The academic viability of general internal medicine. The views of department of medicine chairmen

A national survey of department of medicine chairmen was conducted to learn their views of the status of academic general internal medicine. Developing a research program in general internal medicine was considered a high priority by 60% of the department chairmen at the time their general internal medicine divisions were established, and by 1981, 83% considered this a high priority. However, only 17% stated that significant progress had been made by the division at their institutions toward achieving this goal. Chairmen identified problems with funding for research, their faculty's ability to do research, and available time of faculty to conduct research. They stated their intention to assist the division of general internal medicine in developing a research program through financial and organizational support. At least two thirds planned to recruit selectively general internal medicine faculty who had research backgrounds and interests and to require the existing faculty to do research as a condition for continued appointment.     

Academic and career development of pulmonary and critical care physician-scientists

RATIONALE: The supply of research-oriented physicians is declining. OBJECTIVES: Define barriers to successful career development in academic pulmonary/critical care medicine and discover strategies that promote the recruitment and retention of research physicians. METHODS: Focus groups and Web-based survey of fellows and junior faculty in pulmonary/critical care and neonatology divisions in 2002. Primary survey areas were educational debt, mentoring, institutional resources, information needs, and academic productivity. MAIN RESULTS: Monthly educational debt payments were a small fraction of junior faculty household income, but the debt/income ratio was larger for fellows and less for female faculty. The debt/income ratio was not associated with the perceived likelihood of an academic career. Respondents felt they lacked understanding of the roadmap to success and formal assistance in career development. Mentors were perceived as personally supportive, but less helpful in career development. Perceived likelihood of an academic career was most associated for faculty with institutional research support and for fellows with mentors' academic advising. Better research skills and more career development activities were associated with respondents having a Ph.D. mentor. Perceptions about academic physicians' job security were pessimistic. CONCLUSIONS: Multiple factors influence decisions to pursue an academic medical career. In addition to alleviating financial pressures, academic careers may be aided by (1) providing more information about career pathways, job expectations, and success rates; (2) increasing career development mentoring; and (3) implementing formal curricula similar to Ph.D. programs. For pulmonary/critical care medicine faculty, current federal educational debt relief programs may have only a modest effect on academic retention.     

Guiding Academic Clinician Educators at Research-Intensive Institutions: a Framework for Chairs,Chiefs, and Mentors

Department chairs and division chiefs at research-intensive academic medical centers often find mentoring clinician educators challenging. These faculty constitute the majority of academic physicians. Supporting excellent clinician educators is key to ensuring high-quality patient care and developing tomorrow’s physicians. Little has been written for leaders on strategies to advance academic clinician educators’ career success. We present a framework to guide chairs, chiefs, and mentors seeking to address clinician educator retention and satisfaction in academic medical centers.KEY WORDS: clinician educator, academic medicine, mentoring     

Development of geriatrics-oriented faculty in general internal medicine

The need for adequate geriatrics training for the physician workforce has been recognized for decades. However, there are not enough academic geriatricians to provide for the educational needs of trainees, and this situation is not expected to change in the future. General internists are often responsible for teaching medical students and internal medicine residents to care for elderly patients in inpatient and ambulatory settings. These academic general internists could play a pivotal role in providing geriatrics instruction. To characterize what is being done to develop geriatrics-oriented general internal medicine faculty, we identified current practices, "best practices," goals and targets, and barriers to achieving those goals and targets. We reviewed the literature on faculty-development programs for general internal medicine faculty, and we held focus groups and structured interviews with general internal medicine unit chiefs and directors of Geriatric Centers of Excellence at 46 medical schools throughout the United States. We found a need for programs to develop geriatrics-oriented academic general internists. Although general internal medicine faculties seem receptive to further geriatrics training, important obstacles exist. These include inadequate time and resources as well as motivational and attitudinal challenges. We discuss potential solutions for overcoming these barriers and the implications of these solutions for stakeholders.     

General internal medicine and technologically less developed countries

OBJECTIVE: To assess the international health activities of departments of medicine, divisions of general medicine, and general medicine faculty and the interest among departments of medicine in joint international health ventures. DESIGN: 15-item, mailed questionnaire. PARTICIPANTS: 100 chiefs of divisions of general medicine associated with training programs in internal medicine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Completed questionnaires were returned by 87 division chiefs representing 1,355 general medicine faculty. 49% of division had faculty with six weeks' experience in less developed countries. 8.5% of general medicine faculty had six weeks' experience in less developed countries. 7.6% of general medicine faculty were interested in spending extended time in less developed countries. 19% of departments had formal collaborations with schools in less developed countries. 45% of departments were interested in affiliations with U.S. institutions for the purpose of joint international health ventures. CONCLUSIONS: The international health interests of current general medicine faculty may not be satisfied. Departmental and divisional encouragement of international interests would increase the number of U.S. general internists participating in less developed countries. The authors discuss the potential for greater involvement of general medicine faculty in international health.     

Brief report: Resident and faculty perceptions of conflict of interest in medical education

OBJECTIVE: To determine resident and faculty perceptions of the pharmaceutical industry's influence on medical education. DESIGN, SETTING, AND PARTICIPANTS: Anonymous survey of categorical residents and faculty in the department of medicine at a large, Midwestern, urban, independent academic medical center. MAIN RESULTS: Eighty-one residents (69.2%) and 196 faculty (75.7%) responded to the survey. Residents believed that a significantly higher percentage of primary care and subspecialist faculty receives industry income or gifts compared to faculty respondents. Many faculty, and to a significantly greater degree residents, indicated that income or gifts influence the teaching of both internal attending physicians and visiting faculty in a variety of educational settings. The majority of residents (61.7%) and faculty (62.2%) believed that annual income or gifts less than $10,000 could influence an attending physician's teaching. Most residents (65.4%) and faculty (74%) preferred that lecturers report all financial relationships with industry regardless of which relationships the lecturer believes are relevant. CONCLUSIONS: Most internal medicine residents and their faculty perceive that industry influences teaching in different educational settings, and want teachers to disclose all of their financial relationships with industry. This information may guide further development of policies and curricula addressing industry relationships within graduate medical education.     

The challenge of teaching occupational and environmental medicine in internal medicine residencies

Using a mailed survey questionnaire directed toward division chiefs of general internal medicine, we have confirmed that despite increased interest among faculty, few medical residents currently receive required or elective training in occupational medicine. However, recent changes in societal perceptions about environmental risks, corporate health care practices, and medical reimbursement patterns favoring provision by hospitals of contractual outpatient services to healthy workers all portend expanded involvement of residents in certain occupational medicine activities in the future, in response to economic pressures on both consumers and providers. These same forces may, unfortunately, undermine the scientific and ethical quality of such training experiences, compared with emerging, more academically motivated approaches. The implications of these prospects are analyzed in the hope that a proper balance can ultimately be struck between economic and academic imperatives.     

Expert ratings of primary care goals and objectives

OBJECTIVE: To develop consensus on proficiencies internal medicine residents should master in the area of primary and managed care. DESIGN: A draft compendium of primary care educational objectives including important clinical topics was developed at the Sepulveda Veterans Health Administration Medical Center Pilot Ambulatory Care and Education (PACE) Program as part of a local and regional primary care curricular review. Fifty-one experts, including leaders in the Society of General Internal Medicine, the Association of Program Directors in Internal Medicine, the American College of Physicians, general internal medicine division chiefs, and Veterans Affairs (VA) associate chiefs of staff for ambulatory care rated the compendium. MEASUREMENTS AND MAIN RESULTS: Eleven objectives and nine clinical topics were rated “critically important” (4.7 or above on a five-point scale). General internal medicine chiefs and associate chiefs of staff for ambulatory care judged them to be covered adequately in fewer than half of the 17 VA Western Region-affiliated internal medicine programs. Forty-five objectives and 77 clinical topics were considered at least somewhat important to the education of general internal medicine residents in primary care. The VA raters reported that in the prior academic year, their housestaffs had spent between 21% (postgraduate year I) and 33% (postgraduate year III) of their time in ambulatory care settings. CONCLUSION: With the emphasis on primary and managed care, there is a need for national consensus on educational objectives in primary care general internal medicine. This review provides educators with a benchmark to test the adequacy of their institutions’ curricula in primary care internal medicine. Presented in abstract Jorm at the annual meeting of the Society of General Internal Medicine, April 28, 1994, Washington, DC.     

Academic emergency medicine: a national profile with and without emergency medicine residency programs.

STUDY OBJECTIVE: Formal data are lacking regarding emergency departments in academic medical centers, particularly those without an emergency medicine residency program. The Education Committee of the Society for Academic Emergency Medicine conducted a survey to define a national profile of academic emergency medicine. DESIGN: Prospective survey with telephone follow-up. SETTING: Academic medical centers. PARTICIPANTS: One hundred twenty-three academic medical centers as defined by the Association of American Medical Colleges. RESULTS: Results were obtained from 94 (78%) institutions: 27 (29%) had an emergency medicine residency program and 67 (71%) had no emergency medicine residency program. Significant differences were found between those with and without emergency medicine residency programs regarding 24-hour attending coverage (96% versus 73%), mean weekly clinical faculty hours (26 versus 33), the number of emergency medicine board-certified faculty, faculty recruitment difficulties (25% versus 75%), and the presence of a curriculum for housestaff (96% versus 38%). No significant differences were noted regarding the presence of a curriculum for medical students (78% versus 64%). Of the 67 institutions with no emergency medicine residency programs, 42% were actively planning a program, and 42% would consider future development of a program. CONCLUSION: This article provides the first comprehensive profile of emergency medicine in the Association of American Medical Colleges academic medical centers. Programs with emergency medicine residency programs provided more 24-hour attending coverage, had more emergency medicine board-certified faculty, and reported less difficulty recruiting additional faculty than institutions with no emergency medicine residency program. Both need to expand their undergraduate educational activities. Many institutions with no emergency medicine residency program are attempting to develop emergency medicine residency programs.     

Confidence of academic general internists and family physicians to teach ambulatory procedures

OBJECTIVE: To evaluate and compare the readiness of academic general internal medicine physicians and academic family medicine physicians to perform and teach 13 common ambulatory procedures. DESIGN: Mailed survey. SETTING: Internal medicine and family medicine residency training programs associated with 35 medical schools in 9 eastern states. PARTICIPANTS: Convenience sample of full-time teaching faculty. MEASUREMENTS AND MAIN RESULTS: A total of 331 general internists and 271 family physicians returned completed questionnaires, with response rates of 57% and 65%, respectively. Academic generalists ranked most of the ambulatory procedures as important for primary care physicians to perform; however, they infrequently performed or taught many of the procedures. Overall, compared with family physicians, general internists performed and taught fewer procedures, received less training, and were less confident in their ability to teach these procedures. Physicians’ confidence to teach a procedure was strongly associated with training to perform the procedure and performing or precepting a procedure at least 10 times per year. CONCLUSIONS: Many academic general internists do not perform or precept common adult ambulatory procedures. To ensure that residents have the opportunity to learn routine ambulatory procedures, training programs may need to recruit qualified faculty, train current faculty, or arrange for academic specialists or community physicians to teach these skills. Presented in part at the 1996 and 1998 meetings of the Society of General Internal Medicine and at the 1998 meetings of the Midwest Society of General Internal Medicine. This work was supported in part by grant 2D28PE54004 from the Bureau of Health Professions, Health Resources and Services Administration, to the Faculty, Development Program for General Internal Medicine, University of North Carolina at Chapel Hill, and by Grant 52285 from the Summa Health System, Akron, Ohio.     

The medical chief residency and its relation to academic sections of general medicine

The role and function of chief medical residents in academic programs were reexamined in light of the advent of departmental units of general internal medicine. Of 87 chief medical residents responding to a questionnaire, 74 worked in departments with active general internal medicine sections. There was much interaction between chief medical residents and general internal medicine faculty: 36 percent of chief medical residents participated formally in general internal medicine section activities, 54 percent shared teaching responsibilities with general internal medicine faculty, and 45 percent of chief medical residents interacted with general internal medicine faculty in administrative activities. Despite this interaction, most basic administrative tasks were handled by chief medical residents alone. Forty-eight percent of chief medical residents thought the position had declined in prestige. Recent literature on the evolution of the chief residency in internal medicine and in other specialties is reviewed, and recommendations for capitalizing on the presence of general internal medicine faculty to make the position more rewarding are made.     

Academic general internists’ work roles and motivations for learning

As part of an assessment of interests and needs for continuing medical education among academic general internists, a 20 per cent random sample of the 1985 physician membership of SREPCIM was asked to describe how they divided their time among basic work activities (patient care, teaching, housestaff supervision, administration, and research), how they perceived the importance of specific skills related to those basic activities, and how interested they were in participating in a faculty development program in order to improve those skills. Although respondents reported a great diversity of work roles, attitudes, and values, there was a strong and consistent tendency to value and want to improve upon only those skills related to basic activities in which physicians were already spending more time. Also, physicians who spent more time in direct patient care were significantly less likely to value classroom teaching or research, less likely to be doing teaching or research, and less motivated to improve their skills in those activities. Likewise, faculty who spent more time doing research were less interested in improving their patient care skills. The implications of these findings for meeting current and future manpower needs of divisions of general internal medicine are discussed. Received from the Department of Medicine, Division of General Internal Medicine, University of California, Los Angeles, CA 90024. Supported by a Faculty Development Contract from the Health Resources and Services Administration (240-84-0058).     

Career choices of 135 cardiology trainees at Duke University Medical Center from 1970 to 1984

Alarm has been expressed at recently presented evidence showing that diminishing numbers of physicians are entering academic careers. The experience of the cardiology training program at a university medical center between 1970 and 1984 was reviewed to determine the career paths chosen by its trainees. During the study period, 135 physicians received training. Between 1970 and 1978 the percentage of trainees making academic medicine their initial career choice fluctuated considerably. Beginning in 1978, the percentage entering academic medicine steadily increased; in the most recent class, 8 of 9 trainees accepted academic faculty positions. Among 72 former trainees who joined an academic faculty after finishing training, approximately 7% per year left academic medicine for clinical practice. The median length of an academic career was 10 years. Individual institutions may be able to reverse the national trend of trainees making clinical practice their initial career choice. However, physicians who leave academic medicine for clinical practice may continue to deplete faculty ranks.     

Recruitment and retention in academic medicine--what junior faculty and trainees want department chairs to know

Attracting and retaining bright and motivated physicians remains a high priority for academia. Historically, the recruitment of trainees into academia and the retention of junior faculty have been suboptimal. To learn more about the perceived obstacles that discourage the pursuit of academic careers, a Workshop on Academic Career Pathways was conducted during the 2011 Southern Regional Meetings held in New Orleans. The audience included mainly residents and fellows as well as junior and senior faculties. Speakers described career options in academic medicine focusing on the clinician-investigator and the clinician-educator tracks. Afterward, the audience was asked to identify perceived obstacles to recruitment and retention in academic medicine. The group identified 10 major obstacles in 3 categories: financial challenges, personal mentoring and academic skills acquisition. This article summarizes the workshop proceedings and ends with recommendations to chairs and department leaders for improving recruitment and retention in academic medicine based on the discussion.     

General medical care and the education of internists in university hospitals. An evaluation of the teaching hospital general medicine group practice program

Fifteen general internal medicine group practices in university teaching hospitals were studied to evaluate their primary care services and education. Data were collected over 9 months from physicians, patients, and medical records, and by observation. All institutions had closed their general medical clinics. Many patients being treated in group practices were very sick; 57% had hypertension; 21% were diabetic; and 45% could not work. Most were satisfied with their care. Care for acute problems from a health care provider in the practice was available quickly; regular physicians were harder to see. House staff and faculty spent little time in the practices. Few practices used teams; most used traditional attending and house staff models. Practice physicians could not easily determine when patients were seen in the institution's emergency department or were hospitalized. Quality of care standards were not uniformly met. Finally, the structure of academic centers appeared to inhibit the practices' performance, suggesting a need for further appraisal of relationships between university hospitals and their ambulatory care units.     

The Role for Clinician Educators in Implementing Healthcare Improvement

Clinician educators—who work at the intersection of patient care and resident education—are well positioned to respond to calls for better, safer patient care and resident education. Explicit lessons that address implementing health care improvement and associated residency training came out of the Academic Chronic Care Collaboratives and include the importance of: (1) redesigning the clinical practice as a core component of the residency curriculum; (2) exploiting the efficiencies of the practice team; (3) replacing “faculty development” with “everyone’s a learner;” (4) linking faculty across learning communities to build expertise; and (5) using rigorous methodology to design and evaluate interventions for practice redesign. There has been progress in addressing three thorny academic faculty issues—professional satisfaction, promotion and publication. For example, consensus criteria have been proposed for both faculty promotion as well as the institutional settings that nurture academic health care improvement careers, and the SQUIRE Publication Guidelines have been developed as a general framework for scholarly improvement publications. Extensive curricular resources exist for developing the expert faculty cadre. Curricula from representative training programs include quantitative and qualitative research methods, statistical methodologies appropriate for measuring systems change, organizational culture, management, leadership and scholarly writing for the improvement literature. Clinician educators—particularly those in general internal medicine—bear the principal responsibility for both patient care and resident training in academic departments of internal medicine. The intersection of these activities presents a unique opportunity for their playing a central role in implementing health care improvement and associated residency training. However, this role in academic settings will require an unambiguous development strategy both for faculty and their institutions.     

Advanced heart failure: prognosis, uncertainty, and decision making

Heart failure is a serious clinical management challenge for both patients and primary care physicians. The authors studied the perceptions and practices of internal medicine residents and faculty at an academic medical center in the Southeast to guide design of strategies to improve heart failure care. Data were collected via a self-administered survey. Eighty-nine faculty and resident physicians in general internal medicine and geriatrics participated (74% response rate). Items measured perceived skills and barriers, adherence to guidelines, and physician understanding of patient prognosis. Case studies explored practice approaches. Clinical knowledge and related scales were generally good and comparable between physician groups. Palliative care and prognostic skills were self-rated with wide variance. Physicians rated patient noncompliance and low lifestyle change motivation as major barriers. Given the complexities of caring for elderly persons with heart failure and comorbid conditions, there are significant opportunities for improving physician skills in decision making, patient-centered counseling, and palliative care.     

Attitudes of clinical faculty about career progress, career success and recognition, and commitment to academic medicine. Results of a survey

OBJECTIVE: To assess attitudes about career progress, resources for career development, and commitment to academic medicine in physician faculty at an academic medical center who spend more than 50% of their time in clinical care. DESIGN: Faculty survey. SETTING: Academic medical center and associated Veterans Affairs medical center. RESULTS: A total of 310 physician faculty responded to the survey. Half of the faculty reported spending 50% or less of their time in clinical care (mean, 31% of time) (group 1) and half reported spending more than 50% of their time in clinical care (mean, 72% of time) (group 2). Group 2 faculty had one third of the time for scholarly activities, reported slower career progress, and were less likely to be at the rank of professor (40% and 16% for groups 1 and 2, respectively; P<.001) or to be tenured (52% and 26%, respectively; P<.001) despite similar age and years on faculty. Group 2 faculty were 50% more likely to report that tenure and promotion criteria were not reviewed at their annual progress report (P =.003) and that they did not understand the criteria (P<.001). Group 2 faculty valued excellence in patient care over scholarship and national visibility. Group 2 faculty reported greater dissatisfaction with academic medicine and less commitment to a career in academic medicine. CONCLUSIONS: Physician faculty who spend more than 50% of their time in clinical care have less time, mentoring, and resources needed for development of an academic career. These obstacles plus differences in their attitudes about career success and recognition contribute to significant differences in promotion. These factors are associated with greater dissatisfaction with academic medicine and lower commitment to academic careers.     

Faculty attrition among three specialties

STUDY OBJECTIVES: To survey faculty attrition in emergency medicine and compare it with faculty attrition in the specialties of orthopedic surgery and cardiology. DESIGN: Chairmen of the three departments were surveyed regarding faculty attrition, work hours, and motivation for leaving. Those emergency physicians having left also were surveyed. MAIN RESULTS: Responses were obtained from 67 of 68 emergency medicine programs, 53 of 58 orthopedic programs, and 47 of 54 cardiology programs. Overall, there were 670 total faculty in emergency medicine, of which 67 (10%) left their positions during 1988-38 to enter private practice, 18 to take another academic position, and 11 to do something unidentified. There was no difference in faculty attrition among the three specialties or in what the physicians left to do (P = .75). Both the orthopedists and the cardiologists worked more total hours each week (P = .001) but fewer night hours (P = .03) than the emergency physicians. Among the 67 emergency medicine programs, 28 reported no attrition; 39 reported one or more physicians leaving the program. These two groups of programs did not differ in terms of faculty size, hours worked, or night hours worked.