, and (5) better epidemiologic research is conducted, informed by clinical insights.Today's center is the primary home for epidemiology and biostatistics at Penn, linking epidemiology, biostatistics, clinical medicine, and the health sciences. The center's core faculty manage their own research programs, conduct primary research in epidemiology and biostatistics, serve as members of collaborative research teams, manage cores and service centers that support research projects, and lead graduate training programs in epidemiology and biostatistics. The department provides an academic home and structure for faculty, provides primary research in epidemiology and biostatistics, supports the center's mission, and provides training in biostatistics. This organizational approach has wide applicability across schools of medicine in the United States and abroad and has been a model for many.     

Promoting an environment of professionalism: the University of Chicago "Roadmap".

In 2005, the University of Chicago Pritzker School of Medicine unveiled an institution-wide Roadmap to Professionalism designed to both increase awareness about issues of medical professionalism across the institution and gain a better understanding of how medical trainees' professional behaviors' change during their training as a result of the medical learning environment. The authors describe the institution's approach and progress to date. To gain buy-in from all levels of learners at the Pritzker School of Medicine, the initiative uses vertically integrated advisory groups to engage medical trainees in the assessment and development of experiential workshops and evaluation initiatives based on the principles outlined in the American Board of Internal Medicine / American College of Physicians / European Federation of Internal Medicine's Physician Charter for Medical Professionalism. Advisory groups provide targeted assessments and programming at each stage of the medical learner: preclinical students, clinical students, residents, and faculty. Surveys of medical students' perceptions of professionalism have provided an important baseline assessment of the learning environment, from which the professionalism steering committee plans to target future curricular interventions. Efforts to engage residents have focused on experiential workshops addressing interactions with the pharmaceutical industry and patient-care hand-offs, as well as the development of a tool for patients to evaluate their resident physicians. The establishment of a series of medical education grants aimed at supporting professionalism research has helped raise faculty awareness. This institution's approach and experience to date may provide valuable lessons for educators and leaders aiming to assess and improve their learning environments.     

Addressing global health through the marriage of public health and medicine: developing the University of Washington department of global health.

Widespread interest in global health issues is a common characteristic of students and faculty in schools of public health and schools of medicine. Building on strong university-based and community-based programs in global health, the University of Washington has created a unique Department of Global Health that is housed jointly in its School of Public Health and Community Medicine and its School of Medicine. The creation of this department has generated significant enthusiasm throughout the university and the Seattle community as a new paradigm for addressing global health education, research, and service. Placing the new Department of Global Health in two university schools and finding the appropriate niche for the department among the university's many global health initiatives presented challenges, as well as opportunities. This article describes the goals of the department, the process by which it was created, and what it expects to accomplish.     

Criteria of the "educators' pyramid" fulfilled by medical school faculty promoted on a teaching pathway.

PURPOSE: To compare the results of academic promotion to associate professor and professor via the teaching pathway at the Wake Forest University School of Medicine (WFUSM) with the criteria of the "educators' pyramid" of Sachdeva et al. METHOD: Data on all candidates promoted to associate professor and professor in the academic years 1995-2000 at WFUSM were collected from candidates' portfolios and compared with the criteria for educator (level three) and master educator (level four) from a modified version of the educators' pyramid. RESULTS: Of 186 faculty promoted, 38 were on the teaching pathway. Everyone promoted on the pathway fulfilled all teacher and master teacher criteria. All educator criteria were found among the associate professors, and all but one of the master educator criteria were found among professors. More than 75% of associate professors demonstrated "sustained participation in significant amounts of effective teaching in more than one modality" and "service as a medical student clerkship, course, or residency director." Less than 30% demonstrated "service as assistant dean of education or student affairs" or "service as the chair of departmental education committees." Most associate professors had not regularly participated in national education meetings. For professors, more than 50% demonstrated "achievement of leadership positions in national organizations, committees, and medical school education"; "recognition as a national leader in specialty education"; and "mentorship of other faculty members locally and nationally." Less than 30% demonstrated "pursuit of further training in education through workshops, faculty development programs, or educational fellowship programs" or "development and implementation of nationally-recognized (in education) innovative curricula or teaching programs." No one promoted to professor on the teaching pathway had made what was considered to be a landmark contribution to educational research and development. CONCLUSION: The findings suggest that the educators' pyramid is generalizable to medical faculty being promoted on a teaching pathway at WFUSM. Documentation of achievement in teaching criteria is essential and faculty should be encouraged to maintain records of accomplishment before becoming candidates for promotion.     

Commentary: The battle of Louisville: money, power, politics, and publicity at an academic medical center

In 2009, the entire clinical faculty of the Department of Neurosurgery of the University of Louisville School of Medicine elected to become employees of a nearby community hospital. This took place in the context of the financial burden of caring for the indigent, declining reimbursement, clinical demands for neurosurgical coverage of a level 1 trauma center, rising salaries for neurosurgeons, and competitive pressure on hospitals. The author, who was dean of the school of medicine at the time, would not accept the abrupt withdrawal of these clinicians from the faculty practice plan, single-point contracting, and academic governance of clinical work assignments. Politicians, the press, and accreditation bodies quickly weighed in as the university, the school, and the public good were placed in jeopardy. The motivations for this event-the community hospital defending its market share and physician recruitment and retention pipeline, the dean defending principles of academic governance and the faculty practice plan-and the responses of the participants offer an instructive case study for academic medical management. The author concludes that one might view the protagonists of this episode not as defenders of principles but, rather, as pawns in a larger drama playing out related to a perfect storm of economic and social pressures in American medicine.     

Alternative funding for academic medicine: experience at a Canadian Health Sciences Center.

In 1994 the School of Medicine of Queen's University in Kingston, Ontario, its clinical teachers, and the three principal teaching hospitals initiated a new approach to funding, the Alternative Funding Plan, a pragmatic response to the inability of fee-for-service billing by clinical faculty to subsidize the academic mission of the health sciences center. The center was funded to provide a package of service and academic deliverables (outputs), rather than on the basis of payment for physician clinical activity (inputs). The new plan required a new governance structure representing stakeholders and raised a number of important issues: how to reconcile the preservation of physician professional autonomy with corporate responsibilities; how to gather requisite information so as to equitably allocate resources; and how to report to the Ontario Ministry of Health and Long-term Care in order to demonstrate accountability. In subsequent iterations of the agreement it was necessary to address issues of flexibility resulting from locked-in funding levels and to devise meaningful performance measures for departments and the center as a whole. The authors conclude that the Alternative Funding Plan represents a successful innovation in funding for an academic health sciences center in that it has created financial stability, as well as modest positive effects for education and research. The Ontario government hopes to replicate the model at the province's other four health sciences centers, and it may have applicability in any jurisdiction in which the costs of medical education outstrip the capacity of faculty clinical earnings.     

Improving the retention of underrepresented minority faculty in academic medicine

BACKGROUND: Although several studies have outlined the need for and benefits of diversity in academia, the number of underrepresented minority (URM) faculty in academic health centers remains low, and minority faculty are primarily concentrated at the rank of assistant professor. In order to increase the diversity of the faculty of the University of California, San Diego (UCSD) School of Medicine, the UCSD National Center for Leadership in Academic Medicine, in collaboration with the UCSD Hispanic Center of Excellence, implemented a junior faculty development program designed in part to overcome the differential disadvantage of minority faculty and to increase the academic success rate of all faculty. METHODS: Junior faculty received counseling in career and research objectives; assistance with academic file preparation, introduction to the institutional culture; workshops on pedagogy and grant writing; and instrumental, proactive mentoring by senior faculty. RESULTS: After implementation of the program, the retention rate of URM junior faculty in the school of medicine increased from 58% to 80% and retention in academic medicine increased from 75% to 90%. CONCLUSION: A junior faculty development program that integrates professional skill development and focused academic career advising with instrumental mentoring is associated with an increase in the retention of URM faculty in a school of medicine.     

Retraining faculty for the problem-based curriculum at the University of Hawaii, 1989-1991.

The problem-based learning (PBL) curriculum, adopted by an increasing number of medical schools, requires retraining faculty for new roles as tutors with small groups of medical students. This study describes the procedures and results of four PBL training workshops (1989-1991) given at the University of Hawaii John A. Burns School of Medicine. Eighty-eight faculty volunteers each answered a 20-item multiple-choice questionnaire testing their knowledge of PBL both before and after they participated in a workshop. The posttest results were used to identify deficiencies in the tutors' knowledge and practice of both their role and their function. The authors conclude that these deficiencies, now identified, will be addressed in a systematic fashion in subsequent workshops.     

Obstacles to promotion? Values of women faculty about career success and recognition. Committee on the Status of Women and Minorities, Virginia Commonwealth University, Medical College of Virginia Campus.

PURPOSE: To assess attitudes of female faculty about career progress, resources for career development, and values related to academic success and recognition. METHOD: In 1997, the authors surveyed all faculty at Virginia Commonwealth University School of Medicine and its associated Veterans Affairs Medical Center. RESULTS: Of 918 faculty, 567 (62%) responded to the survey; 33% of the respondents were women. Compared with men, women faculty were less likely to be tenured or at the level of professor, spent more time in clinical activities, had less time for scholarly activity, and reported slower career progress. Women were more likely to report that promotion and tenure criteria had not been reviewed with them. Significant differences were found between female physicians and non-physician faculty; female physicians reported the least time for scholarly activities and poorest understanding of promotion and tenure criteria. When the authors asked faculty how they valued certain indicators of career success, women were less likely to value leadership than were men. Female physicians were less likely to value scholarship and national recognition as indicators of their career success. CONCLUSION: This survey found important differences in career progress of male and female faculty, with women reporting less time for career development. In addition, there were differences in values related to career success and recognition, which were most pronounced for female physicians. These differences may have an important impact on promotion for women in general and particularly for female physicians.     

Results of an academic promotion and career path survey of faculty at the Johns Hopkins University School of Medicine.

PURPOSE: Clinician-educator faculty are increasing in numbers in academic medical centers, but their academic advancement is slower than that of research faculty. The authors sought to quantify the magnitude of this difference in career advancement and to explore the characteristics of faculty that might explain the difference. METHOD: In 1999, a questionnaire was administered to all MD faculty at the rank of instructor and above (259) in the Department of Medicine at the Johns Hopkins University School of Medicine. RESULTS: A total of 180 (69%) faculty returned questionnaires. Of these, 178 identified with one of four career paths: basic researcher (46), clinical researcher (69), academic clinician (38), or teacher-clinician (25). Career path did not differ by age, gender, rank, years on faculty, hours worked per week, family responsibility, or global work satisfaction. After adjusting for age, gender, time at rank, and work satisfaction, the odds of being at a higher rank were 85% less for academic clinicians (odds ratio,.15; 95% confidence interval, 0.06-0.40) and 69% less for teacher-clinicians (odds ratio,.31; 95% confidence interval, 0.11-0.88) than for basic researchers. Clinical researchers did not differ from basic researchers in the likelihood of being at higher rank. Similarly, compared with basic research faculty, the adjusted odds of being more satisfied with progress towards academic promotion were 92% lower for academic clinicians and 87% lower for teacher-clinicians. CONCLUSIONS: Clinician-educator faculty were less likely to be at higher rank at this institution than were faculty in research paths. Differences in rank may be explained by lower rank at hire for faculty in these career paths, time available for scholarly activities, or other resources available to support scholarship. Retaining clinician-educators will require further exploration of barriers to promotion inherent to these career paths and methods of modifying these barriers.