Faculty Development Handbook

PREFACE

Authors: E. John Gallagher, MD, Marcus L. Martin, MD

EMERGENCY MEDICINE, AN EMERGING ACADEMIC DISCIPLINE:

At the turn of the millennium, Emergency Medicine had been recognized by the American Board of

Medical Specialties (ABMS) as a freestanding entity for little more than a decade. In an explicit

acknowledgment of Emergency Medicines relatively youthful status as an emerging academic enterprise,

in May of 2000, the Board of Directors of the Society for Academic Emergency Medicine (SAEM) charged

its Faculty Development Committee with the task of creating a handbook and website intended to provide

Emergency Medicine faculty with an academic primer of basic information pertinent to career

development. Because many of the SAEM members asked to contribute chapters to the handbook were

chairs of academic departments, the Association of Academic Chairs of Emergency Medicine (AACEM)

was invited by SAEM to become a co-sponsor of the Handbook.

The Faculty Development Handbook is intended as both a supplement and sequel to the 2000 edition of

the Emergency Medicine Academic Career Guide, which is an excellent, thoughtfully-written, well-

organized, and lucid publication, co-sponsored by SAEM and the Emergency Medicine Residents

Association (EMRA). The Academic Career Guide is available both in hardcopy and on the SAEM

website at http://www.saem.org. Although the Academic Career Guide contained several chapters

pertinent to junior, and, to a lesser extent, senior Emergency Medicine faculty, it was targeted primarily at

graduating residents. The Faculty Development Handbook is intended to complement the Academic

Career Guide by extending that focus to encompass Emergency Medicine faculty of all academic ranks,

ranging from entry-level Instructor to full, tenured Professor.

SCHOLARSHIP IN ACADEMIC EMERGENCY MEDICINE:

The development of a successful career in any branch of academic medicine is predicated upon the

systematic accumulation of a body of scholarly work. The Faculty Development Committee therefore

began by seeking a working definition of the term scholarship to serve as the organizing principle for this

Handbook. Ultimately, we settled upon a classification originally proposed a decade ago by Ernest Boyer

of The Carnegie Foundation, and subsequently adopted by the Council of Academic Societies (CAS) of

the Association of American Medical Colleges (AAMC). This taxonomy divides scholarship into four major

categories, as defined below:

1. The scholarship of discovery is that of original research. This is the predominant form of scholarship

that has traditionally found the greatest favor with medical institutions during the latter half of the 20th

century.

2. The scholarship of integration is that of trans-disciplinary merger of information from disparate

branches of science and medicine, with the goal of formulating creative and novel insights. This is often

the most difficult form of scholarship to characterize because it typically operates at the periphery of

several disciplines, and may consequently be relatively far-removed from the mainstream of any single

area of knowledge.

3. Closely allied to the scholarship of integration is the scholarship of application, which bridges the gap

between theory and practice by bringing new information to bear on practical problem-solving, e.g., bench

to bedside translocation of knowledge.

4. Finally, there is the scholarship of teaching, which requires intelligible communication of valid and

reliable information supported by thoughtful, coherent reasoning from a knowledgeable source to

students, younger physicians, and other colleagues.

Thus, academic emergency physicians may discover, integrate, apply, and teach new knowledge. As is

clearly articulated in the SAEM mission statement, the Society is dedicated to the advancement of all four

domains of scholarly activity, each in the service of improving the care we provide to our patients.

DEVELOPMENT OF SCHOLARSHIP IN THE U.S.:

American universities have struggled for centuries to define scholarship and achieve academic

equilibrium. In contrast, European countries have long viewed research as the primary, if not the sole,

focus of scholarly activity. Over much of the past century the stated mission of many American institutions

of higher learning has been to provide >teaching, research, and service. While the intent may have been

for this scholarly triad to be considered as academic equals, achieving parity has proven elusive. In

recent years, the dominant position has been one of equating scholarship with research. Prior to this in

the history of American higher education there have been two distinctly different views of scholarship:

During the 17th century, schools such as Harvard College were founded to educate exemplary teachers.

Teaching was considered an act of dedication and was honored as legitimate scholarly activity. As the

focus in the 19th century began to shift toward technology and nation-building, land grant agricultural and

technical colleges, supported by federal funding, came to embody the notion of scholarship as service.

The belief that faculty spread knowledge, which in turn improved agriculture and manufacturing, gave

impetus to this notion.

Emphasis on research as scholarship first appeared in American colleges in the 18th century. Some U.S.

scholars went abroad to Germany and other European countries to pursue research activities. However, it

was not until the mid to late 19th century that research in the United States began to gather momentum.

By the middle of the 20th century, largely as a result of World War II, the National Defense Research

Committee was formed and federal grants began to fund an extensive research enterprise whose indirect

costs subsidized many other important activities of the university. Although many American institutions

hired young faculty to teach and perform research, their academic success was almost entirely contingent

upon their contribution as investigators. As the balance of scholarly activity continued to shift toward

greater emphasis on research, teaching and service became less well rewarded and steadily lost value

as academic currency.

In the late 1980s Ernest Boyer of the Carnegie Foundation visited colleges and made the following

observation: What really is being called into question is the reward, and the key issue is what activities of

the professoriate are most highly prized. After all, it is futile to talk about improving the quality of teaching

if in the end faculty are not given recognition for the time they spend with students@. As a result of

Boyers and his colleague Glassick's work, two books were published by the Carnegie Foundation for the

Advancement of Teaching: Boyer's Scholarship Reconsidered@ in 1990, followed by Glassick's

Scholarship Assessed@ in 1997. Through these classic works, the four areas of scholarship defined

above were developed, and are now widely used by institutions of higher education throughout the nation,

including many U.S. medical schools.

THE SCHOLARSHIP OF TEACHING:

Although a critically important and rapidly growing minority of Emergency Medicine faculty are engaged in

the scholarship of application, and to a lesser degree that of discovery and integration, the majority at the

present time are clinician-educators involved primarily in the scholarship of teaching. Because so many

academic emergency physicians are appointed in the clinical track, the Faculty Development Committee

wished to ensure that this Handbook contained information pertinent to the career advancement of those

clinicians dedicated to the scholarship of teaching. This decision was based upon several considerations:

1) As academic medical centers have found it increasingly necessary to expand clinical service in order to

remain financially solvent, clinicians have been recruited as faculty in unprecedented numbers. This

phenomenon is not confined to Emergency Medicine, but now characterizes most of the 24 medical

disciplines within the American Board of Medical Specialties (ABMS).

2) Although most medical schools (about three-fourths) currently have a separate Clinical Track for faculty

whose scholarly focus is teaching, the road to promotion in this track is not as clearly demarcated or well-

traveled as its more Traditional counterpart in research.

3) Valid and reliable tools for measuring scholarship in teaching, such as educational and teaching

portfolios, are untested and less familiar to promotion and tenure committees than are traditional

curriculum vitae containing enumerated peer-reviewed citations clearly demonstrating order of authorship.

4) As the missions of medical schools and their academic teaching hospitals continue to diverge, faculty

valued for their clinical expertise and teaching in the Emergency Department at the medical center have

found academic recognition of their scholarly contributions through promotion at the medical school an

increasingly elusive pursuit. This is a logical consequence of medical colleges and universities assigning

differential values to different forms of scholarship, thus creating a scholarly hierarchy with discovery

situated squarely on top, teaching very much at the bottom, and integration and application located

somewhere in between.

THE SCHOLARSHIP OF APPLICATION:

The decision to highlight career development among clinician-educators should not be misconstrued as a

judgment about the relative merits of other forms of scholarly activity. Rather, it simply reflects the desire

of the Faculty Development Committee to apportion the information contained in this handbook in a

Ademocratic fashion. Because most academic emergency physicians are presently appointed in the

clinical track and heavily engaged in the scholarship of teaching, the Faculty Development Committee

reasoned that the first edition of this handbook should begin by preferentially targeting this majority.

We have no wish, however, to place an emphasis on clinician-educators at the expense of clinician-

scientists, who have been repeatedly characterized as an endangered species, not only in Emergency

Medicine, but throughout all of academic medicine. Indeed, it seems likely that these individuals,

particularly those engaged in the scholarship of application in the form of patient-oriented research, will

play a critically important role in Emergency Medicines maintenance of academic credibility in the future.

Twenty years ago, James Wyngaarden stated, "I continue to believe that there is now a short supply and

an impending scarcity of dedicated physician investigators, and that they are essential to the orderly

introduction of scientific advance into clinical practice." More recently, Harold Varmus of the NIH wrote:

"We simply cannot deliver the enormous promise of the genetics revolution without close attention to

careers in clinical research." In consideration of this, the Faculty Development Committee has chosen to

include a substantial amount of information in this handbook pertinent to Emergency Medicine faculty

interested in developing careers in the scholarly domain of application, particularly as it applies to Clinical

Research.

THE SCHOLARSHIP OF DISCOVERY & INTEGRATION:

Finally, an effort to emphasize the scholarship of teaching and application should not minimize the

importance of the scholarship of discovery and integration. Uncovering new knowledge to achieve a more

fundamental understanding of human illness through basic scientific research will always be a core

activity of academic medicine. Just as the scholarship of discovery increasingly requires collaboration

among different branches of the basic medical sciences, the scholarship of integration furthers the

eclectic possibilities of such interactions by bringing basic scientists together with clinician scientists and

others such as mathematicians, physicists, and engineers. Such cross-pollination logically extends itself

into the terrain of translational research and invokes the scholarship of application. Wherever scholarship

ends, whether with application or teaching, it must begin with discovery and the integration of new

knowledge into what is already known.

ORGANIZATION OF THIS HANDBOOK:

Consistent with the preceding, we have chosen scholarship as the primary organizational axis for this

Handbook. This strategy is similar to that of the Faculty Development Website, whose primary axis is also

organized along the four domains of scholarship. In contrast to the Faculty Development Website,

however, the handbook has a secondary axis, which follows the order of escalation in rank associated

with successful academic advancement:

Section I: Setting the Stage for Faculty Development, contains an introductory section of seven

chapters, intended to place faculty development in Emergency Medicine into a scholarly context; it is

targeted at individuals of Instructor rank, just out of training.

Section II: Early Faculty Development, includes ten chapters aimed at junior Emergency Medicine

faculty of Assistant Professor rank, with the goal of helping these young physicians obtain a coherent

picture of the academic landscape.

Section III: Mid-career Faculty Development, contains eight chapters directed at those academic

emergency physicians approaching Associate Professor rank, which in many institutions is the juncture at

which tenure is considered for eligible faculty.

Section IV: Career Longevity & Strategies for Continued Growth and Success, includes nine

chapters, geared toward more senior academic emergency physicians moving up the promotional ladder

to full Professor and concomitantly into leadership and key administrative roles within their departments

and institutions.

To this we have added a fifth and final section entitled:

Section V: Resources for Faculty Development, a final section that closes with a brief overview of the

Faculty Development Website followed by an extensive Annotated Bibliography of links and references

pertinent to faculty development.

Please direct any criticisms, suggestions, or other comments pertinent to the Handbook to:

jgallagh@montefiore.org.

The term triple-threat is attributed to an anonymous sportswriter, who used it to describe the gridiron

talents of one Paddy Driscoll, a quarterback for the Chicago Cardinals, the oldest franchise in

professional football. Driscoll, who played both offense and defense, not only passed and ran with equal

facility, but on a particularly memorable fall day in 1924, successfully drop-kicked a field goal from the 50

yard-line. One does not have to be much of a football fan to know that, as the game has evolved and

become increasingly specialized, no single individual would be expected to perform all three tasks of

passing, running, and kicking at a professional level. Hence, with the passage of time, the original

meaning of the term triple-threat has become obsolete.

The analog of the triple-threat in football is baseball's Triple Crown, awarded to the player leading his

league in homers, batting average, and runs batted in (RBI's). No one has won the Triple Crown since the

60's, and many serious observers of the national pastime believe such a feat to be so deeply improbable

that it effectively rivals the impossibility of achieving triple-threat status in the NFL.

It is tempting to conclude from the foregoing that the athletes of today are somehow made of lesser stuff

than those of earlier generations. However, other data, such as the shattering of Babe Ruth's home run

record - which had stood for more than 70 years - twice in the last half decade, belies such an assertion

as a unifying hypothesis. Indeed, the weight of evidence supports the contention that there may never

again be a Triple Crown winner, not so much because players cannot hit the ball, but rather because they

have become specialists. Thus the great hitters of recent years are either swinging for the fences, or

consistently hitting safely, but not both - and without both, the triple crown cannot be won. Baseball still

contains extraordinary hitters, as good as the Cobbs, Hornsbys, Mantles, Ruths, and Williams of the past.

Similarly in football, the Clarks, Driscolls, Hubbards, Hutsons, and Tarkentons are still out there, even

though it is no longer possible to be a triple-threat. This is because, over time, both sports have evolved

and undergone deep and fundamental changes.

In academic medicine, the game has also changed in equally deep and fundamental ways. Shortly after

the second World War, and continuing for several decades thereafter, those academic medical faculty

held up to students and house officers as role models were commonly described as "triple-threats", i.e.,

independently funded investigators, inspiring teachers, and stellar clinicians. In recent years, such

individuals have become very nearly as extinct as bird's teeth. Although extinction is among the most

natural of biological phenomena, when a highly venerated species becomes endangered because the

cultural ecosystem that once supported it can no longer be sustained in an altered intellectual climate,

there is a natural inclination to try and preserve the dying breed. Nowhere is such behavior more evident

than in academic medicine, where the triple-threat seems to have attained the unique fictional status

ordinarily reserved for myth.

Mythology, Joseph Campbell tells us, builds upon the truths and ideals of an earlier time. Viewed as

metaphor, myth is entertaining and often profoundly revealing. However, taken literally, it provokes a kind

of naive nostalgia that holds the present hostage to a selectively remembered past. This latter condition

approximates the dilemma of academic medicine currently and for the last several decades. The

consequence of any attempt, no matter how earnest, to become a triple-threat in the 21st century seems

more likely than not to result in the hollow grandiosity of a double-fake. Although the etymology of the

term double-fake is more elusive than that of triple-threat, its meaning is clear. When used in reference to

an individual, the term describes one who is not what they purport, or might otherwise appear, to be.

To maintain even a modicum of clinical expertise in caring for the nearly infinite variety of ED patients

presenting with undifferentiated illness requires constant vigilance and frequent exposure to minimize skill

decay. The challenge of supervising residents and teaching students requires additional levels of

understanding and the ability to reduce mountains of clinical complexity to molehills of clarity. Add to that,

the demands of basic or clinical extramurally funded research, and one is not only committed to a

minimum of roughly 80-100 hours per week - essentially guaranteeing the absence of any semblance of a

sustainable personal life - but is also looking down the barrel of a future that holds a likelihood of success

only marginally better than the probability of winning the Triple Crown in the American League or

becoming a triple-threat in the NFL.

Perhaps the unarticulated expectation that an individual, given sufficient talent, intelligence, and drive

should somehow be able to do it all in 2002 - as was possible 50 years ago, at a time when one might

actually have been a triple threat in academic medicine (or a Triple Crown winner in baseball) - is one of

the reasons why so many of our most talented young physicians leave residency, turn away from

academics, and enter directly into the private sector. Certainly, the enormous debt service medical

students now carry upon graduation - likened by some to the mortgage on a first home, absent the house

- plays a role in driving such a decision. Nevertheless, the dim prospects of job satisfaction, working

under a set of expectations that become increasingly difficult with each passing year, must also figure

somehow in the choice to forego an academic career.

Based on all of the preceding, we would strongly encourage young faculty to choose carefully, to 'play to

their strengths,’ and to focus their interests as narrowly as possible either on teaching and clinical care or

upon research as an area of primary concentration. Because clinical expertise often goes hand in glove

with clinical teaching, combining these two skills in the role of the clinician-educator is quite common, and

not at all unrealistic. Nor is it difficult to imagine an investigator who is also an outstanding teacher within

the circumference of that individual's research interests. However, to expect independent investigators -

who need at least 75% of their time protected from clinical responsibilities if they are to make meaningful

contributions, obtain independent extramural funding, and avoid becoming "hobbyists" - to perform at the

same level of clinical expertise as faculty colleagues who see patients daily, is a prescription for feelings

of inadequacy and burnout.

Coming to terms with the realization that virtually no one can any longer juggle all three academic balls

with equal agility for the duration of a career - is the first step toward moving beyond the myth of the triple-

threat. Then perhaps, academic physicians can establish for themselves more sensible expectations and

standards to which they can reasonably be held.

This is not to suggest that those engaged in the scholarship of teaching should never involve themselves

in the scholarship of application, nor that scholars of discovery should never set foot in the clinical arena.

Rather, each group must recognize the very substantial limits imposed on meaningful expertise in any

area by dint of the way in which the game of academic medicine has been transformed over the last half

century. Clinicians must limit their research activities to goals appropriate to their knowledge, training, and

experience. This means asking early and often for help from their colleagues in the traditional academic

(tenure) track, and taking care not to tackle unreasonably large or complex questions. There are many

forms of academic writing that are appropriate for the clinician-educator; however, few clinician-educators

should harbor expectations of obtaining RO1 funding. Likewise, successful investigators in the traditional

tracks should see patients, but with the requisite humility and respect for the extraordinary clinical

challenges of Emergency Medicine, lest they unwittingly do harm. They too should seek the frequent

consultation of their clinical counterparts within the department who care for patients regularly - just as the

latter ought to seek guidance when circumstances are reversed. It is the reciprocal relationships among

faculty as a group, fueled by mutual self-respect and a realistic, open appraisal of individual strengths and

limitations, that drives the machinery of a successful academic department. The chair must take the

responsibility for the choreography required to balance such a delicate ecosystem, in order that the

department as a single, integrated, interdependent entity - rather than each of the individual faculty

comprising that whole - becomes a triple threat.

Thus, we end the first edition of this Handbook on Faculty Development on a cautionary note. Either we

must soften the unrealistic expectations we have placed upon ourselves in the past, or risk driving some

very talented young people away from academic medicine. It is critically important that junior faculty focus

as single-mindedly as possible on an achievable goal, without regard for the lingering and slightly

pernicious mythology of the triple threat. If this can be accomplished - difficult as it may be to let go of

longstanding, cherished illusions - young faculty will at least be given an opportunity to rediscover the

enormous personal rewards and intellectual satisfaction that a career in academic medicine can provide.

Setting the State for Faculty Development

What is Faculty Development?

Author: Glenn C. Hamilton

Introduction

Faculty development is about planned change over the course of one’s academic career. Just as

learning represents changed behavior, faculty development reflects a conscious effort to recognize the

skills necessary to succeed in academic medicine, and to set about attaining them in a planned and

paced manner. It is an endeavor pursued over the entire span of one’s career and should be

consciously integrated into daily activities. Having a "Faculty Development Conference" once a year or

even once a month misses the point. It is a fundamental element of our responsibility as academicians

to our students, patients, and institutions.

Origins

There is an etymologic basis for the term "faculty development". The word "envelope" is derived from

the French term meaning to encircle or encapsulate. Therefore, to "develop" is to expand or set free. A

"faculty" is not only an academic role, but also something that "one can do". Therefore, faculty

development can be considered expanding one’s abilities to perform new and different tasks.

My own experience with faculty development began in 1981 when I became the new Chair of the

Department of Emergency Medicine at Wright State University. Moving into an academic administrative

role only a few years after residency gave immediate insight into the skills necessary to succeed in this

new role. Many of these skills were not clinical, and the focus of my academic activities to that date had

been on teaching. Employing the fundamental principle of "enlightened self interest", a skill set

necessary for me to learn was created and one that also would be exciting for the new faculty I

anticipated hiring into the department. In July, 1982, our first "scope" document was created (a faculty

development process in itself) which included an outline for fundamental skills necessary for all faculty

to succeed in the Wright State University SOM academic environment. This effort grew into

presentations at the Society of Teachers for Emergency Medicine in 1983, first published in the STEM

Newsletter. After that, it was simply a matter of working with a number of interested individuals with a

wide variety of ideas on how to institutionalize this concept as a cornerstone of our specialty growth.

That opportunity came in 1988-89 when the Resident Review Committee in Emergency Medicine was

completing one of its several iterations of the Special Requirements in Emergency Medicine. Included

for the first time was a section that expressed faculty development was a requirement of an academic

faculty and one of the accreditation criteria for a residency training program. The willingness of the

membership of the RRC in Emergency Medicine at that time to include this small addition has had

significant impact on the excellence of both faculty and training programs in the specialty. There are

obviously many other components to insure this excellence, but the fact remains Emergency Medicine is

the only one of 24 specialties that requires faculty development as part of its own Special Requirements.

This is at least one of the reasons why you are reading this now.

Fundamentals

Just like Stephen Covey’s "Seven Effective Habits", there are at least seven fundamental principles to

integrating faculty development into one’s departmental/divisional activities and individual career

planning.

Organization and Implementation is the responsibility of the department/divisional leadership.

Although individual faculty will have motivation to develop themselves, the organization and

implementation of a faculty development program should begin at and be sustained from "the top". The

Chairperson or equivalent has the vision for the institutional unit, the vestment in its success long term,

and the resources available to make planned change as both a tactical and strategic decision. Just as

Demming’s Continuous Quality Improvement principles begin at the leadership level, this kind of

sustained effort supporting faculty development must have the Chair’s understanding and personal

commitment.

Motivation methods are part of success in faculty development. Despite all good intentions, many faculty

members are uncomfortable with change or unsure how to initiate it in an effective way. They need

guidance and encouragement as well as stimulation. Guidance can come from mentorship,

encouragement from rewards, and stimulation from incorporating faculty development as part of the

evaluation process. The educational adage "evaluation drives learning" is as true with faculty as it is with

students. The goal of the rewards is to always emphasize the positive, but on occasion the negative

consequences of avoiding a planned change activity must be clearly communicated. This can only be

done by the leadership of the institutional unit, and the faculty must recognize the leader’s commitment,

or they will be tempted to side step the effort, knowing that it will "blow over" soon enough.

Link activities to the value of the school reflected in promotion criteria.

There are many tangible and intangible rewards to faculty development but one of the most prominent is

promotion. What is valued by an individual must be linked to what is valued by the institution. A faculty

who loves to teach at the bedside, but resides in an institution that only values bench research will

eventually become tired and dissatisfied with being under-appreciated by peers and the institution. It is

the Chair’s role to assure this alignment between individual talent and institutional values.

Part of this orientation is simply faculty awareness of the promotion criteria. These need to be reviewed

with new faculty and again with experienced faculty on at least an annual basis. This can be part of the

annual faculty evaluation. Another part of this evaluation should be the establishment of a promotion file

(Table 1). This simple outline gives one example of a file that can be used to maintain documentation in

anticipation of a promotion application. An annual review of this promotion file by the Chair will go far to

make sure that it is kept reasonably up-to-date. There is no reason for a faculty member to be

scrambling to try and remember what he or she had accomplished five years earlier at the time of their

being considered for Associate Professor promotion. This information is not retained in the curriculum

vitae and documentation of actual scores and performance responses must be included as part of the

document.

Another component of linking individual values to school values is to integrate planned promotion into

the job description. If it takes 8-10 papers to be considered for promotion to Associate Professor and 4-5

years as a reasonable time frame then expecting a faculty member to publish two papers per year in

peer reviewed publications is both appropriate and effective planning. Asking each faculty member to

develop goals and objectives on an annual basis, shaping those goals and objectives to fulfill promotion

criteria as well as departmental goals and tracking those goals and objectives in both private and public

forums is one means of translating individual abilities and desires into institutional recognition and

responsibility.

The "perfect faculty" is created by the assembled skills and talents of all the faculty.

The "triple threat" existence of research, service and teaching is difficult, if not impossible, to maintain

without considerable sacrifice of one’s youth and family. In addition, administrative and interpersonal

skills must be added to that triple threat capability to make it fully effective. There are few, if any,

individuals who can carry it all for a sustained time period.

Both the department leadership and individual faculty members should anticipate that their collective

interests will be served by emphasizing the individual strengths of members in such a way that

departmental goals are attained. Starting with faculty goals and incorporating them into an eventual

departmental strategy allows the individual faculty a clearer understanding of decisions and

opportunities available to other faculty. These decisions should be made in an open communication

environment. We must have mutual collegial support in our institutional units, and recognize the benefits

of differing abilities and aptitudes.

The scope of faculty development content must remain as broad as possible.

The principles of adult education must be applied.

Faculty represent one of the most sophisticated groups in which to sustain educational growth. At the

beginning, adult education principles must be integrated into any faculty development program. These

include the following:

The learner must be active in the learning process. Passivity will beget forgetfulness.

The learner must have the opportunity to practice new knowledge or skills. Learning

without responsibility for applying that learning begets forgetfulness.

The learner must receive immediate feedback about performance of new skills. Mastery

of new skills can not be assumed, and ingraining of bad habits can not be allowed.

It is essential that the underlying principles of new knowledge or skills be understood.

We don’t accept superficiality or the term "cook book" medicine in our specialty. There

is no reason to accept rote, repetitive behavior without fundamental understanding in

our faculty.

New abilities must be transferred into the real world. This is part of reinforcing new

knowledge and skills, but just as importantly making them operational to the benefit of

all.

Different learning methods of individuals must be recognized and appreciated. Taking

the time to analyze an individual faculty’s best educational means is one of the earliest

investments in faculty development.

Integrate expectation of faculty development into the evaluative process.

By making faculty development progress part of the evaluative process, the idea becomes integrated

into the departmental/divisional culture. There are many ways by which this can be approached. At our

own institution we use four components:

1. Spring Retreat - in advance of the academic year, faculty are expected to develop goals and

objectives for their activities during the upcoming year and present them to the other faculty. This

specifically includes a discussion of faculty development skills to be attained. In this discussion, it is the

Chair’s and other faculty’s roles to make suggestions about how this interest in new skills may be

translated into adult learning principles, especially active responsibilities in the department. For

example, one faculty expressed an interest in gaining internet skills. She was given the assignment to

develop the departmental/residential web site, with a time table appropriate for resident review of the

program the following Fall.

2. Fall Retreat - in addition to other topics, each faculty briefly reviews their goals and objectives at a

"mid-course evaluation", and occasional "mid-course confession and need for correction". Having the

responsibility for a public dialogue about one’s progression toward previously espoused goals adds an

appropriate accountability for accomplishing them. If two or three years pass with the same goals being

presented but not accomplished, it is reasonable for both the Chair and other faculty to suggest the

individual rethink the value they are placing on these proposals, and move on.

3. Regular Chair/Faculty Meetings - since we are a relatively small department, there is the luxury of

individual meetings with faculty on a regular basis throughout the year. Faculty development status and

means by which goal accomplishment may be facilitated are a key part of these discussions.

4. Annual Review - since 1982, we have used a 400 point scoring system to assess the performance of

the faculty on an annual basis. Included in this system is a substantial recognition of faculty

development activities.

An important part of implementing this integration of faculty development into the evaluative process is

to make sure that it is established in advance of the academic year. Faculty should understand they will

be expected to progress in the areas they choose and assignments will be made to assist them in that

progression. At the same time, specific departmental needs will be considered as a means of prioritizing

individual faculty desires for new skills.

Anticipate creativity and accept some failures.

Faculty development can not become burdensome. It has to be integrated into individual values and

become part of regular activities. The more open the discussion about specific faculty needs, the more

potential exists for creativity to occur. Bringing in outside talent, sending individuals to conferences,

collectively putting on presentations with specific themes, group writing, group reading, field trips (such

as to the genomics laboratory) are all a part of a creative approach to success in faculty development.

At the same time, failures will occur and should be expected. Those may be process failures such as

attempts for specific types of retreats that don’t work out, or collective reading efforts that gradually

taper off. There will most certainly be individual failures whereby an individual professes an interest in a

specific skill but demonstrate little aptitude for it. The Chair may support an individual for a prolonged

period of time as part of their growth and then have that individual move on to another setting where that

new skill is applied. Accepting that the end point of faculty development may be the reality of the faculty

member moving on to another venue reflects the truth of promoting individual growth.

Library for Faculty Development

One of the benefits of the maturity of our specialty, and this current monograph reflects it, is there are

now a number of valuable resources for faculty to consider in both choosing faculty development topics

and pursuing them. Listed in Table 3 is a sample library given to each new member of the faculty at

Wright State. Whether each of them reads it or not is another question. But, importantly the tone is set

from the beginning that they will be expected to gain skills and are given resources to assist them in

doing so. Over the years, it is apparent that these books are utilized as necessary, but in some way

serve as a reference based safety net for trying new things. The textbook by Carol Bland, et al.

"Successful Faculty in Academic Medicine: Essential Skills and How to Acquire Them" remains one of

the best of the genre.

Future Directions for Faculty Development.

The exciting future for faculty development is only limited by the level of creativity and interest enjoined

by all of the faculty in our specialty. The departmental/divisional leadership has responsibility for making

this occur, and most fortunately, the RRC in Emergency Medicine has assured that a regular review will

be held on this subject. Therefore, the future is bright, and only a few observations on its potential

direction remain.

A continued emphasis on academic management skills must be made. If a faculty

member can’t manage their time, productivity, and money, they will always have

problems in fulfilling their responsibilities in teaching, research and service.

Clinically based cultural competency will become an essential for faculty over the

course of the next 5-10 years. Our specialty is behind in its recruitment of minorities and

we respond academically to the cultural needs of the populations we serve in a limited

way.

Funding for faculty development in Emergency Medicine will continue to be an issue.

We have not been the recipients of generous federal dollars such as has occurred in

Family Medicine. At the same time, as well demonstrated by this handbook, it doesn’t

necessarily take a great deal of money to facilitate motivated individuals. That fact

remains the strength of our specialty.

Summary

Faculty development represents planned change in academic growth. It represents one of the significant

assets of our specialty, and remains a centerpiece of our survival efforts in the ever competitive and

complex environment of academic medicine. Lastly, the best approach to faculty development is a

mature one. To close where I began 20 years ago, approach the subject with "enlightened self-interest".

Always share the new knowledge you have learned with others.

Table 1 - Faculty Promotion File

An integral outcome of faculty development is faculty promotion. It is appropriate that each faculty

member keep a record of activities in areas that will impact on promotion and/or merit pay raises. This

type of file can be invaluable in assisting department chairmen in writing promotion/recommendation

letters, and it allows the faculty member to keep a tally of activities that may not usually be placed in

one’s curriculum vitae.

I. Teaching Activities

1. Major Conferences

2. Topics in Emergency Medicine

3. Yearly Directed Conferences

4. Small Group Conferences

5. ACLS/ATLS/PALS

B. University/Medical School

1. MS 1, 2

2. MS3

3. MS 4

C. Hospital

1. Emergency Medicine

2. Other Specialties

D. Paramedic

E. Nursing/Other

F. Regional/National

G. Evaluation of Teaching Performance

1. Chairman/Faculty

2. Resident

3. Medical Student

4. Clinical Faculty/Practitioners

5. Nursing/Other

6. Paramedic

7. Regional/National

H. Research

1. Manuscripts/Abstracts

2. Meeting Presentations

3. Projects in Progress

4. Grants Prepared

II. Non-Research Publication

1. Case Reports

2. Clinical Reviews

3. Book Chapters

4. Editorials

5. Letters

6. Other

J. Honors/Awards

K. Editorial Board Activity

L. CME

III. Professional Service/Appointments

A. University/Medical School

1. StandingCommittees

2. Task Forces

B. Department of Emergency Medicine

1. Committees

2. Assignments

3. Faculty Services

a. Advising/Counseling

b. Resident/Student Evaluation/Recommendation

c. Residency Applicant Review

4. Other Contributions

C. Community

1. EMS Council

2. Medical Society

3. Hospitals

4. Local/City Government

D. State/Regional Organizations

1. ACEP

2. SAEM

E. National Organizations

1. ACEP

2. SAEM

3. AAEM

4. ABEM

Table 2 - FACULTY DEVELOPMENT CORE CONTENT

1. Accreditation (RRC) / Certification in EM (ABEM)

2. Business Aspects of Academic EM

3. Clinical and Research Use of Statistics

4. Counseling

5. Curriculum Planning / Design

Specific Curricula

Problem-based

6. Decision Making / Analysis

7. Diversity Issues

8. EM in Health Care System

9. EMS/EMS Research in Academic Setting

10. Ethics/Legal System - applied to academics

Misconduct and Fraud

Consent

11. Evaluation Skills

12. Evidence Based Medicine

13. Faculty Development Process / Outcome

14. International Aspects of EM

15. Interpersonal skills

16. Interviewing Skills

Residents / Match Process

Faculty

17. Managerial Skills

Time Management

18. Manuscript Review

19. Media Techniques and Medical Education

20. Medical Photography

21. Medical School Structure / Activities / Roles

22. News / Media Relationships

23. Physical Wellness

24. Political Awareness / Activism

National EM Organizational Issues

Legislative Process

GME Funding

25. Research Skills

Clinical

Basic Science

Grants / Funding

Education

26. Running the Academic ED

27. Scholarly Writing/Presentation/Publications

28. Stress Management

29. Teaching Skills

30. Technology in EM

31. University Hospital organization

32. Use of computer

33. Work vs the rest of your life

Table 3: Sample Library for Faculty Development

Drucker P The Effective Executive, New York, Harper and Row, 1993. (several reprintings)

King Ls Why Not Say It Clearly. 2nd

Ed, Boston, Little Brown, 1991.

Stunk W, White EB The Elements of Style. 4th Ed, New York, MacMillan, 2000.

Whitman N, Schwenk TL The Physician as a Teacher. 2

nd Ed, Salt Lake City, Whiteman

Assoc, 1997.

Huth EJ How to Write and Publish Papers in the Medical Sciences. 3

rd Ed,

Baltimore, Williams and Wilkins, 1999.

Gehlbach SH Interpreting the Medical Literature. 3

rd Ed, New York, MacMillan,

Boston, Little Brown, 1996.

Ingelfinger JA, et al Ingelfinger, JA, et. al. Biostatistics in Clinical Medicine. 3

rd ed., New

York, Mc Graw-Hill, 1994

Sackett DL, et al Evidence-Based Medicine,Edinburgh, Churchill Livingston, 2

nd ed.

2000

Ogden TE, Goldberg IA Research Proposals. 2nd

Ed, New York, Raven Press, 1995.

General References: Bland CJ, et al

Successful Faculty in Academic Medicine Essential Skills and How to Acquire Them, New York, Springer, 1990.

Is Faculty Development Effective?

How to Evaluate the Effectiveness of a Faculty Development Program

Author: Georges Ramalanjaona

Introduction

Evaluation of the effectiveness of any faculty development program (FDP) is crucial to provide

assessment of existing programs as well as yield valid recommendations for designing future programs

that better address the needs of individual faculty members and the sponsoring institutions. Although

evaluation can be a complex and challenging process, we cannot afford to ignore the need because of its

importance for the growth and reputation of our specialty in the house of medicine.

This chapter offers pertinent suggestions on how to evaluate a FDP at local or national levels based on

current recommendations from educational literature. It will discuss the rationale for evaluation, choice of

potential evaluators, current methodology for evaluation, financing of such assessment, and suggest

future research on the topic.

Rationale

There are a number of reasons mandating the evaluation of a faculty development program in Emergency

Medicine. There is a paucity of published studies in our literature on the short or long-term impact on

participants of any educational program. SAEM instituted a national educational program beginning in

1996 but thus far has not published any peer-reviewed articles on its impact on participants or the

specialty of Emergency Medicine. Our specialty is in need of objective guidelines for evaluating existing

programs to assist in planning future activities.

Most of the research in this field has been done by other specialties such as family medicine, pediatrics,

and internal medicine. However, among the few programs that have published studies on evaluation of

their activities, data consisted mainly of satisfaction surveys collected immediately after the conclusion of

the program. Research has shown that participant satisfaction with instruction does not correlate with

change in behavior after instruction. It has been shown that educators can develop and implement more

effective evaluations that go beyond simple satisfaction data. Therefore, the FDP instituted by SAEM, as

well as other FDPs, should be subjected to a systematic, regular, and comprehensive evaluation to

assess desired outcomes on participants to determine its efficacy. We propose evaluation strategies

(validated from the literature) that include learning, performance, and satisfaction data. General principles

of faculty development program evaluation can be tailored to our national, regional or local educational

programs since there are no current uniform guidelines for evaluating faculty development programs in

emergency medicine.

Assessment of the effectiveness of any FDP can be performed by sponsoring organizations or by

independent evaluators experienced in the field for better objectivity.

The proposed methodology describes the ideal evaluation model that is available to all FDPs. However,

since the full implementation of this model is time-consuming and costly, its application should be tailored

to each individual and regional program, as well as to programs sponsored by national agencies.

Methodology

Kirkpatrick, in his Practical Guide for Supervisory Training and Development Handbook (1), has described

an evaluation model with four levels of program outcomes:

The first and simplest outcome level is reaction (satisfaction data), which focuses on

participants' satisfaction with the program (Level 1).

The next outcome level is cognitive (learning data), which refers to program influences on

changes in knowledge and learning attitudes of the participants (Level 2).

The third outcome level measures behavioral changes (performance data), which point to

measurable trainee activities outside the training environment that can be attributed to

faculty development program influences (Level 3).

The final step is the results outcome level, which focuses on the impact of a faculty

development program's influence on the learner's career (Level 4).

Many experts in the field believe that evaluators should focus on higher evaluation levels

rather than just the participants' satisfaction (Level 1) to increase stakeholder support for

the program.

Following Kirkpatrick's Model three types of data should be collected over a period of

time starting from the first day of the program and continuing until nine months after

completion. These include 1) satisfaction (reaction data), 2) learning (cognitive data) and,

3) performance data (behavioral data).

Three different types of instruments are used to collect the three types of data: 1) End of

Session Evaluation Forms, 2) Pre-Test, Post-Test, and Delayed-Post Test assessments,

and 3) Delayed Follow-Up Interviews.

1. End of Session Evaluation Forms

The focus of this instrument is to report participants' satisfaction with instructors, curriculum, facilities, and

the whole program. Learners may also be asked to provide self-assessments of their competence on

selected session topics.

2. Pre-Test, Post-Test, Delayed Post-Test

The same test is administered as the Pre-Test, Post-Test, and Delayed Post-Test to assess, respectively,

initial knowledge, changes, and retention of cognitive knowledge up to nine months later. This test

instrument should encompass all the essential elements taught during the faculty development program

(i.e. conference, workshop). Testing methods can vary between written and other testing methods

depending on budgetary and time constraints. Participants' knowledge and skills should be tested in the

following six emergency medicine domains, depending on the curriculum of the faculty development

program being evaluated: Research, Education, Grant Administration, Academic Skills, Mentoring, and

Professional Communications.

All three sets of tests (Pre, Post, and Delayed Post) should be scored independently by two raters trained

by the evaluators. To ensure inter-rater reliability, each rater independently scores all three sets of tests.

Then all three-test scores from both raters are averaged to arrive at a single score for each participant on

each test. Cohen's Kappa Test to determine inter-rater reliability should be performed if tabular marginals

are balanced. If they are unbalanced, simple proportionate interrater agreement, although unadjusted for

chance, may be methodologically preferable. . The reliability of this type of process has been reported to

be high (KAPPA > 0.75) and has both content and criterion validity. (2,3)

The effect of the faculty development program on the specialty of emergency medicine can be evaluated

by comparing the outcome scores of the participants of the program (Experimental Group) with the

outcome scores of randomly selected, non-participants (Control Group) using the Pre-test/Post-Test

design on both groups. The number of Control Group Faculty should equal those of the Experimental

Group.

3. Follow-Up Interview

This investigation has the goals of 1) gathering additional information from participants concerning

satisfaction, learning and performance data and application of session content at the participants'

institutions and, 2) determining participants' current status in academic emergency medicine, their

scholarly productivity, and assessing how well their faculty development program prepared them for their

current academic position.

Finally, the evaluator should interview the Program Director of the Faculty Development Program

(National and Regional FDP) using a separate interview protocol with open-ended questions.

Data Analysis

Data analyses should contain both quantitative and qualitative information.

For quantitative items, standard parametric and nonparametric statistics are used, depending upon the

distribution of the data and sample size. Qualitative analysis of open-ended questions is conducted by

grouping similar comments for each question and instrument.

Financing Faculty Development Evaluations

The financial support for development and implementation of evaluation of faculty development programs

can be provided by a variety of funding sources that can be used singly or in combination:

Internal institutional support: Department Chairs must use their resources not only to

balance organizational with individual faculty member's needs but to evaluate the

effectiveness of their faculty development program.

External private funding.

External public grants such as the Federal Grant Program specific for Faculty

Development in Family Medicine.

Future Research

Questions that should be raised to evaluate the effectiveness of the existing programs and the success of

future activities include:

1. How successful is the program in preparing young faculty for their academic careers?

2. Do the current Local/Regional/National Programs fulfill the academic needs of emergency medicine

participants?

3. What is the long-term impact of faculty development programs on participants' academic productivity

and professional careers?

Conclusion

We have provided a guideline for evaluation of existing faculty development programs based on the

current literature of adult medical education and research performed in the field. We need to acknowledge

that this is an evolving field even for the established medical specialties. Our involvement in the research

and application aspect of the evaluation process will be invaluable for the growth and maturity of our

specialty.

References

1. Kirkpatrick D.L. A Practical Guide for Supervisory Training and Development. Reading, Mass; Addison-

Wesley, 1971

2. Hewson M.G., Copeland L.H. Outcomes Assessment of a Faculty Development Program in Medicine

and Pediatrics. Academic Medicine. 1999; 74 (10): 568-571

3. Morzinski J.A., Schubot D.B. Evaluating Faculty Development Outcomes by Using Curriculum Vitae

Analysis. Fam. Med. 2000; 32(3): 185-9

Additional Bibliography

Bland C.J., Stritter F.T. Characteristics of Effective Family Medicine Faculty Development Programs.

Fam. Med. 1988; 20: 282-8

Hamilton G.C. Faculty Development in Emergency Medicine. Am. J. of Emerg. Med. 1988; 6(5): 540-4

Hitchcock M.A. et al. Faculty Development in the Health Professions: Conclusions and

Recommendations. Med. Teach. 1993; 14(4): 295-309

Irby D.M., Hekelman F.P. Future Directions for Research on Faculty Development. Fam. Med. 1997;

29(4): 287-9

Reid A. et al. Assessment of Faculty Development Program Outcomes. Fam. Med. 1997; 29: 242-7

Royse D.D., Thyer B.A. Program Evaluation: An Introduction Chicago: Nelson-Hall, 1996

Sheets K.J., Henry R.C. Evaluation of a Faculty Development Program for Family Physicians. Med.

Teach. 1988; 10(1): 75-8

Organization, Prioritization, and Time Management

Organization, Prioritization, and Time Management Skills

Author: Debra Perina

Introduction

One constant in the universe is that time advances regardless of how much we might wish it wouldn’t.

Day turns into night, we advance in age each year, and deadlines continue to creep up on us before

they’re even set (or so it seems)! Developing organizational skills as well as effective time management

and prioritization techniques are paramount to success as an academician. All who choose an

academic career engage to varying degrees in the components of the "three-legged stool" of clinical

practice, teaching, and research. Of course, each of these components could easily make up a 40 hour

work week. However, to have a fulfilling career and be successful in achieving promotion and tenure

one must demonstrate excellence in scholarship in at least two of these three areas, with the weighting

of each varying greatly from one institution to another. Productivity is largely dependent on effective

time management. Since we all operate with a finite amount of time, it is important to learn techniques

to optimize the time we do have, being ever mindful of the necessity to achieve a healthy balance

between the time needs of an academic career and our personal lives.

Setting Priorities

Early on in an academic career, one quickly realizes that a balancing of priorities must occur. Clinical

practice time will obviously be a constant that will be minimally affected by time management

techniques. The remaining time must be divided between teaching, administrative and research efforts.

Time must be allocated to each of these areas for career growth and success. Establishing priorities for

each of these areas must be individualized according to the career goals one has set. Teaching and

administrative activities often fill the majority of non-clinical time. However one must remember that

effective research is absolutely necessary for academic advancement. This can only be accomplished

if you develop a plan and have specific goals. In spite of this, young academicians rarely appreciate the

necessity for dedicated research time. Research time is frequently carved out of time left over from

clinical, teaching, and administrative assignments. This approach rarely leads to success. Early on, in

an academic career it is just as important to schedule dedicated time for research as it is to allocate

time to other activities. Try to schedule a dedicated time each week devoted to research and guard it

jealously. This works best if the time is spent outside the office to avoid interruptions and impromptu

meetings.

Clinical Workload

As ours is a patient centered specialty, a certain amount of clinical workload is welcomed for personal

satisfaction and clinical teaching opportunities as well as necessary to generate revenues. However, a

certain amount of protected time from clinical activities is necessary to be productive in other academic

areas. Most academic departments reduce clinical load for faculty to ensure their (and the

department’s) academic success. As changing reimbursement patterns whittle down departmental

finances, more pressure exists to offset costs with clinical revenues. In general, if clinical time exceeds

28 hours per week, it becomes extremely problematic for faculty to sustain academic productivity.

Potential ways to offset clinical time beyond negotiated work hours include clinical buy-down time from

contracts or grants, stipends for administrative assignments, or pass-through fees for lectures,

presentations or legal work.

Administrative Tasks

Emergency medicine junior faculty are frequently given more administrative assignments than junior

faculty in other departments. These assignments often require many meetings and significant office

time. If possible, try to limit the amount of administrative assignments during the first 3 years of your

career. This will allow you to establish yourself and develop a routine that can then be used to carve

out administrative time. If you are given an administrative assignment try to negotiate something in

return, such as a decreased clinical workload, more secretarial, or research help to offset the time you

will spend doing administrative tasks. If given a choice of tasks, try to choose one that is most

consistent with your areas of interest or research. Thus you can combine interests and goals to

enhance productivity. One example of this would be appointment of an individual with research

interests in patient outcomes as the quality improvement. Try to combine the research interest with

administrative tasks and design a project looking at patient outcomes that can double as a quality

improvement indicator. Get triple duty from this assignment by developing a lecture series on quality

improvement for the residency and designing a rotation as part of the administrative experience for the

residents. You have now combined the areas of research, teaching, and clinical practice into one area

that coincides with your administrative assignment. This will significantly reduce the marginal time

expenditure required to accomplish each of these tasks, compared to achieving them in unrelated

areas. This also has the added bonus of creating a "focus area" whether you intended to do so or not,

which is something that many promotion committees look for as evidence that you have an area of

excellence.

Meetings: Schedule your own meetings, or make sure that you approve all meetings before they’re

scheduled. If you do not control the number of meetings you attend, you will quickly find they take up all

your free time. Make sure you know the purpose of a meeting prior to agreeing to go. If there is no

defined purpose or the meeting does not have a direct relationship to your area of expertise or

assigned administrative duties, you may not want to invest the time unless your presence is absolutely

necessary. While offers to join committees are flattering, be aware that they can take on a life of their

own. If you are an effective contributor you will likely be solicited for further committees. Although some

committee work is necessary for career growth and can open doors for involvement in state and

national organizations, you must choose how to spend your time wisely to avoid being over-extended.

Time Management Principles

With only limited time to accomplish your goals, time management principles are the key to success

and happiness as an academician. Effective time management revolves around good planning. Experts

estimate that for every hour of planning three hours of time are gained. There are several key

components to managing time effectively. Each are discussed below and in further detail in Chapter

4.9.

Develop a mission statement: This is a statement of what you want out of life and your career in

relation to it. From this statement develop specific goals to help you achieve your personal mission

statement. These goals will help you decide how to spend your time. When faced with a new

assignment or task, compare it against your personal goals and mission statement. This will help you to

decide if the task is worth the time invested, and give you the ability to prioritize the task on your

accomplishment timeline. You should re-evaluate your personal mission statement at least once every

six months to make sure that it is still consistent with your view of what you value in life and where you

want to be.

Set goals: Goals should be set in conjunction with your mission statement. What needs to be done to

get where you want to be? Each step should be a defined goal. Setting appropriate goals can be

difficult. Remember to be realistic. Goals should be challenging, forcing you to grow and develop. If you

reach all defined goals too quickly, you are probably setting them too low. On the other hand, setting

goals that are too high or unobtainable will only frustrate you and diminish your overall productivity.

Take small steps initially building on each success to reach goals. Reset your goals frequently to

ultimately achieve the final endpoint in your mission statement. Deadlines should be set for each goal.

Setting realistic goals is very important. However, they cannot be set unless you understand your job

expectations and requirements. This is where a mentor can be invaluable. A well chosen mentor can

help you review your goals, determine if they are realistic and appropriate, and provide you with ideas

for reaching them. To achieve a balance in one’s life, personal goals should be set in conjunction with

career goals. This synergism ultimately leads to greater productivity because you naturally feel most

fulfilled if both your career and personal life coincide with your image of yourself.

Organizing calendars and prioritizing: Create a daily schedule and stick to it as much as possible. Try

to minimize the number of interruptions that may interfere with staying on schedule. Such "time

robbers" include impromptu meetings and phone calls. Get a personal organizer and keep it with you at

all times. Consult and update it frequently. Prioritize items to be accomplished. This is not simply

creating a "to-do" list, but setting out the proper priority of each task in order to achieve the best quality.

All of us have peak creative times that correspond to our natural circadian rhythms (so-called larks

(day) and owls (night)). Try to use your naturally most creative time to write publications, review

articles, or work on research projects. Since answering email is less mentally tasking, save it for other

times. Try to answer your emails only once a day, as this can be a real time sink. Although it is

important to spend office time when your colleagues and others can interact with you, an open door

policy will likely make it very difficult for you to accomplish your goals. It is better if you can spend a

portion of your office time during off-hours to avoid interruptions. Many seasoned academicians find

this to be their most productive time. Just as important as working in the office is "downtime" to

recharge your batteries. This is the time devoted to the things in life you enjoy doing recreationally.

Remember to schedule this time. It is just as important to your overall success by helping you to

maintain focus and optimum performance.

Delegate: Learn to delegate effectively! Many of us do not delegate items well, believing we can do

them faster and better than others. It is a simple fact of nature that we can’t do everything. It is

important to make the distinction between what you can assign or teach others to do versus those

tasks that only you can achieve. This type of prioritization allows you to be most effective. Others

produce some of the needed items leaving you enough time to produce the items only you can create.

Make a timeline for completion of projects and update your progress weekly. This can help you keep

tabs on how your time is spent and can also be important when asked for accountability and

productivity.

Just say no: Early in your academic career it is important to take advantage of opportunities offered

you. This said, it is equally important not to over extend yourself in order to be able to complete projects

you undertake well and within the defined timeline. Each task should be compared against your

personal mission and goals. Accept the assignment if it is consistent, and time allows you to do a good

job. Never say yes to a project if you don’t have enough time to complete it effectively. To do so will

cause you more harm then good in advancing your career. Learn to say no gracefully to projects that

do not fit with your career goals. If your Chair or others assign you more tasks than you can manage

effectively, speak up and ask which tasks can be delayed in order for you to do the best job possible

with all assignments.

Avoid Procrastination: It is human nature to procrastinate to some extent. We all occasionally defer

activities that seem overwhelming or we dislike. This is the greatest pitfall in time management. When

procrastinating on a project, it is helpful to break it up into small pieces. Working slowly to complete

each small piece will help you get over the "overwhelming" feeling of a particularly difficult project and

past the procrastination hurdle. Some find it useful to build in a series of rewards for those projects that

are particularly problematic (I’ll finish background research for that chapter, then I’ll see that movie I’ve

been wanting to). All of us are overburdened with mail and paper that form obligatory stacks on our

desks. A good way to lose time and one of the most common "time-robbers" is to procrastinate taking

care of these items and constantly reshuffle the stacks. A good rule of thumb is to not pick up a piece of

paper more than twice without taking some sort of action on it. If it has been on your desk for more than

a week without any action, then it probably didn’t really need your attention in the first place. You

should either throw it away or delegate it to others allowing you to spend your time in more productive

pursuits. Reading and answering email can not only be a time sink but can also be an effective way of

procrastinating. As noted above, try to read your email only once a day. Set aside a specific time to do

so. Resist the temptation to log on frequently throughout the day, which will likely result in a loss of

focus for completion of more complicated projects.

Recapture lost moments: Many moments are lost during the day that, if recouped, can add up to a

significant savings of time. All of us spend time commuting to work. Use this time to listen to CME tapes

or plan your day. The careful use of a hand-held dictaphone or cell phone to catch up on

correspondences and calls or create to do lists can be very time saving. Take advantage of time spent

waiting in line by carrying journals, reading mail, or reviewing your personal organizer.

Information management

If you are not computer literate, it is well worth the investment of time to acquire these skills. Using your

computer as an information resource or for database management can save countless hours.

Presentations and handouts can be quickly and expertly created. Databases can be designed or

procured for almost anything, including storing and managing references. These can be indexed and

cross-referenced with key words and a unique number can be assigned to each article. The numbers

can then be used when writing manuscripts, and the computer will automatically place the references in

correct order in the final manuscript. It is also possible to catalogue 35 millimeter slides to allow for

quick cross-referencing to create a variety of "mix and match" lectures. Become skilled in Medline

(Pubmed) and web searches. Develop an effective filing system that will allow you to retrieve

information when needed. Utilizing computer technology to document scholarly activities can also be

very useful. Not only will you quickly be able to sort items for inclusion in teaching, research, and

clinical portfolios, you will capture items otherwise long forgotten when putting your promotions packet

together. You can pre-program reminders to solicit needed promotion documentation after each activity

if it is not forthcoming.

Practice and Reap the Benefits

Effective time management requires careful planning and a great deal of concentrated effort on your

part to make the concepts part of your daily routine. Once you embrace these techniques you will

quickly find the benefits of maintaining control over time, rather than being dragged along by it, far

outweigh the effort expended. Productivity will increase, and there will be more time to do the things

you enjoy. The overall result is a more satisfying and successful career.

References:

1.Applegate WB: Career development in academic medicine. Am J Med 1990;88:263-267.

2.Perina D, Chisholm C: Physician wellness in an academic career. Hobgood C, Zink B (eds):

Academic Career Guide. Society For Academic Emergency Medicine, Lansing Michigan, 1999, pp 53-

55.

3.Sheely G: New Passages: Mapping Your Life Against Time. Random House, New York, NY, 1995.

Faculty Development for Women

Author: Rita Cydulka

Until a few decades ago, the main challenge for women in medicine was achieving access to a faculty

position. Now, women constitute almost one quarter of full time faculty in academic emergency

medicine. This closely reflects Only 5% have achieved tenure in their institutions. Compared to men,

women in emergency medicine are over represented in the lower ranks (instructor and assistant

professor) and under represented in the higher ranks (associate professor and full professor) and in

achievement of tenure. In addition, women lag behind men in leadership positions and administrative

responsibilities. Men in emergency medicine are more likely than women to spend more time performing

administrative tasks, and to hold or to have held, leadership positions. Women, on the other hand,

spend a higher proportion of their time in clinical practice and teaching. In a recent more books than

their female counterparts.

Of note, in the same survey, women were 15 times more likely than men to indicate that their career

advancement was made more difficult as a result of their gender. Although access to faculty positions is

no longer the problem it was a couple of decades ago, creating a successful and satisfying career may

still be. This monograph is intended to help women avoid some of the pitfalls in a career in academic

medicine that those who have preceded them have reported.

Upon entering a career in academic medicine, women must decide what opportunities exist and what

pathway to choose. Choices include a career in academics in the strictest sense, i.e. a grant supported,

publish or perish pathway, a career devoted to clinical medicine, a career that centers around

educational endeavors, or a career in academic administration. It is crucial that women beginning in

academic medicine understand their career path and, more important, what leads to success in that

path. It is also crucial to appreciate fully the mission of their institution and their department. Knowledge

about their institution’s structure, career path rewards, key players, and promotion procedures is crucial

to success. If the institution’s system of reward and promotion within the academic center is not "in

sync" with that of the faculty member, she will be unsuccessful.

Determining Goals

As one embarks on a new career as a woman in academic emergency medicine, consider short term

and long-term goals and ask the following questions:

Where do I want to be in one year, in five years, and in ten years?

What are my skills? Do I have particular strengths that are in demand?

Do I have all the skills I need to achieve my goals? If not, what additional skills do I

need? What extra training should I consider to be qualified to achieve my goals?

On what schedule must I advance? Who will make the determination whether I

advance? Who will evaluate me in addition to my department chair? Do non-clinical

faculty from other departments within the university influence my promotion?

What are my needs? What are my limitations?

Will the position I currently have enable me to advance toward my ultimate goal or will I

need to pursue other opportunities to meet my goals? Can I modify my current job so

that it will help me achieve my goals?

How do I respond to authority? How do I feel about being in authority?

Understanding the Environment

It is vital to understand the rules by which evaluations are determined: the written rules in the university

handbook and- perhaps more important- the unwritten rules. For example, if one chooses education as

the pathway of pursuit, one must ascertain whether teaching and clinical activities are rewarded with

academic promotion in your institution. Women in academic emergency medicine tend to spend more

time in clinical practice and teaching than do men, even though teaching and clinical time rank low

among the criteria for academic promotion in most institutions.

Many women have noted that they begin their careers at a disadvantage because of unequal footing at

the start of the race. Women must insist on the support that is needed for development. This support

includes secretarial, technological, and financial support. Women must clearly understandthe

compensation used in their departments. Is the compensation based on clinical productivity, academic

productivity or both?

Early on, note the department’s and the school’s record on 1) recruitment policies for women, 2) efforts

to recruit senior women to tenure positions, 3) mentoring of women, 4) faculty development of women,

5) salary lines of women compared to men, 6)procedures to monitor trends of appointments,

promotions, and numbers of women faculty at all ranks, 7) strategies for retaining women faculty at all

ranks, 8) family/parental leave policies that allow extended time for promotion and tenure during child

bearing years and, 9) retention records for women. A school that actively and successfully recruits

women but fails to retain them is not likely to be a school that is friendly to the needs of women. If this is

true at your medical center, stay alert!

Issues affecting the advancement of women vary from institution to institution. How these issues are

addressed, however, will affect the environment one faces in academic emergency medicine. Many

academic medical centers are examining the issue of gender equity and trying to address a particular

obstacle that affect female faculty (Carr, 1999). Women should note whether their institution is one that

has had problems with gender bias in the past and, if so, what steps (if any) are being taken to address

these problems.

Several studies have shown that women faculty continue to face disadvantages compared to men in

garnering resources, equitable compensation, and gaining promotion and tenure. Be sure that women

are starting on equal footing with male colleagues. Watch early for feelings of isolation and alienation,

not only because of outward discrimination but because of subtle forms of discrimination, such as not

being included on research projects, not being invited to discussions, and being "benignly" ignored.

Some of the reasons put forth to explain why women in academic medicine do not achieve success at

the same rate as men include a sense of isolation, sexism, cultural stereotypes, and difficulties

combining family responsibilities with professional demands.

Research has shown that as women in academic medicine progress they become more and more

isolated and feel they are subject to more intense scrutiny than men. As a result, women may

experience decreased self-confidence, exclusion from access to informal networking, and lack of

continuity of helpful relationships with colleagues.

The Value of a Mentor

Choosing a mentor or entering into a mentoring relationship is crucial. Mentors can help with knowledge

and skill transfer to the mentee, provide motivation, direction, and confidence building, actively promote

the interest of the mentee among others, and provide access to institutional resources that may

otherwise be unavailable to junior faculty. Finally, a mentor may help the mentee secure appointments

on committees and among select groups. Women should feel free to call on different individuals for help

with different goals and needs and take into account the values and characters of individuals from whom

they seek advice. Mentors can provide advice on career management, help one to understand the

values, norms, and expectations of academic emergency medicine in the institution, and can assist one

in developing and maintaining a productive network of colleagues.

Relationship and communication skills are critical to becoming a successful academician. Women must

try to discover important researchers and collaborate with them on projects that are likely to become

successful. These informal networking relationships will support one’s productivity and introduce women

to other people who are similarly productive. Research has shown that women in mentoring

relationships publish significantly more papers than do women not in mentoring relationships, but also

work significantly more hours per week.

Unfortunately, networks of women faculty have not been as effective as those of their male colleagues.

The former tend to include fewer faculty of high rank and fewer associates from previous institutions.

Perhaps the most important source for developing collegial mentoring relationships among women is

through professional associations such as SAEM or ACEP.

Communication and negotiation skills are essential for women wanting to succeed in academic

emergency medicine for defining and modifying job responsibilities, as well gaining resources, obtaining

a raise, formulating limitations on expectations, and recognizing and dealing with conflicts. To be an

effective negotiator, women must be able to recognize and deal with conflict. Women, as a group, must

overcome the desire to dodge confrontations, accommodate the other person, compromise goals, or

avoid conflict altogether. Learn to say no. As a junior faculty, one’s tendency will be to say "yes" to all

opportunities that come one’s way. Agreeing to too many tasks that won't ultimately achieve one’s

goals, which are done at the expense of tasks that are important to both the individual and to her Chair,

will ultimately prove frustrating and will negatively impact achieving one’s goals. Women must learn to

appear confident, recognize the opportunity for self promotion, and prepare for negotiations by

understanding the negotiating style of their superiors.

The Leadership Role

Women must plan to be leaders. Women in our society have been conditioned from birth to suppress

taking a leadership role. A commanding voice and fighting are considered undesirable traits in girls

while encouraged in boys. Women in medicine have developed the trait of leadership inadvertently: they

have convinced their families, college advisors, medical school administrators, and their residency

directors that they have a right to a position in medicine. Women in academic medicine should plan to

take this role one step further and advocate for a position among their departments’ leadership. They

should ask their Chairs what training he or she can offer in leadership skills. For only when women are

represented as leaders in emergency medicine will they be able to serve as role models for younger

physicians.

Balancing Career and Family Needs

There are no easy answers in addressing the family issue. Each individual (both females and males)

must decide for themselves how much time to commit to their personal relationships and family and how

much time to commit to their academic career. Successfully combining parenting with medicine takes a

lot of planning, a lot of luck, and many supportive relationships in the home and in the work place. Some

schools have acknowledged these problems and have made provisions, such as lengthened periods on

the tenure track, flexible scheduling, and job sharing. Whether choosing to work full or part time, one

must be sure of the following: clear expectations for performance are established; some time is

protected for research and writing, and time spent on committee work and administration is initially

minimized. Women must be ever vigilant that they are pulling their weight. There is no substitute for

hard work!

It has been frequently noted that when men leave work early or fail to attend a meeting because of

childcare responsibilities, they are looked at as exceptional fathers. Unfortunately, the same doesn't

hold true for women. They are labeled as uninterested in academic success or delegated to the

"mommy track". Be aware of how and why these issues are addressed by peers and department

leadership.

Conclusions

In summary, women have come a long way in academic medicine in the past few decades but still have

a long way to go in order to achieve equity with men. Planning for success is the first step in achieving

this goal.

References:

1. Anonymous. U.S. Medical School Faculty 1997: Faculty Roster System. In: Colleges AAMC, ed.

Washington, D.C., 1997.

2. Cydulka RK, D'Onofrio G, Schneider S, et al: Women in academic emergency medicine. Acad Emerg

Med 2000;7:999-1007.

3. Carr PL, Friedman RH, Moskowitz MA, et al: Comparing the status of women and men in academic

medicine. Ann Intern Med 1993;119:908-913.

4. Tesch BJ, Wood HM, Helwig AL, et al: Promotion of women physicians in academic medicine. Glass

ceiling or sticky floor? [see comments]. Jama 1995;273:1022-1025.

5. Carr P FR. Gender diversity-struggle in the glass house. Mayo Clin Proc 1999;74:201-203.

6. Bickel J: Women in academic medicine. J Am Med Womens Assoc 2000;55:10-12,19.

7. Bickel J. Scenarios for success--enhancing women physicians' professional advancement. West J

Med 1995; 162:165-169.

8. Cole JR SB. The Outer Circle: Women in the Scientific Community. In: Zuckerman H CJ, Bruer RT,

ed. A Theory of Limited Differences: Explaining the Productivity Puzzle in Science. New York: W.W.

Norton and Company, 1991.

9. Hall L. Negotiation: Strategies for Mutual Gain. Newbury Park, CA: Sage Publications, 1993.

10. Caplan P. Lifting a Ton of Feathers: A Woman's Guide to Surviving the Academic World. Buffalo,

NY: University of Toronto Press, 1993.

Faculty Development for Minorities

Author: Marcus L. Martin

In this chapter Faculty Development for Minorities is discussed. It is important first to delineate who are

considered minorities in medicine.

Minorities in medicine may be classified in broad terms to fall in the ethnic/racial groups of Asian,

Hispanic, Native American, African American and other.

The Association of American Medical Colleges (AAMC) has classified under represented minorities in

categories of black Americans, Native Americans, mainland Puerto Ricans and Mexican Americans. As

the number of underrepresented minorities (URM’s) in the US population has risen over the years

(currently between 20 – 25%) the number of medical school applicants has only attained an all time high

of around 12% or about 0.5 representation factor, (ie 20% US population only 10 to 12% medical school

applicants.)

In 1954 the US Supreme Court decision Brown vs The Board of Education ended with a mandate to

desegregate public schools. However, many schools did not desegregate until many years later. I

attended first grade in Virginia in 1954 but my school system did not desegregate until my senior year of

high school. Many school systems in Virginia shut down rather than integrate. Lower socioeconomic

status, inadequate schools, labs, and lack of well trained teachers have hurt minorities historically.

Resources and opportunities are generally better now than years gone by. The civil rights act of 1964

has helped to bring about further changes which enhance advancement of all people of color, whether it

is academic medicine or some other arena.

Underrepresented minority medical students in the 1950’s approximated 2% of the total student

population and stayed at that level throughout the 60’s. By the 1970’s the number of underrepresented

minorities in medical school had increased to around 8%. This progress to a large extent was due to the

affirmative action efforts of the AAMC and the Robert Wood Johnson Foundation’s provision of

scholarships for women and minorities. By the 1990’s the underrepresented minorities in medical school

enrollment reached 10%. During the mid to late 1990’s anti-affirmative action activity thwarted to some

degree the AAMC’s "3,000 by 2,000" efforts. The AAMC pursued achieving 3000 URM students enrolled

in the first year classes of medical schools by the year 2000. The maximum URM enrollment had

reached around 12% (about 2000 students) in the first years class by year 1998 but quickly sagged to

10% again in subsequent years.

First year medical students entering each year roughly approximates 8.0% for black Americans, 2.7%

for Mexican Americans, 0.7% for mainland Puerto Ricans, 0.8% for Native Americans and 19.3% for

Asians.

URM’s comprise about 8% of Emergency Medicine residents, while practicing URM’s in emergency

medicine equal about 5% of total emergency physicians. In academic emergency medicine URM’s

account for about 3.5% of the total faculty.

Underrepresented minorities as a population are associated with a disproportionate share of medical

and economic ills, as well as disproportionate utilization of emergency services. It is very important for

underrepresented minorities to become larger in numbers in medicine as well as academic emergency

medicine for many reasons.

1) The advancement of cultural competency. Underrepresented minorities are needed to be a part of

medical institutions and faculties, in particular emergency medicine because of the potential for

improving upon the cultural competency of patient care provided by all races/ethnicity. As we improve

upon our scientific competence, it is also important to obtain cultural competence so that we can

communicate appropriately with patients and improve patient compliance and enhancement of care.

2) Considering the low numbers, minorities in academic medicine may be viewed as an important

addition to the faculties of institutions for various reasons, not the least of which will be financial security

of the institutions required by law to actively hire minorities.

3) A diverse emergency medicine research agenda is essential, and conceptualizing health problems is

dependent upon a diverse research work force.

4) Diverse students and faculty learn and teach about cultures, values and beliefs of their communities.

5) It is important to remedy the effects of past discrimination, protect diversity of human talent, provide

rewarding career opportunities and increase the minority mentor pool.

6) Diversity among health care leaders is economically essential as medicine is a trillion dollar annual

corporate enterprise.

Faculty development needs in emergency medicine are essentially the same for URM’s as for non-

URM’s. However, this chapter covers some additional suggestions beyond the general requirements

that minorities should consider.

GENERAL REQUIREMENTS

To achieve success in academics, faculty must have achieved academic success in college and

medical school. Entry into residency programs is competitive and in past years graduation from

residency was often the primary requirement for participation as a faculty member. A resident

completing a three or four year emergency medicine residency program could apply to most academic

programs and would receive serious attention. Although this is still true to some extent today, it has

been my experience that with the addition of five year combined programs and fellowships that the

competition for these positions has become stiffer. Even in the situation where completion of a three or

four year program as a chief resident potentially makes a candidate more attractive, completion of

fellowships make the candidate far more attractive for academic faculty positions. Therefore, it is

suggested that some advanced preparation such as a fellowship in research, administration or sub-

specialty such as EMS, Toxicology, Sports Medicine, Pediatric Emergency Medicine, Neuroscience or

advanced degrees such as a Ph.D. or MPH should be considered as additional preparation for faculty

development.

INTERVIEW PROCESS FOR AN ACADEMIC FACULTY POSITION

During the interview process for a faculty position a potential new faculty member should get as much

information as possible about the job requirements and should review a written description of the

particular job and academic track in the medical school or hospital where he/she will be working. It

should be clear whether the clinician is entering the clinician-educator track/pathway or a clinician-

investigator track/pathway. There are very important distinctions between academic tracks/pathways. A

clinician-educator track usually involves more clinical work and more teaching and the clinician

investigator track usually involves more time in the lab or performing clinical research. The potential new

faculty member should receive a letter from the department chair and/or medical school dean outlining

the job description and the particular track. The letter should indicate whether the faculty member is

coming in at the instructor level (typical for fellowship positions) or the assistant professor level. You

should understand clearly how many years in rank is ordinarily required to advance from assistant

professor to associate professor and from associate professor to professor, and how long it takes to

become tenured if you are on a tenure track. You should also find out in advance of taking an academic

position what constitutes scholarly activity and excellence in the Medical School with which you will be

affiliated. Generally, research with publications that impact the specialty, constitutes scholarly activity in

the traditional track. Many institutions also consider educational development (ie, course curriculum,

teaching modules) that impact the specialty as examples of scholarly activity in the clinical track.

SCHOLARSHIP

As noted in the Preface, Scholarship was chosen as the primary organizaing principle of this Handbook.

There are four areas of scholarship as defined by Boyer. They are the scholarship of discovery, the

scholarship of integration, the scholarship of application and the scholarship of teaching. The

scholarship of discovery or research for decades has been the area of primary focus for promotion and

tenure in medical schools even though faculty have had major responsibilities in the other areas of

scholarship (Beattie). Find out what types of publications qualify at your institution, (ie will book chapters

and abstracts qualify as well as publications in peer reviewed journals?) Generally, scholarly activity is

that activity which focuses on a specific area of the specialty and which has an impact upon the

specialty, (ie education or curriculum that could be used in medical schools, residency programs or by

clinicians) and/or research that affects how we practice. Institutions may require excellence in one or

more categories such as excellence in education/teaching, clinical excellence or excellence in research.

Find out what is expected and in how many categories and to what degree you must demonstrate

excellence. Make sure during your negotiation with the chair or medical school dean that you get

everything in writing including your salary offer, the description of your position, and the promotion and

tenure information. On top of that you must make sure that supportive items such as computers, office

space, CME support, and lab space, if relevant, are all clearly spelled out in a letter.

PROMOTION AND TENURE

Minority faculty at both the assistant and associate professor rank are lagging in rates of promotion

compared to white faculty, even though their representation in academic medicine has steadily

increased over time. (Fang) Comparing cohorts from the 1980’s, by 1997 46% of white, 37% of Asian

Pacific Islanders, and 30% of URM assistant professors had been promoted. Similarly by 1997, 50% of

white, 44% Asian Pacific Islanders, and 36% URM associate professors had been promoted. (Fang)

Minority faculty are less likely to be tenured or on tenure tracks, less likely to be RO1 or other NIH

award recipients, and more likely to have appointments in private medical schools. (Fang)

In Fang’s study, compared to whites, URM assistant professors were more likely to be graduates of US

medical schools whereas Asian Pacific Islander assistant professors were more likely to have a Ph.D.

degree or be affiliated with basic science departments. URM and Asian Pacific Islander assistant

professors were more likely to be female.

BARRIERS

Thirty years ago it was clear to most people that overt racial/ethnic discrimination was a major factor in

the underrepresentation of minorities in a variety of highly desirable sectors in our society. Now the

causes for such underrepresentation are much more subtle and relate primarily to long standing

economic, social, and educational inequities which result in a low representation of minorities among

those who receive MD’s as well as Ph.D.’s in science. (Nickens)

According to Nickens, there are nine barriers to success for minority scientists. They are:

1) Educational pipeline leaks (a miniscule proportion of minority youth emerge from our national

educational system with the requisite skills to do college level science work)

2) Isolation in university departments

3) Excessive demands for time

4) Absence of mentors

5) Complexity of minority health problems. Young minority scientists have a very high probability of

being interested in a problem with direct relationships to minority population, which tend to be clinically

oriented, highly complex and difficult to research. While on one hand an interest in these complex

problems is important, it may run counter to the mind set of scientists and NIH study sections, which is

to simplify so that you minimize the number of variables for which one must adjust.

6) Deficiencies in Grantsmanship and knowledge of the NIH system (Most of the underlying causes for

underrepresentation of minorities among NIH grantees are the result of factors beyond the control of the

NIH)

7) Demographics of study sections and NIH staff (unacceptably low representation of minorities both on

NIH study section and among NIH scientific staff)

8) With contraction of resources due to increasing competition for grants, the probability of obtaining an

NIH grant becomes less likely.

9) No game plan (there is the need for an organized national strategic plan to address the nation’s

health, to increase minority health targeted research and increase minority investigators.) Likewise,

minority faculty must develop individual game plans to succeed.

SPECIAL CONSIDERATIONS FOR MINORITIES

As a faculty member and particularly as an underrepresented minority you can become overloaded with

committee work. Although any faculty member can become overloaded with committee work, since you

will most likely be only one of a few of your race/ethnicity in medicine and involved in Emergency

Medicine you will be asked by the Dean of the medical school or your Department head to be a member

of such committees as the following: Departmental committees, Hospital committees, Women and

Minority (diversity) committees, Medical School committees and other University committees where a

minority is required to participate based on state and federal mandates, (ie equal opportunity programs

which may require a minority to be available to interview prospective candidates for hire).

It is important to be involved on committees at the local, state and national level. However, an overload

of committee work can distract from scholarly activity. On the other hand involvement in committees

particularly at the national level will give you more recognition in the eyes of your peers and specialty

leaders and may serve you well eventually when it comes time for letters of recommendation from

national figures who know you. Involvement in your specialty organizations is very important and often

provides an opportunity for personal and national advancement.

Community involvement is very important but can be taxing so you will have to gauge and balance your

involvement. However, religious, school, and family activities help to sustain balance in life. Involvement

in charitable activities is also important. Promotions and tenure committees in general will be looking at

your scholarly productivity principally. Some institutions are now considering public service activities if

highlighted as part of your job description and/or promoted by your chair as important and consistent

with institutional mission.

Publications including book chapters, abstracts and other manuscripts are important, but in general P &

T committees will give more weight to original research and the resulting manuscripts/publications.

Lectures given at the local, state and national level and the quality of these lectures, though difficult to

gauge, are important. Grants obtained are very important. Keep records of all sources of money you

receive associated with your scholarly work. Bringing in research dollars always carries weight. Find out

how much weight first authorship versus second or last authorship carries on publications.

It is important to know whether or not clinical activity counts towards promotion. For instance, if you are

scheduled to work 24 clinical hours per week it may be considered (based on a 40 hour week) as 60%

clinical time as the requirements of your job description. The productivity may also be important. For

instance, some institutions record relative value units (RVU’s) or some unit of measurement to

determine how many patients you see and how much income you generate. Find out if this is an

important activity at your institution. Make sure you document your clinical productivity. Non-clinical

activity can also be formulated into relative value units.

Annual or biannual performance evaluations generally takes place at most institutions. Make sure you

get feedback from your chair or dean on how well you are doing during these evaluations. Most

importantly, make sure that there is an annual plan agreed to by yourself and your department chair

regarding your goals and objectives for the academic year. You may have simple goals such as two

publications per year. But in general you should outline what you anticipate your clinical, teaching,

education, and research goals will be annually. Also project what your 5-year goals are for academic

productivity and advancements. There may also be an administrative task associated with a title, (ie

residency program director, vice chair, research director, medical student curriculum coordinator,

prehospital division director, clinical operations director, etc…)

BE SURE TO SEEK A MENTOR

A mentor for an underrepresented minority can be someone of the same race or gender or someone of

any other race or gender. Mentorship in terms of the race/ethnicity of the mentor is not that important.

There are recognizable URM’s who are doing important research, who are chairing departments and

who run residency programs and otherwise are involved in academic emergency medicine. There are

not enough of these individuals currently to provide mentorship for all of the underrepresented minorities

who may need it. Throughout residency and fellowship and the early stages of faculty development you

should seek mentorship. Most importantly, getting involved in a specific focus area often requires a

mentor to get you started. Make sure goals are set early and follow through on those goals. The mentor

may even be someone of another specialty but whose area of interest is similar to your own.

Underrepresented Minority Medical Students who are inspired to become physicians benefit from

wisdom and guidance of seasoned physicians who can mentor them. These physicians can help

students and residents navigate through their education and training. The National Medical Association

(NMA) has established the national minority mentor recruitment network. NMA has partnered with the

National Health Services Core or the US public health service. The network was created with the goal of

providing culturally sensitive role models for African American medical students and increasing the

representation of African American primary care physicians.

Opportunities are also available through programs such as the Health Services Research Institute

(HSRI). In the spring of the year 2000, twenty nine minority faculty members were selected as HSRI

fellows. Begun in 1991 and funded by the agency for health care research and quality (AHRQ), HSRI

has helped over 100 minority faculty members improve their skills in health services research, from the

development of a concept paper to the submission of a grant application to federal funding agencies.

ISOLATION

You must have confidence in your feelings and your thoughts and your capabilities to compete in the

academic world. There may be some "behind the scene" forces that you are unable to see or control.

Within your own working group there may be someone jealous of you and feel that you may not deserve

to advance. Members of your own race/ethnicity may be jealous of you and may not necessarily help

your cause. There will be those individuals who will feel that your position or achievements have

occurred only because you are an underrepresented minority, (ie someone may say, you have obtained

your job only because you are black or because you are hispanic.) You may be placed in an

environment where your social and cultural world differs from others. Networking generally occurs in

social/cultural circles such as, golf course/country club, church, school etc. Members of your

department/institution may attend the same church and their children may attend the same school and

you and your family may not be a part of that circle. Discussions in those circles may take place about

you and the quality of your work. This is not something new in our society. You need not focus on the

networking but you should be aware that circles/networks may play a role in whether you advance or

not.

As a minority you are probably different in the way you look, talk and possibly act compared to other

physicians. I am sure you have accepted that fact and hopefully others will accept that fact as well. It is

important for you to know that when you join a faculty, become a committee member at your academic

institution and work primarily in the emergency department seeing patients you will most likely stand out

because you look different. Traditionally, making mistakes carries a heavier burden and penalty for

minorities. Minorities have historically been depicted as inferior in capabilities. This statement is made

based on experience and observation. You must understand that not only are you watched and followed

by administrators inside and outside of your department but your own peers, and coworkers look very

closely at you. Don’t be surprised when you make a recommendation in a committee or amongst a

group of people that your recommendation may not be clearly heard or accepted. Don’t be surprised

that someone already more established than you may make a comment that is clearly heard and

accepted but in essence is identical to the one that you just made. This can happen to any body but

historically women and minorities have been plagued with this type of minimization or marginalization.

Your peers can be helpful to you but beware that your peers may also pose a barrier to you and set

roadblocks. You often have to prove yourself many times over.

FACULTY DEVELOPMENT COURSES

Attend faculty development seminars early. Such seminars exist in academic emergency medicine,

such as Navigating The Academic Waters Conference that is held annually, cosponsored by AACEM

and CORD. The Association of American Medical Colleges has a Faculty Development course for

minorities (Minority Faculty Career Development Seminar). This course stresses the teachings and

understandings of the NIH Application and Research process, information technology in medical

education, conflict management, financial basics, academic writing and special challenges for minority

faculty. It is very important to understand the NIH application process since it is used as a "Gold"

standard throughout medicine. Make sure you collaborate with others within and outside your institution

and that you attend regional and national meetings.

TIME MANAGEMENT

Time management and balance of activities is extremely important for all new faculty as well as

seasoned faculty. Time management and balance of activities is not a new concept. It is even more

important in Emergency Medicine since we work our shifts around the clock, holidays and weekends. If

you have a family, you have a lot of decisions to make regarding your involvement in academic

emergency medicine. Honestly you may end up sacrificing a lot of your own personal needs, but you

should certainly look out for your health and your family’s well being. Your general goals should be

clinical/academic productivity leading to promotion, a rewarding career and a stable and happy family

life. Social and religious fulfillment is certainly very important. Avoid taking on responsibilities in areas

where you have no interest. Again, I will emphasize suggestions that you may make may be over looked

or rephrased by someone else. You may get overlooked for certain jobs. Someone else could get the

job just because of the network. Speaking up is what you should do in most cases. It’s the way you do it.

Don’t carry a chip or grudge. Acceptance will eventually come if you maintain a steady pace and you are

fair to all. Find your niche, focus on a specific area and become authoritative (not authoritarian). Be

timely and don’t be afraid to take risks or chances.. You may be in the "series of firsts": First to integrate

a certain school or church, first to integrate a residency, first to integrate a sports team or first to become

a faculty member as a representative of your race or ethnicity. You may be running interference or there

may be someone running interference for you. As you seek opportunities you may find that there are no

other, or few other, URM residents or faculty members at the institution to which you are applying.

Always keep your tools sharp. Be accountable. Be focused.

Remember that everyone you work with is a member of the human race and has frailties. Look for

signals from the chair or division head that he or she will stick with you if you are recruited to the faculty.

There is added pressure on female minority faculty members. In some cases these faculty may need

time off the tenure or promotional clock. A typical clock continues to tick (ie the requirement to advance

from assistant professor to associate within six years and another four years to become tenured.) In

some cases, institutions have expanded the time frame and will either stop the clock for or extend it for

pregnancy, childbirth and other family related leave matters.

Seek letters of support from coworkers and faculty members particularly when it comes to promotion

time. Develop national ties. Seek national recognition and participate in special forums such as the

National Medical Association meetings.

FINAL THOUGHTS

Our society must ensure that leadership in academic emergency medicine is as diverse as the

population that our medical centers serve. Underrepresented minorities must become more prominent in

numbers and position. We must examine the climate for inequities for underrepresented minorities

especially in areas of leadership, education, research, and community service. Student bodies at

universities may closely reflect a rich diversity of the American population but, our faculties in leadership

in health systems and other organizations do not reflect such diversity. There have not been adequate

mentors nor role models to encourage minority students and residents to become teachers,

researchers, and leaders. Underrepresented minorities have been undervalued. Socialized, traditional

ways of thinking and acting, perpetuated out of habit and lack of awareness have been imbedded in US

culture. It is important that changes occur and our medical culture increase representation and visibility

of underrepresented minorities in positions of authority and leadership. More mentoring programs will

need to be instituted and earlier in the educational years (ie. as early as middle school). Minorities

should utilize the professional development leadership programs that are currently in existance and our

society should create more opportunities. It is inevitable that more minorities will enter a career in

academic emergency medicine, but unwavering support and commitment from current academic

programs, other physicians, and society is essential for those careers to flourish.

REFERENCE LIST

1. Boyer EL. Scholarship Reconsidered: Priorities of the Professoriate. Princeton, NJ: The Carnegie

Foundation for the Advancement of Teaching, 1990.

2. Glassick CE, Huber MT, Maeroff GI. Scholarship Assessed: Evaluation of the Professoriate. San

Francisco, CA: Jossey-Bass 1997

3. Fang D, Moye, Colburn L, Hurley J. Racial and Ethnic Disparities in Faculty Promotion in Academic

Medicine. JAMA 2000; 284: 1085-1092.

4. Palepu A, Carr PL, Friedman RH, et al. Minority Faculty and Academic Rank in Medicine. JAMA

1998; 280: 767-771.

5. Johnson JC, Jayadevappa R, Taylor L, et al. Extending the Pipeline for Minority Physicians: A

Comprehensive Program for Minority Faculty Development. Academic Medicine 1998; 73: 237-244.

6. Nickens HW, (Vice President for Minority Health Education and Prevention. Association of American

Medical Colleges) Remarks Before NIH Clinical Research Study Group Committee. June 10, 1994,

Chicago O’Hare Airport.

7. Beattie DS. Expanding The View of Scholarship: Introduction. Academic Medicine 2000; 75: 871-876.

8. Glassick CE. Boyer’s Expanded Definitions of Scholarship, The Standards for Assessing Scholarship,

and the Elusiveness of the Scholarship of Teaching. Academic Medicine 2000; 75: 877-880.

9. Dauphinee D, Martin JB. Breaking Down the Walls: Thoughts on the Scholarship of Integration.

Academic Medicine 2000; 75: 887-894.

10. Fincher RME, Simpson DE, Menin SP, et al. Scholarship in Teaching: An Imperative for the 21st

Century. Academic Medicine 2000; 75: 887-894.

11. Shapiro ED, Coleman DL. The Scholarship of Application. Academic Medicine 2000; 75: 895-898.

12. Barchi RL, Lowery BJ. Scholarship in the Medical Faculty From the University Perspective:

Retaining Academic Values. Academic Medicine 2000; 75: 899-905.

13. Levinson W, Rubenstein AR. Integrating Clinical-Educators into Academic Medical Centers:

Challenges and Potential Solutions. Academic Medicine 2000; 75: 906-912.

Experiments Utilizing an Expanded Definition of Scholarship in Promotional Process

Mayo Clinic

The Clinician-Educator Award: A Tool to Foster Creativity in Education

Authors: Wyatt W. Decker & Thomas R. Viggiano

The past 20 years have seen major changes in health care delivery in the United States. The impact of

these changes on academic medical centers has been significant(1). An increasingly competitive health

care market has tightened budgets at academic medical centers, causing many to re-evaluate their

business strategies and refocus their efforts on clinical practice(2). During this same period, the balanced

budget act of 1997 curtailed the amount of funding available for graduate medical education (3). This has

made time and funding for education increasingly limited in academic centers in general(4)and in

academic emergency departments in particular (5,6).

Coupled with this trend of decreasing resources for medical education has been the growing recognition

among academics that being expert in practice, education and research is becoming increasingly

unrealistic(7). Within the specialty of emergency medicine, the challenges faced by an individual in

academic practice have been enumerated (8), and the literature is replete with accounts of scaling back

or leaving the academic career tract(9).

The importance of education in academic centers and within the specialty of emergency medicine has

been well documented(10,11). Therein lies the challenge: To preserve education and nurture creativity in

education in an era of fiscal constraint and minimal time available for this enterprise. In response to this

challenge, in 1998 the Education Committee at Mayo Clinic Rochester developed the Clinician-Educator

Award (12). This program provides time and resources for educational projects judged to be meritorious

by an impartial multidisciplinary panel of experienced educators(12). The Clinician-Educator Award is

funded in part by gifts from benefactors, with the remainder coming from institutional resources.

The goals of the program are to provide developmental support for scholarly innovations, and help foster

careers in biomedical education. The program design is as follows:

1) Interested faculty submit applications following a structured outline (five page maximum).

2) Each application requires two letters of endorsement; one from the department chair and a second

from the head of the teaching program concerned (e.g. Residency Program Director).

3) All applications are reviewed at the institutional level by an independent panel of peer reviewers.

4) Each application is scored, and awards are granted on a competitive basis. Criteria on which a

proposal is judged include:

? scholarly merit

Creativity and Innovation

? potential to add value to the educational

program in which it will be conducted

5) Projects that receive the award are given up to 10% faculty time and $10,000 for a one-year period.

6) All applications receive feedback from the selection panel with suggestions for enhancing the proposal.

7) Six-month progress reports and year-end reports are required of awardees.

Initial Experience

Two funding cycles have now been completed, 1999 and 2000. For these two years, 46 applications were

received and 17 were funded. The table lists examples of funded projects. The impact of this

developmental award program has been overwhelmingly positive. Faculty have expressed appreciation

for the program’s peer reviewed mentoring process for scholarly educational initiatives. Faculty are also

more motivated to develop proposals, and projects which do not qualify for award funding often go on to

be implemented through alternative funding mechanisms. It is too early to assess the impact of the

Clinician-Educator Award program on individual career advancement, although this program has become

a meaningful and effective addition to Mayo’s education and faculty development programs.

References

1. Iglehart JK: Support for academic medical centers—revisiting the 1997 Balanced Budget Act. N Engl J

Med 1999;341:299-304.

2. Alpert JS, Flanagan DM, Botsford NA: The future of academic medical centers in the United States:

Passing through the valley of the shadow of death. Arch Intern Med 2001;161:1047-1049.

3. Congressional Budget Office. Budgeting implications of the Balanced Budget Act of 1997. Washington,

DD: CBO, December 1997.

4. Kuttner R: Managed care and medical education. N Engl J Med 1999;341:1092-1096.

5. Moorhead J: The future of academic emergency medicine. Acad Emerg Med 1999;6:255-258.

6. Stead L, Schafermeyer RW, Counselman FL, et al: Effect of changes in graduate medical education

funding on emergency medicine residency programs. Acad Emerg Med 2001;8:642-647.

7. Anon: Lancet: Researcher, clinician, or teacher? 2001;357(9268):1543.

8. Syverud S: Academic juggling. Acad Emerg Med 1999;6:254-255.

9. Clark R: A midlife crisis in academic emergency medicine. Ann Emer Med 1999;34:562-564.

10. Biros H: What really matters? Educating academicians. Acad Emerg Med 1999;6:253-254.

11. Martin ML: A perspective of the process of educating academicians. Acad Emerg Med 1999;6:258-

259.

12. Viggiano TR, Shub C, Giere RW: The Mayo Clinic’s Clinician – Educator Award: A program to

encourage educational innovation and scholarship. Acad Med 2000;75:940-943.

TABLE – Selected Examples of Funded CE-10 Projects at Mayo Clinic Rochester

· Training New Physicians to Prevent Complications of Hospitalization in the Elderly.

· Introduction of Hand-Carried Echocardiography as an Extension of the Cardiac Physical Exam .

· Basic Airway Management for the Third-Year Medical Student.

· A Curriculum to Teach Ethical, Legal, and Practical Aspects of Withdrawing Life-Saving Treatments in

the Intensive Care Unit.

· Trauma Education for Mayo Medical Students.

· Development of a Course in Clinical Decision-Making.

· Development and Evaluation of a Musculoskeletal Injection Technique Curriculum.

· Development of a Web-Based Application to Facilitate Clinical Investigation.

Experiments Utilizing an Expanded Definition of Scholarship in the Promotional Process: The Medical College of Wisconsin Experience

Authors: Robert R. Leschke, Deborah E. Simpson, and Stephen Hargarten

Successful junior faculty members typically receive a great deal of advice regarding critical focus areas

during their first few years after graduation from residency. Most of the advice comes from experienced

senior colleagues who help the junior faculty member interpret the written (and unwritten) rules, values,

and expectations of an academic physician. This guidance is particularly critical in the area of faculty

promotion.

In today’s academic medical center market place, the primary foci for new junior faculty center around

efforts to boost clinical acumen, prepare for necessary board examinations, and establish new

relationships. Promotion is a topic for "the future", a foreign concept that is not of immediate importance

for most junior faculty who have emerged from a structured residency environment in which the process

by which one progresses from PGY1 to PGY3 is clear with explicit expectations. In contrast, faculty

promotion requires a sustained effort to accumulate evidence of one’s scholarly activity (e.g. papers,

grants, teaching evaluations), personal references, and institutional citizenship. Unfortunately,

promotion remains a foreign concept for some junior faculty who may have sufficient time in rank for

promotion but often find themselves empty handed scrambling for data to support their advancement.

Such is the case with the junior faculty member in the opening scenario.

The purpose of this article is to help junior faculty members avoid such a scenario using a step-by-step

approach to promotion. (See Figure 1). It will discuss the broadened concepts of scholarship1 that have

emerged in academic medicine with a focus on implications for clinician educators. Building on this

focus, it will outline how to make what you do as a faculty member "count" for promotion, and what and

how to gather and present the data necessary to get promoted. Finally, it will provide two examples of

how the process works at the Medical College of Wisconsin (MCW). One demonstrates how a lack of

guidance and documentation fails to result in promotion and the other shows how utilization of the

process ends with successful promotion.

Broadening the Concept of Scholarship

The 1980’s sought a change in academic culture to recognize the disparity between an institution’s

increasing demands for clinical teaching and its inability to sway from traditional promotional tracks.

Rarely were faculty promoted for their excellence outside of the research arena and as one institution

discovered, winners of a "Teacher of the Year" award were more likely to leave a department sooner

than nonwinners. In 1984, the Medical College of Wisconsin (MCW) approved a clinician educator

promotion track with assessment measures that primarily focused on teaching and clinical service.

Despite the establishment of this track, there was still a struggle to alter the perception that education

detracted from the "real" path to academic promotion and recognition through research. Key MCW

educators and administrators implemented a change strategy to influence beliefs about the form of

scholarship that was consistent with the role of clinicians and educators. This change strategy centered

on an expanded view of scholarship which necessitated a fundamental change in the academic culture

of MCW. MCW’s approach to building this new culture began by recognizing that without a change, the

institution would be unable to attract or retain outstanding clinical educators who are often at the

forefront of training the next generation of clinicians.

The next step was to create a tangible product, the outcome of which was a document called The

Educator’s PortfolioÓ . This system provided an evidence based approach toward documentation of an

educator’s accomplishments in a way that concretely established value. The Educator’s Portfolio

approach was then widely communicated and targeted at chairs and members of the Rank and Tenure

Committee with examples to highlight the "gold standard". Guidebooks were created for clinical

educators to model their data collection using portfolios of successfully promoted faculty.

The culture change, while slow, began to send the message that educators could be promoted when

evidence of quality was documented. Over time, faculty development initiatives and educational forums

were started in response to increasing demands for formal training in education. Not only did clinical

educators want to be recognized and rewarded, they wanted to become better educators. Today at

MCW there are formal promotion standards for clinician educators, a mission to recognize and promote

our best educators, and equal standing with traditional tracks for tenure. This strategy of change at

MCW has gone far beyond the experimental stage. It is now a part of an established culture for over a

decade.

Step 1: Does Education Count?

One of the first steps toward building a successful promotion portfolio is to understand what counts. All

institutions have promotion criteria and these criteria should be easily accessible to all faculty. However,

the degree to which institutions’ value and hence recognize the diverse roles for promotion of today’s

academic faculty vary. Recognizing what an institution will deem important allows a faculty member to

focus energies, talents, and time on promotable tasks that are consistent with scholarly interests.

Fundamentally, promotion is the result of selecting an academic focus consistent with one’s professional

values/ interests, and creating a list of promotion criteria to match those professional interests with what

is institutionally valued. Unless an academic focus is clarified, it will be difficult to say "no" to those

activities that are inconsistent with the focus and that are time consuming without promise of improving

chances at promotion.

Most junior faculty already understand that publication in peer-reviewed journals is a fast track to

promotion. But not all academicians’ roles and associated products lend themselves to "publications" in

the traditional sense. Tracing the roots of the word "publish" reveals that it emerges from the Latin word

meaning public - to make what one does visible. Publications are merely one way in which

academicians can make what they do public.

Many institutions now recognize that some of their best educators are not researchers and the "publish

or perish" philosophy causes many quality teachers to search for jobs elsewhere. In response to this,

many institutions have developed a clinical educator track that recognizes the critical role of teaching

and clinical service. Underlying all of the discussions of scholarship is the key assumption that what

faculty do is to advance knowledge in one’s field as judged by one’s peers. By approaching with

common criteria the evaluation of faculty, be they researchers, leaders in the community-academic

partnerships, or teachers, using the four-part definition of scholarship noted in the Preface to this

Handbook (discovery, application, integration, and teaching), allows the diversity of faculty roles to be

recognized and rewarded through academic promotion. What varies for each role is the type of

evidence used to judge the quality of the scholarly work that is made "public".

Traditional forms of evidence used to document scholarship for research (e.g., publications, grants, NIH

study groups ) provide evidence that one’s work is public, has been reviewed by peers, and is available

so that others may build on the work to advance what is known in the field.2 For educators, equivalent

evidence of scholarship can be presented that addresses curriculum development, teaching, and

advising. Assessment instruments that document this include student and resident evaluations, CME

ratings, data regarding student outcomes, curriculum evaluations, residency match success, or other

indicators that demonstrate the educator’s highest quality efforts.3 Research and publication in these

instances compliment, but may not be necessary for advancement if the non-traditional evidence

presents a strong and continuous record of advancing the field of education, and thereby the

scholarship of teaching.

Step 2: Deciphering the Criteria for Academic Promotion and Chair Support

Recommendation for promotion is typically determined by a faculty committee composed of appointed

and elected peers at the senior faculty ranks (associate to full professor) who advise the Dean. To allow

for flexibility, institutional criteria for promotion are often nonspecific. Understanding what counts

becomes more challenging under such circumstances. The easiest course is to contact other physicians

at one’s institution who spend a similar amount of academic time educating. Determining how they were

successful in promotion provides a model for success. This mentorship with other educators on the local

level can be an invaluable resource.

The next step is to examine the criteria for promotion from several comparable institutions that have a

well defined clinical educator track. A recent national project of the AAMC’s Group on Educational

Affairs is available to stimulate discussion about "what counts". Using several case studies of educators,

a national and regional audience of educators was asked to evaluate whether the individuals would be

promoted. The results of this project are available in an article entitled "Making a case for the teaching

scholar"4 with the actual "case studies" available on the AAMC’s Central Group on Educational Affairs

website, http://www.medlib.iupui.edu/cgea/geasclrpro.html.

By finding out what is acceptable for promotion nationally and incorporating those fundamentals into

your documentation and promotion plans one can begin to build a record of clinical educational

scholarship. Once one has a clear idea of what counts, it becomes imperative to discuss those

academic responsibilities with the chairman to evaluate the level of support s/he will have for these

national and local perspectives. If adequate scholarly evidence is present, it will be crucial to know if the

chairman will be a strong advocate for your promotion.

Gathering the Evidence

Promotion requires the clinician educator to make "public" what his or her activities are in order that

peers on the promotion committee can judge the quality of the work. What should be provided to the

promotion and tenure committee that demonstrates evidence of a successful clinical educator? Some

data are easier to collect or recover than others.

Published articles in peer-reviewed journals are easily producible at promotion time.

CME lectures are required to have evaluations in order to meet accreditation guidelines.

The institution’s CME office should have lecture evaluations and can provide data

comparing one’s ratings to similar CME lectures.

Involvement in hospital committees can be tracked through that committee’s meeting

minutes.

These data are easy to collect in retrospect.

Often, however, faculty fail to track what, over time, can become evidence of a continuous record of

excellence as a teaching scholar. What about all of those student advisees, those lectures given to a

group of residents, the time spent during clinical time explaining the salient points of some disease

process to the team of white coats following behind? The general consensus suggests a good job and

that appreciation is in order but there must be data to prove it. Trying to scramble to reconstruct events

and the evidence in hindsight is incredibly difficult.

Faculty time is important and if it is spent on an activity that could enhance the portfolio, it needs to be

accounted for and evaluated both on its own merit and in comparison to other similar activities. One

must discover what evaluation tools are currently in place at one’s institution. Clerkship evaluations that

ask students or residents to comment on the effectiveness of a faculty member’s participation in their

education provide one with the accountability of one’s time as well as an evaluation of comparative

teaching excellence. Some institutions or individual departments utilize an internet based service such

as E-value which provides an easy way for students, residents, or other faculty to conveniently evaluate

one’s performance in any capacity (e.g. teacher, advisor). This system or others like it amass the data,

which can then be analyzed for both individuals and groups to provide comparison data of excellence as

a teacher relative to others. If a faculty member acts as an advisor for a medical student, the medical

school may have a tool that allows students to comment on how beneficial the advice was. Invited

lectures provide an opportunity to document teaching excellence with a standard evaluation tool.

If there are no departmentally based evaluation tools currently in place one can be created with the

education leadership of another department or the affiliated medical school. Remember, the important

pieces to include in the tool are the accountability (what type of activity and to whom the activity is

directed) and the actual evaluation, both on its own merit and in comparison to similar activities. For

example:

Student advisees can be asked to write a letter detailing their experiences. Since most

students will not have more than one advisor, comparison data can be ascertained by

asking how strongly the student is likely to recommend the advisor to another student.

Lecture evaluations are easy to create by listing a few questions and having the

audience answer those questions based on a 1 through 5 (Likert) scale. Be sure to

identify clearly what the numbers on the scale represent. One of the last questions

should be "relative to other presenters you have heard in this venue, please rate my

performance."

The evaluation tool now has accountability (what type of lecture and to whom) as well as peer

evaluation in comparison to others.

Creating Your Promotion Document

After discovering what counts and how to collect the data necessary to document a clinical educator’s

worth, the final step is to assemble it into a finished product that is presentable to the committee. This

Educator’s Portfolio5 or teaching dossier6 should compliment a curriculum vitae written in an

institutionally specific format. Most young physicians begin this assembly process by saving everything

from invitations for lectures to attendance records at national conferences because they are not

completely sure what is ultimately important. All of these data usually wind up in a folder or large binder.

While this is a good start, since having too much information initially is better than not enough, it is very

difficult to ascertain promotion progress at any given time. One may also be lulled into a false sense of

security with a thick binder of paper before coming to the realization that quantity does not substitute for

evidence of advancing the field of education through high quality forms of scholarship.

Using the Educator’s Portfolio or a teaching dossier provides established categories. For example, the

MCW’s Educator’s Portfolio categories include: curriculum development, teaching, advising, learner

assessment, and educational administration.7 The goal of assembling data in a categorized fashion is to

assure timely quantification that is easily retrievable and understood. A category such as teaching can

be subdivided into: invited lectures, clinical teaching, or core curriculum instruction. Another choice

would be to divide a category into its audience (e.g., medical student, resident, CME, allied health, or

community.) Each time a lecture is given, the evaluation of that lecture can be easily placed in that

section of the binder.

Alternatively, some data can be organized in chronological fashion. Evaluations of clinical teaching

ability kept chronologically can then be easily trended. Other categories such as advising or committee

participation when kept chronologically can easily demonstrate increasing participation or increasing

responsibility. Compiling data in chronological fashion is important in its impact on unfavorable

evaluations. A noticeable upward trend from evaluations at the beginning of one’s career can

demonstrate progress and improvement.

As one’s career progresses, it will naturally become focused on a few targeted areas rather than in all

forms of education. The portfolio should highlight these key areas with evidence of one’s best work. It

may not be important to spend the time creating an evaluation tool for one medical student advisee to

assess quality in this area since that is not the strongest aspect of the portfolio and not likely to be the

evidence that supports promotion. In contrast, if the majority of time is spent teaching clinically and that

is the one’s scholarly focus, it is imperative to have evaluations of that activity and assemble them in a

manner that demonstrates time spent, progress, and excellence. Ongoing collaboration with an

experienced colleague to structure your portfolio can be invaluable.8

Even with real time construction of the Educator’s Portfolio and ongoing collaboration, the final product

is something that should take a considerable amount of time and effort, akin to that required for writing

an original journal article. Following are two examples of the same person’s Educator Portfolio. The first

lists work that is of significant merit. However, without guidance or a specific plan, he embarked on a

hastily prepared document that he would call his promotion portfolio. He organized it in a way that

delineated what he had done at his institution for residents, students, and other personnel. All who know

him would surely advocate for his promotion as a contributing and beneficial faculty member.

Unfortunately, what his portfolio lacks is the necessary data that demonstrates that contribution. The

Rank and Tenure Committee will therefore not be able to support his promotion. Just as a researcher

seeking promotion utilizes peer reviewed manuscripts to demonstrate quality and contribution, so must

an educator produce similar data.

The second example is the same faculty member’s portfolio after consulting with his chair and utilizing a

document like the Educator’s Portfolio for a template. It took a while to find or synthesize the data but

the end result shows strong evidence of progress and contribution. As you review these brief portfolios,

attend to:

How his accomplishments are categorized into the different arenas in which faculty may

be active as educators rather than into the type of audience toward which those

accomplishments are directed.

How actual comments are used to demonstrate the effectiveness his accomplishments

have had.

How objective data is used to demonstrate the educator’s effectiveness on its own merit

and in comparison to his colleagues.

How trended data is used to demonstrate improvement with time.

How the use of a simple pretest and post test can show the effectiveness of the

curriculum project that this faculty member wrote for the housestaff.

How asking advisees to write letters outlining the benefit of advice and listing the

ultimate success of advisees can add to the demonstration of excellence.

BENJAMIN ELLIOTT, MD

Resident Involvement

Resident Teaching

a. Full time faculty at St. Matthew’s Hospital, 1997 - 2001

b. Teacher of the Year, 2000

c. Gave two lectures per year on various topics to ED grand rounds

Advisor for one resident every year 1998 - 2001

HIV for ED Housestaff - A manual for ED housestaff describing HIV care, including basic immunology,

post exposure prophylaxis, medication regimens, and the care of opportunistic infections.

Student Involvement

Student Teaching

a. Full time faculty at St. Matthew’s Hospital, 1997 - 2001

Advisor for the following students:

a. Max Jones, 1998

b. Lisa Smith, 2000

c. Jason Evers, 2001

Clinical Procedures Rotation – This is a required course for junior medical students to introduce them to

simulated critical care settings and procedures and to train them in modified ACLS. I authored the

curriculum and implemented it.

Other Involvement

Trauma Nurse Specialist course 1999 - 2001

EDUCATOR’S PORTFOLIO

BENJAMIN ELLIOTT, MD

Section I: Curriculum Development

2000 - present Clinical Procedures Rotation

Co author Curriculum and EM director

This is a required course for junior medical students, which provides them with an

overview of critical care type settings and procedures including modified ACLS.

Evidence of quality:

College wide Curriculum and Evaluation Committee required evaluation

4.7 on a scale of 1 - 5 with 5 being outstanding

All other rotations 4.5.

Representative comments from students

"great addition to the curriculum. Exposed students to emergency situations"

"wish I would have had this information earlier in my third year"

"excellent integration of materials into a concise and useful class. I feel prepared"

1999 - present HIV for ED

A manual for ED housestaff describing HIV care including basic immunology, post

exposure prophylaxis, medication regimens, and the care of opportunistic infections.

Evidence of quality:

Housestaff averaged 86% on a pretest prior to receiving the packet and 94% after

receiving the packet.

Representative comments from housestaff

"I feel more comfortable with this type of patient scenario now "

"Clarified how I would recommend post exposure prophylaxis to my patients"

Section II: Teaching

1. Resident Teaching

a. Full time faculty at St. Matthew’s Hospital, 1997 - 2001

b. Teacher of the Year, 2000, voted by the residents

E-Value scores:

2000 - Score 4.4/5 Mean for group 4.3/5 Rank 5/14

2001 - Score 4.7/5 Mean for group 4.0/5 Rank 2/14

"One of the clinically smartest faculty we have. Very easy to work with"

"Staff member that takes the most time to teach, case by case throughout a shift"

"Points out a couple of good teaching points on most patients while allowing autonomy"

2. Student Teaching

a. Full time faculty at St. Matthew’s Hospital, 1997 - 2001

Rotating student’s faculty evaluation form results:

1998 - 7.5/10 for teaching effectiveness average other faculty = 7.0

1999 - 8.0/10 for teaching effectiveness average other faculty = 6.9

2000 - 8.7/10 for teaching effectiveness average other faculty = 7.2

3. Other Teaching

a. Trauma Nurse Specialist course 2000 - 2001

i. Gave lecture twice per year on blunt abdominal trauma

Student’s evaluation of the lecture

2000 - 4.7 / 5 total lecturers = 4.5 / 5

2001 - 4.7 / 5 total lecturers = 4.6 / 5

Section III: Advising

1. Advisor for one resident every year 1998 - 2001

100% of advisees passed board exam on first attempt

Each advisee secured job of choice after graduation

2. Advisor for the following students:

A. Max Jones, 1998

B. Lisa Smith, 2000

C. Jason Evers, 2001

All of the above students matched with their first or second choice

Please see attached letters from Ms. Smith and Mr Evers.

It is possible to be promoted successfully as a clinician educator. The Medical College of Wisconsin has

been a leader in proving this statement, and since its early work in this area, has been successful in

establishing a culture that fosters the advancement of clinician educators. Part of creating this culture

was to show that collecting data demonstrating quality in education is just as effective, just as worthy,

and just as imperative in the process of promotion as NIH study sections and peer reviewed

publications. We have outlined here how to decipher the criteria for promotion, how to gather the

evidence necessary for promotion, and have suggested a template for presentation of the data in a

concise format called the Educator’s Portfolio. Early education of these principles and continued

mentorship on this subject will make the process easier and the acceptance of educators as scholars

universal.

Figure 1: Step by Step to Clinician Educator Promotion

1. Identify yourself as a clinician educator

2. What Counts for Promotion

a. Local perspective

b. National Perspective

3. Meet with Your Department Chair Annually

a. Discuss the criteria for promotion with your Department Chair

b. Agree on focus and resources available

4. Gather the Evidence

a. Categorize major types of educational activities

b. Collect evidence for major areas of focus

i. Comparative

ii. Longitudinal

iii. Excellence

5. Creating Your Promotion Document

a. Ask for help - peer review

References

Boyer EL. Scholarship Reconsidered Priorities of the Professoriate 1990; Carnegie Foundation for the

Advancement of Teaching

Shulman L, Glassick CE, Huber MT, et al: Scholarship Assessed 1997; Jossey-Bass: San Francisco.

Fincher RE, Simpson DE, Mennin SP, et al : Scholarship in Teaching: An Imperative for the 21st

Century Acad Med 2000:75:887-894

Simpson D, Fincher R: Making a Case for the Teaching Scholar Acad Med 1999;74(12):1296-1299

Simpson D, Marcdante K, et al: Valuing Educational Scholarship at MCW Acad Med 2000;75(930-934)

Simpson De, Beecher AC, Lindemann JC; Medical College of Wisconsin. Available from the Society of

Teachers of Family Medicine Bookstore. http://www.stfm.org/bookstore/

Faculty Development Committee - Association of Surgical Educators, Teaching Dossier. Available from

Association for Surgical Educators. http://www.surgicaleducation.com/educlear/index.htm#table4

Simpson D., Morzinski J, Beecher A, et al: Meeting the challenge to document teaching

accomplishments: the educator’s portfolio. Teach. Learn. Med. 1994;6:203-206.

Seldin P. The Teaching Portfolio: A Practical Guide to Improved Performance and Promotion/Tenure

Decisions (2nd edition) Boston, MA: Anker Publishing Co: 1997

A Fellowship in Faculty Development

Author: Glenn C. Hamilton

1. Administrative Module (Year-long)

Purpose:

These discussions and assignments run over the entire 12 months of fellowship. They address the

administrative aspects of faculty with a specific orientation toward emergency medicine.

Faculty Responsible:

Chair with assistance from selected faculty and outside discussants.

Primary Reading:

Drucker PF, The Effective Executive, New York, Harper Business. 1967.

Cialdini RB, Influence, 2nd Edition, Boston, Scotts. Foreman/Little Brown, 1988.

Cohen, You can Negotiate Anything

On Leadership

Multiple Handouts

Format:

1-2 weekly discussions.

2-3 specific managerial task assignments.

Topics covered:

AAMC

Academic marketing

Addressing poor performance

Approaches to brain storming/Delphi technique

Attaining departmental status in emergency medicine

Attaining regional/national recognition

Basic financial skills, including budgetary planning

Committee structure

Communication skills: telephone vs memo vs in person

Conflict management/resolution

Counseling skills

Counseling techniques

CV vs resume

Defining personal goals and objective short and long term

Elements of being a manager

Entrepreneurship

Ethical issues in academic medicine

Funding sources for grants

NIH Structure and funding system, review or individual grants and categories

Hiring procedures/firing procedures

Identifying constituencies/scope document

Individual Societies including ACEP, SAEM, AAEM, ABEM, EMRA, CORD and others

Interpersonal skills/networking

Interviewing skills

Introduction to diversity

Leadership skills

Legal Issues in academic practice

Mentorship

Mentorship for the "problem" resident

Negotiating skills

Organizational behavior

Power and Influence

Product/Innovative development

Project management

Promotion and Tenure

Relationship with medical students as a faculty

Relationship with other faculty as a faculty

Relationship with residents as a faculty

Relationship with your immediate supervisor

Social psychology

Structural assessment medical school, LCME

Structure of academic emergency medicine

Structure of organized academic emergency medicine

Structure of the hospital, AMA/state/local medical societies

Structure of the medical school

Tactical planning vs strategic planning

Techniques/Approaches to evaluation

Technology management

Time management

Who do you trust?

Women in medicine

Working with staff

2. Writing/Publishing Module (2 months)

Purpose:

The Academic faculty must write and write well. This two month block focuses on medical writing, the

English language, the elements of a paper, editing skills, and specific computer programs helpful to

authors.

Faculty Responsible:

JS and contributions from selected faculty within Department and at WSUSOM.

Primary Reading:

Huth EJ, Writing and Publishing in Medicine, Baltimore, Williams and Wilkins, 1999.

King, Why Not Say it Clearly?

Strunk W, White EB, The Elements of Style, New York, MacMillan.

Format:

Writing in all formats: papers, chapters, letters.

Understanding and practice in use of dictation to guide writing.

Active editing of individual and Departmental projects.

Many activities will be linked to other modules.

Planned submission of 2-3 scholarly works for publication.

Opportunity to develop and submit potential chapters or book proposal.

Writing skills workshops.

Topics covered:

Essentially the index of Huth’s book .

Effective writing structure.

Developing the irresistible book proposal.

Approaches to editing.

Reviewing others scholarly work.

Writing to communicate in English.

3. Teaching/Bedside Teaching Module (2 months)

Purpose:

These two months introduce the structure of curriculum design, adult education, and bedside teaching

through a variety of readings, discussions and assignments.

Faculty Responsible:

TJ (3 Time Teaching Award Winner, WSUSOM), plus selected contributions from other faculty.

Primary Reading:

Mager, R.E. Preparing Instructional Objectives, Making Instructions Work, Measuring

Instructional Results.

Whitman, N. The Physician as Teacher, Essential Hyperteaching.

Selected readings ACEP Teacher’s Workshop.

Bedside Teaching Synopsis.

Many Handouts.

Format:

6 hours per week assigned teaching time, initially observed. Each session is graded by

recipients.

Several planned didactic lectures on a variety of topics. Initial 2-3 videotaped and

specific instructions given based on performance.

Planned design, review, and implementation of specific segment of curriculum. May be

linked to Fellow’s specific interests.

Participation in MS-IV OSCE on clinical skills and procedures.

Wide variety of observed, then unobserved teaching activities with PAs, medical

students and residents.

Specific writing projects(s) on educational activities.

Topics Covered:

Curriculum design.

Developing content for teaching.

Writing effective goals and objectives.

Planning implementation method to optimize teaching environment.

Evaluation techniques for student and teacher

Establish clear feedback mechanism to modify teaching approach and effectiveness.

4. Media Module (1 month)

Purpose:

Understanding media and the internet as a means of communication and education is

essential for any academic faculty. Specific training in computer programs to facilitate

this area is necessary.

Faculty Responsible:

Natalie Cullen, M.D. Media and Internet Coordinator

Primary Reading:

Stack, LB, et al. Handbook of Medical Photography, Philadelphia, Hanley and Belfus,

2001.

Teaching Series on PowerPoint, Digital Cameras, Internet resources, PDA, and Adobe

Photoshop.

Format:

Practical applications of PowerPoint, Word, and Excel.

Understanding and use of Digital camera in the clinical setting.

Practical applications of Adobe Photoshop.

PDA use (all Fellows will be required to purchase PDA used by EM residents at

discounted rate.

Internet as a resource.

Basic web-site development (based on Fellow interest and skills level).

Integration of electronic media into educational programs.

Topics Covered:

Internet and education, including evaluation.

PowerPoint, to enhance teaching.

Digital media, and manipulation with Photoshop.

Use of PDAs, benefits/problems.

Integration of PDAs into clinical and didactic teaching.

Internet programming skills.

5. Research Grantsmanship Module (2 months)

Purpose:

Academic advancement is often predicated on the successful design and completion of a scholarly work

or activity. During this block the fellow will: become acquainted with resources to identify funding

sources for educational, clinical and basic research, examine the requirements and limitations of a

typical grant in one of these areas, and develop a research idea into the basic elements of the grant

proposal. Additional skills related to these activities will be acquired including developing a basic

understanding of biostatistics and critically reading and analyzing pertinent primary literature.

Faculty Responsible:

JO and other staff from the Research and Sponsored Projects office and Medical Library.

Primary Reading:

Reif-Lehrer, L, Grant application writer’s Handbook, Jones and Barnett, 1995.

Ogden, T.E. and Goldberg, I.A., Research Proposals, Raven, 1995.

Bailar, J.C. III and Mosteller, F., Medical Uses of Statistics, NEJM Books, 1992.

Format:

Weekly meetings with Dr. Olson.

Participation in workshops on computer literature searches.

Participation in workshops on grant writing.

Participation in Evidence Based Medicine workshops.

Attendance at SAEM regional and national meetings.

Development and design of research project.

Completion of grant application.

Topics Covered:

Defining an area of research interest.

Biostatistics.

The environment of medical research:

Budgetary constraints

Medical and biomedical ethics

Grantor expectations

Evaluating medical research and research reports.

6. Administrative Aspects of Academic Medicine Module (1 month)

Purpose:

There are specific skills unique to academic medicine that might not be addressed in the other modules.

These topics will be introduced or reviewed during this month. Some information will be repeated from

the broader perspective during the year long Administrative Model.

Faculty Responsible:

Chair, with assistance from selected faculty and outside discussants.

Primary Reading:

The Evaluative Interview

Evaluation of Residents, American Board of Medical Specialties Services.

Maguer R, Analyzing Performance Problems, Measuring Instructional Results

Time Management

Wilson MP, McLaughlin CP, Leadership and Management in Academic Medicine,

AAMC

Role of the Academic Chair, 2nd Ed. Josey-Bass, 1999.

Additional Handouts

Format:

1-2 hour weekly discussions

One specific administrative assignment

Participation in resident candidate interviewing schedule with observation

Specific time management assignment.

Review Promotion File details.

Topics covered:

Interviewing skills

Techniques/Approaches to Evaluation

Structural assessment Medical School, LCME

Time Management

Counseling skills

Promotions and Tenure

Mentorship

Where does research fit in? Some thoughts on the Scholarship of Discovery and

Application

Why Do Research?

Author: Arthur L. Kellermann

I. Scholarship

Faculty members at medical schools are generally evaluated in 3 domains: service (including patient

care), teaching, and scholarship. For tenure-track faculty, scholarship is the most important for

promotion, and is absolutely essential to earn tenure. For clinical faculty, most medical schools require

achievement of at least "adequacy" in scholarship for promotion to the Associate Professor or full

Professor level. The sine qua non of scholarship is research.

Most promotion and tenure committees measure scholarly productivity in two ways - 1) the quality and

quantity of the candidate's publications in peer-reviewed journals, and 2) the number, size and quality of

the candidate's grants, and the role the candidate played in obtaining them.

Publications come in 2 forms - "peer-reviewed" and "non peer-reviewed". As a general rule, non-peer

reviewed papers count for little in terms of promotion; examples include review articles in "throw away"

journals and submissions to newsletters. Tenure committees favor original research that is published in

peer-reviewed specialty journals such as Annals of Emergency Medicine or Academic Emergency

Medicine; publications in highly regarded general readership journals, such as JAMA and the New

England Journal of Medicine count the most.

Evaluating the quality of scholarship is highly subjective. It is generally based on two factors - 1) the

prestige (i.e., academic rigor) of the journals in which you have published, and 2) the candid opinions, at

the time your promotion is being considered, of 2-5 professional peers as to the merit of your

publications and your overall contributions to the field. To judge the former, the committee will

sometimes ask for a representative sample of your publications. To satisfy the latter requirement, your

chief or chair will solicit letters from academic EM faculty at other institutions who hold the rank of

Associate or Full Professor. Some committees request comments from1-2 colleagues from non-EM

clinical departments at your institution as well

The quantity of publications is measured by counting the number of original, peer-reviewed papers (i.e.,

original contributions and brief reports) you have published over the course of your career. First-

authored and single authored papers are given more weight than co-authored papers, but the latter are

valuable because they demonstrate that you are willing to work collaboratively with others. Editorials,

review articles, and book chapters count as well, but they are less important than original, peer-

reviewed manuscripts. A few book chapters are good, but a lot of book chapters isn't much better.

Committees look for creativity, not rehashing the data of others. Letters to the editor and non-peer

reviewed articles don't matter very much, but include them in your CV anyway. Nothing is too minor to

leave out, particularly when you are striving for "adequacy" in scholarship.

How many papers are enough? There is no hard and fast rule. Criteria vary from school to school. It

matters whether you are being considered for promotion on the tenure track or a non-tenure (e.g.,

"clinical" or "teaching") track. Non-tenure track promotions are much less demanding in terms of paper

counts to achieve adequacy in "scholarship", because it is understood that the candidate has spent the

bulk of her/his time involved in patient care, service, or teaching. Most tenure track promotions, on the

other hand, set very high standards for scholarship. If you are in doubt about how many publications you

need, consult your chair or a senior colleague at your institution.

Research grants come in two forms as well – "intramural" and "extramural". - "Intramural" grants

originate inside the inside the institution and are generally used to support small scale studies or pilot

projects that are intended to generate preliminary data for a later grant. Getting one or more intramural

grants is considered a solid sign of your interest in research, but it won't help you much if you don't

follow them up by obtaining one or more external grants. Extramural grants, also known as external

grants, - are valued more than intramural grants because they bring research funding into the institution

from outside organizations, such as foundations or the federal government.

An informal hierarchy exits as to the value of extramural grants. It is based on the source of the funds.

National Institutes of Health (NIH) grants are the most prestigious, because they contribute to your

medical school's "NIH ranking" and therefore its status in the circles where this sort of thing matters. NIH

grants are followed closely by National Science Foundation grants, for the same reason. These two are

followed by grants from other federal agencies (e.g., Agency for Healthcare Research and Quality

(AHRQ), Centers for Disease Control and Prevention (CDC), National Highway Traffic Safety

Administration (NHTSA), Maternal and Child Health (MCH) and others. In addition to conferring status

on the investigator and the institution, federal research grants are more valuable because they pay a

higher rate of indirect costs (extra money to the institution to support its general operating costs). They

are also hard to get. Obviously, the bigger the amount of the award, the better. In the world of research

grants, size matters!

Foundation grants (such as the Robert Wood Johnson Foundation, the Gates Foundation, The Andrew

Carnegie Foundation, The Annie Casey Foundation, the Woodruff Foundation, and others) are relatively

prestigious, but they pay much lower indirect costs and are therefore considered less valuable by the

institution. Also, they don't count towards your school's NIH ranking. Foundation grants are followed by

"investigator-initiated" industry grants (i.e., you came up with the idea, designed the study, and got

industry funding). Industry-sponsored studies that involve a lot of money and/or generate an institutional

patent count for a lot, but those that don't bring in a patent or a lot of dough count for relatively little.

"Industry sponsored" studies (i.e., the study was designed by the company's in-house research staff and

your role involved little more than enrolling cases) count for very little. While the latter are useful for

learning how to conduct a clinical trial, and may even bring some money into the department, they are

not highly regarded by most P&T committees.

Role:As was the case with publications, your role in the grant matters as well. Being the Principal

Investigator or "P.I." of a study counts for more than being co-PI, since the PI is ultimately responsible

for designing the study and leading the team. Being a Co-PI (for example, acting as "site director" on a

multicenter trial) counts for more than being a co-investigator, since the former implies more managerial

responsibility. However, doing any extramurally-funded research (as PI, co-PI, or co-investigator) counts

much more than doing only intramural (i.e., internally funded) research, and conducting any research

(whether it is funded externally, internally, or not at all) counts for more than not doing research of any

sort.

Currently, most EM faculty obtain promotion on the clinical track. Generally, clinical-track faculty are

expected to compile a modest but meaningful record of publications, combined with some invited

lectureships at other institutions or at national specialty meetings. This level of accomplishment (and

ideally, some external grant funding) is generally sufficient to establish "adequacy" in scholarship in the

eyes of all but the most demanding promotion committees. This level of productivity, combined with the

high levels of teaching and service typical of a career-committed EM faculty member, should earn you

promotion.

Do not, however, take promotion for granted! Meet regularly with your Chief, or Chair to review your

progress. Her or his support will be essential when you go up for promotion.

The fact that you are an outstanding teacher, have worked a ton of shifts, served on 15 hospital,

community or departmental committees, and get along with your chair, does not guarantee that you will

earn promotion. Most candidates for promotion to Associate Professor level or above are required to

show evidence of that they have achieved a measure of national recognition in their specialty. This can

be done by establishing excellence in service (e.g., getting involved in or chairing a committee or task

force for SAEM, ACEP, or other EM organization); excellence in teaching (by giving invited talks at

regional or national meetings, "grand rounds" at other EM residency programs, and/or being visible in

other national EM education projects), and/or excellence in scholarship (by securing grants and

publishing a substantial number of high quality, peer-reviewed papers). For promotion to Professor,

institutions generally require an even higher standard of proof that you have achieved national, if not

international, standing in your field.

II. Why do research?

There are several reasons to conduct research. They can be grouped in 4 broad categories - personal

reasons, departmental reasons, specialty reasons, and societal benefit:

A. Personal reasons:

Career advancement: Most institutions require Assistant Professors to achieve at least "adequacy" in

scholarship before they can be promoted to the rank of Associate Professor or above on the clinical

track. That typically means publishing (as first author as well as co-author) several papers. To insure

that this happens, you should get involved, at the outset of your career, in some sort of research.

Residents respect you for your clinical acumen, but medical students and Deans look at your record of

publications.

"Protected time": Successful investigators (particularly those who are clever enough to secure

extramural funding for their work) generally get "protected time" to pursue their research interests. This

translates into fewer clinical shifts, fewer night shifts, and fewer weekend shifts, than a full-time clinician-

educator in the department. By the way, if your chair refuses to give you a break in your schedule to

pursue research if your time is funded by a federal grant, it is not only unfair, it's illegal.

Travel: In addition to getting to regularly attend nifty meetings like SAEM, researchers often have

opportunities to attend other scientific meetings, both inside and outside the U.S. Those who achieve

national prominence are frequently invited to give "guest lectures" at other programs as well as state,

regional, or national professional meetings. A medical school dean once noted, "Academic Medicine

doesn't pay as well as private practice, but you can't beat the travel."

Ego: It's exciting to see your name in print in a top journal like Annals of Emergency Medicine. Mothers,

fathers, and relatives will love getting reprints, and your residents will enjoy critiquing your work in

journal club!

Satisfaction: Research, no less so than patient care and teaching, is hard work. However, it is also fun

and highly satisfying. It offers an interesting break from the daily (and nightly) routine of clinical practice.

Research in EM often focuses on clinical issues, with the goal of improving our approach to care. As a

result, research can give you and your colleagues better ways to take care of patients. Given the

inherent frustrations of ED care, it is important to set aside time to drain the swamp, instead of spending

all of your time and energy battling alligators.

B. Departmental reasons:

Recognition: Deans at prestigious medical schools are judged by their institution's NIH ranking (i.e., how

many dollars in annual NIH funding the medical school secures relative to its peers). If your clinical

department contributes to the school's NIH ranking goal, your Dean will appreciate it. Academically

productive departments have greater national visibility, tend to attract high caliber residency and faculty

applicants, and maintain a higher profile at the SAEM annual meeting and other venues. Strong,

research-oriented departments tend to attract and retain strong, research-oriented faculty. Success

begets success.

Financial: In successful departments, extramural research grants provide a significant boost to

departmental revenue. To provide departments with a strong incentive to conduct research, many

Deans return a share of indirect cost recovery from grants to the departments that secured them. This

money can be used to support further research and career development. Salary support from grants

buys "release time" for faculty researchers and pays the salary of research nurses and research

assistants. It also allows your department Chair or Division Chief to hire more doctors, enhancing the

departments' size and influence.

Clout: Collaborating departments respect excellence in research. They are much more likely to include

EM faculty members as co-investigators in their own studies if they respect your program's science and

its output of publications. Research collaboration is a good way to build trust and promote cooperation

on other fronts.

Recruiting: Medical students and residents are avid readers of journals. Most, if not all, are drawn to

departments and individual faculty members who appear frequently in print. Since a program is only as

good as its personnel, anything that helps recruit and retain high-quality residents and junior faculty is

worth its weight in gold.

Pride: People like to be part of a top-tier program. Research productivity is an easily measured

parameter of a program's standing in academic EM. Programs that conduct research typically have

higher esprit de corps, and are arguably more careful about patient care, than those that do not.

C. Specialty reasons

Status: As the specialty of Emergency Medicine produces more high quality studies, and accomplished

researchers, it gains respect in the house of medicine.

Funding: Research brings substantial funds to EM investigators and the programs and laboratories in

which they work. It also helps drive clinical innovation in our specialty.

Influence: Thanks in large part to their academic achievements; Emergency Physicians are occupying

increasingly important and influential roles. An Emergency Physician serves as senior editor of JAMA;

three others currently or recently directed a major federal agency, and others are rising to the level of

Associate Dean in their medical schools. E.R.s are being assigned to study sections at NIH and other

funding agencies. The number of Emergency Physicians that have been elected to the Institute of

Medicine has reached double digits. More will be named in the years to come.

D. Societal benefit

Clinical impact: EM generated research has made a major impact on emergency cardiac care, acute

stroke management, asthma, injury control, our understanding of cellular ischemia, use of diagnostic

technologies in the ED (both lab and imaging) and other laboratory and clinical innovations. We practice

better and more efficient emergency medicine today than ever before, thanks in large part to the work of

EM researchers.

Public health - Patients who receive better and more timely ED treatment have better outcomes and live

longer than those who do not. Using the ED as a window into the health status of communities is a

powerful tool for public health.

Social Justice - Because Americans know that they can always to an ED when the chips are down,

Emergency Departments serve as barometers of the health status of a community. For this reason,

Emergency Physician researchers can use ED data to shine a spotlight on important social problems

such as the plight of the uninsured, poor access to care, substance abuse, mental illness, and domestic

violence.

III. Getting Started

The biggest hurdle to conducting research is getting started. To do that, you must overcome a number

of mental obstacles to initiating research

"I don’t have sufficient time." Make your clinical practice your "lab". There are thousands of worthwhile

projects that need to be conducted in EDs or other settings that are within the domain of Emergency

Medicine.

"I don’t have formal training." If you want it, get it. One of my top attendings went to night school on his

own to earn his MPH. Many Universities offer evening MPH courses, research seminars, Web based

learning, and other opportunities. Two semesters of Epidemiology and two semesters of Biostatistics

can go a long way. Attend Journal club and any other seminar that looks worthwhile. Learn research

methodology in courses and seminars, and then apply it to your chosen area of interest and expertise.

"All the good ideas are taken"

Rubbish! Be a good listener. Ideas are all around you. You don't have to steal them, because people

give them away all the time. Alternatively, select the most frustrating issue in your department, and

decide how you can improve it. Evaluate your efforts and viola - you are in business. That is how I

began my first two projects as a faculty member. Strive for something original, or at least fairly new.

Which type of movie do you prefer - an original film, like "the Matrix" or a worn out sequel, like "Rocky

XVIII"?

"I’m not smart enough."

If you are smart enough to read and listen, you are smart enough to be a successful researcher. Don't

invest five minutes on a project before you have spent at least two days learning what has been already

been done on the topic. You may find that the answer has already been found, or alternatively, that

there is a gaping hole in the literature that your study will fill. Once you have done that, seek out a

trusted colleague or a mentor and solicit their opinion of your idea. Listen to their feedback, and

incorporate their advice where you can.

"I can’t get money for my project" More than half of the manuscripts I have published to date (including

several in JAMA and New England Journal of Medicine) were conducted with little or no funding. Some

cost nothing more than my time. Pilot studies should be done first, to lay the groundwork for descriptive

or an analytical study. Successful descriptive or analytical studies set the stage for experimental trials.

Major universities often offer small "seed grants" that can provide the funds needed to mount a pilot

study or test a new idea. Once you have secured a start-up grant, go for something bigger.

"I don’t know how to write." If you realize this, you are better off than most. Writing is an acquired skill,

like learning how to start a central line or perform endotracheal intubation. The more writing you do, the

better you will get. Find a trusted mentor who is willing to edit your work, and don't get your feelings hurt

when he/she returns your manuscript in tatters. Learn to write simply and clearly. This is far more

effective than the turgid prose some researchers pass off as "medical writing".

"I don’t have a mentor" Some people are lucky enough to land a job in a department with a seasoned

investigator who can help them learn the ropes. Others are not so fortunate. It is not necessary for your

"mentor" to be from your own institution, or to be an emergency physician. Close proximity helps, as

does disciplinary understanding, but neither is essential to develop a productive mentoring relationship.

A mentor's willingness to give you advice, and your willingness to receive it, is more important than

whether or not they work in your department. During my research fellowship, my primary mentors were

a Neurologist and a General Internist. During my formative years as a junior faculty member, my mentor

was a Geriatrician. Over the course of my career, I have mentored young Emergency Physicians from

several programs around the country as well as my own faculty. I have also mentored young faculty at

Emory from other departments.

"I’ll be rejected, so what’s the point?" Everyone gets rejected! It's part of the process! Learn from the

feedback, pick yourself up, revise and/or try again. If one journal won't take your paper, the chances are

good that another one will. Most specialties have more journals than they need. If, however, you

discover that your paper is fundamentally flawed, ditch it and move on. You probably did not secure, or

listen to good advice at the outset - this is why thinking a study through and bouncing the idea off others

before you start is so important.

"No one respects me (or EM) anyway." They will, if you get your butt in gear. Publications (and even

more important, grants) are the coin of the realm in academic medicine. House staff respect clinical

acumen, but Deans, department chairs, and faculty members from other departments respect your

research. It is not necessary for everyone in your department to publish, but it is vital for enough

members of the department to publish to give it visibility. In an era of collaborative practice, excellence

should be defined in collective rather than individual terms.

"No one will collaborate with me (or us)."

Our colleagues need us more than we need them. You would never dream of walking up to the CCU

and expecting a cardiologist to help you do a study of thrombolytic therapy in their unit without

attribution. Why should cardiologists, neurologists, internist or surgeon expect emergency medicine to

conduct case finding in the emergency department without a similar degree of recognition? My answer

to queries from other departments is quite simple - "We may be able to help. Who in my department

have you identified to serve as your collaborator and co-author?"

IV. Secrets of success

Start simple. Many research projects sink under their own weight. Collect only the information you need,

and nothing more. Every element of a data collection instrument or questionnaire should be justified, or

left off. My fellowship research project, a study of drug screening in the ED involved far too many

variables and almost sank under its own weight.

Build on success. Small projects carried forth to completion are much more satisfying than ambitious

failures. As you acquire confidence and credibility, you can do more. (Examples from my early research

include a study of outcomes of refractory prehospital cardiac arrest, a descriptive study of gun deaths in

the home, a quasi-experimental study of dispatcher CPR, an observational study of the use of portable

pulse oximetry in the ED, and a descriptive study of patient "dumping").

Don’t put too may balls in the air at one time. Avoid the temptation to start multiple projects or construct

an "assembly line". If you are getting started, and you are attempting to run more than 2 projects, you

are over your head. During my own research fellowship, I attempted to simultaneously study drug

screening in the ED, firearm-related deaths in the home, and a landmark medical-legal case. I

eventually published work from the first two studies, but I failed to publish anything from the third. Had it

not been for my wife's demand that I focus my attention, I probably would have failed to publish

anything.

Invite criticism. If your idea is flawed, fix it. If you can't, ditch it and move on. A well-reasoned critique will

save you months of work and years of heartbreak.

Find a mentor. It is almost impossible to succeed alone. A mid-career investigator or professor who

knows the ropes is worth her/his weight in gold. If need be, go outside your discipline. My first faculty

mentor was Bill Applegate, a gerontologist. My top collaborator in the first phase of my faculty career

was Bela Hackman, a cardiologist. The co-author of my best work in injury control is Frederick Rivara, a

pediatrician.

Be an opportunist. If you see an opening, take it! Some of my best studies came from turning salesmen

into collaborators to conduct technology assessment projects (e.g., my AED and pulse oximetry

papers). Any program worth implementing is worth evaluating to determine if it works.

If you have to choose between love or money, choose love. Don't select a project you hate because it is

"fundable" or someone offers to make you co-investigator. Follow your heart. Research is hard work

when you are fascinated with the idea, pure misery if you aren't. Life is too short to work on an issue that

you don't believe in, or one that bores you to tears.

Pick a subject that matters. If you are going to do research, choose a topic that matters. The first NEJM

special article, a descriptive study of firearm fatalities in homes, did not include a single P value or

statistical test. Pick something in your department that bugs you, and turn it into a study. This is what led

me to conduct studies of patient "dumping", ambulatory visits to EDs, "bounces" and asthma treatment.

Write clearly. If your mother can't understand your research, your colleagues won't either. Turgid writing

isn't "scientific" - it's bad writing. Ask a respected colleague or mentor to edit your work before sending it

out. If you haven't worked through at least 5 to10 drafts, the odds are great that you haven't polished it

enough. Beginning writers invariably produce manuscripts that are twice as long as they need to be.

Some experienced writers do the same thing.

The best way to learn how to write a competitive grant proposal is to read a competitive grant proposal.

The first grant I ever wrote (a case-control study of violent death in the home in relation to gun

ownership) was adopted from a very well written case-control study of the relationship between breast

cancer and prior use of oral contraceptives. One of the best ways to hone grant-writing skills is to read

good grants written by others.

Have fun! - Clinical research is a great way to pace yourself through an academic career. Patient care is

exciting but wearing over time. While the satisfaction of making a difference for a patient is great, it is

also satisfying to take an idea that was generated at the bedside and use it to make a difference.

Research as a career foundation

Author: Charles V. Pollack, Jr.

Career development in academic practice is a process that begins in medical school (or even before)

with the establishment of a work ethic and areas of specific interest, continues through residency and

perhaps fellowship training with the identification of mentors and the selection of a first and then

subsequent academic positions, and then is shaped and adapted every day of our professional careers

by factors both intrinsic and extrinsic to the physician. Throughout this career-long process, however,

there are certain activities or "core competencies" that serve as foundations for intellectual and

professional development. Although it is certainly possible to have a successful academic career without

achieving specific goals or expertise in research, most academicians view research as the cornerstone--

or least one of the cornerstones--of a career that is palpably different from that of colleagues who

choose community-based over academic practice.

"Research" and "academics" are not synonymous terms, although many think that they are. The role of

research in academic practice is driven by (1) the individual’s interests, (2) the department’s degree of

involvement in research, and (3) the institution’s level of support for research. Furthermore, research in

emergency medicine (4) may or may not require specialized training; (5) may be clinical or laboratory-

based; and (6) may center on issues integral to other specialties as well as our own. In short,

"emergency medicine research" is as diverse as are practitioners of emergency medicine. The

remainder of this chapter will consider each of these six factors in some detail.

(1) The individual’s interests. Research is a frustrating, fatiguing, stress-inducing, time-consuming chore

. . . for those who do not enjoy it. The exact same regimen may be the highlight of another’s day. To

build a career in research, one must have a questioning mind, a tireless work ethic, an innate sense of

organization, the personality of a cheerleader, an enjoyment of (or at least the lack of an aversion to)

medical writing, and a willingness to take potshots from pundits, colleagues, and intellectual competitors

on a regular basis. "Research" may include medical writing (review papers, invited manuscripts,

textbook chapters), laboratory studies or analyses, retrospective clinical studies, prospective clinical

studies, and surveys. Many traditional academicians (and promotion and tenure committees) tend to

discount somewhat at least the first and last of this list, and some similarly disdain retrospective studies.

Statistical inquiries such as meta-analyses fall somewhere in between. All of these efforts, however,

involve the basic element of formulating a question, researching related issues to refine the question,

and proposing a way either to summarize or direct previous answers or to derive a new answer.

The first generation of emergency physicians attacked such questions with boundless enthusiasm,

limitless energy, and an utter lack of discipline. Lacking the framework of an established specialty,

seeing all clinical issues as being pertinent to EM, and having essentially no funding sources from which

to draw support, these pioneers studied just about everything . . . moving from asthma to urinary tract

infections to trauma to airway. Interesting data were generated that in retrospect helped define our

specialty, but these clinician-researchers with only occasional exceptions were unable to establish

"research niches" for themselves, from which they might have been able to establish ties to more

established researchers and specialties (and their funding sources). Most of these early EM researchers

eventually ascended the academic ranks, but this was often because P&T committees of the day--faced

with this new specialty about which they knew little--failed to develop and uphold consistent standards

for career milestones for emergency physicians. Today’s academicians face a much more exacting

standard, and therefore must seek to focus their research interests and energies in one or at most two

clinical areas if they are to secure funding and peer recognition.

This "focusing" need not occur on day 1 of one’s academic career, but the earlier it occurs, the more

likely one will be able to develop fully his or her potential in that area. "Areas" of focus in EM research

are exemplified by this list, which the author in no way holds as all-inclusive:

Basic science:

Resuscitation

Preconditioning

Ischemia/reperfusion

Toxicology

Infectious disease

Trauma/injury

Clinical science:

Cardiovascular

Neurovascular

Shock/resuscitation

Infectious disease emergencies

Complications/trauma in pregnancy

Trauma

Airway management

Toxicology

Emergency medical services (EMS/out-of-hospital)

Respiratory emergencies

Pediatric emergencies

Wound care

GI/GU emergencies

Gynecologic emergencies

Environmental emergencies

Endocrine emergencies

Psychosocial emergencies

Epidemiologic/population research

An important note to make in reviewing this list is that perhaps only EMS is not accompanied by a

readily apparent overlap with interests of other specialties and disciplines. If handled adroitly, this

realization may make the emergency physician researcher’s task more possible, more fundable, and

more fun. An academic environment in which two or more members of the department share similar

research interests typically results in an even more productive interplay and greater satisfaction.

In most institutions, some proficiency and demonstrated productivity in research is necessary for

continued advancement and career development. The choice not to pursue research does not

necessarily obviate the likelihood of advancement, but it may make it much more problematic.

(2) The department’s interests. The remainder of this discussion includes several factors that are

external to the individual; clearly this is one. The physician-researcher requires the tangible support of

his or her chairman in order to develop a research career, or even to develop a recognizable research

facet to a non-research-focused academic career. The currency of this support is time--time

prospectively released from other academic and clinical responsibilities so that the research can be

pursued. One may complete one’s first and even second research project in one’s "spare time," but the

dedication required to make research efforts a substantive part of one’s academic career requires paid

time away from other duties and distractions.

The other critical component a chairman can provide to nurture young investigators is seed funding,

from the department or elsewhere within the institution, to support preliminary studies that may in turn

attract outside funding. Seed funding may also be sought from a research training grant (for example,

an NIH K1 award), which may be less competitive than traditional research grants, but also require

significant institutional infrastructure to support successful applications; and from foundations such as

the Emergency Medicine Foundation (EMF) and the Fund for Academic Emergency Medicine (FAEM).

One must also be realistic, especially early on in an academic career. Most chairs do not have limitless

sources of seed funding nor of uncompensated attending time. One’s research career generally starts

"on one’s own time," a fact that results in many promising research interests being left behind. Junior

attendings who are interested in developing a significant research aspect to their careers should expect

to devote 60-70 hours per week to the combination of assigned clinical and teaching duties and the

building of one’s own "research infrastructure." Right out of residency, this may not be appealing. On the

other hand, chairs are anxious to reward and nurture the focus and early productivity in research that

can result from this effort.

In basic science research, the department’s role in encouraging research career development is to

provide laboratory space and funding, in addition to time. Unfortunately, few EM departments today

have independently funded research laboratories. It then becomes the chair’s responsibility to link the

interested emergency physician with faculty from other specialties or on the institution’s basic science

faculty with whom shared interests and "grunt work" (made available by protected time) can potentially

be parlayed into shared productivity. Many successful EM-based basic science researchers have

established themselves in other researchers’ labs prior to qualifying for their own funding. The chair’s

wholehearted support is also required in any application for funding, and must be presented along with a

pledge to cover shortfalls both of money and time for supported projects.

In clinical research, the support needed by the successful researcher starts with the chair but extends to

the entire department--attendings, residents, nurses, research clerks, consulting teams, unit secretaries,

even registration personnel. The well-developed departmental research program is primed to screen for

potential study subjects at every interaction between the patient and the "system". Only with a sufficient

example set by and mandate from the chair is this feasible. The successful researcher will learn from his

or her interactions with colleagues what reminders of ongoing studies work best, whether application of

incentives or disincentives result in better patient enrollment, and how to leverage his or her research

goals into cooperative research efforts by others, to the benefit of all. Furthermore, the researcher

cannot rely solely on the chair’s support; he or she must set the work ethic and enthusiasm example for

screening and enrolling patients if others without a vested interest in the research are expected to do

the same.

The department’s support of building attendings’ research careers is also measured by the resources

allocated to necessary equipment, to ancillary research personnel, and to special instruction (usually at

a price) for researchers-in-training. It is nearly impossible to build a research career, or even to have a

substantive research agenda within an otherwise non-research-focused career, without this level of

support. On the other hand, faculty who expect this type of support must be prepared to show

productivity--measured at least in publications and probably in (eventual) external funding as well--in

return. One must strike a proper balance between guiding and advising residents on their research

projects and maintaining time, energy, and effort for one’s own primary work.

(3) The institution’s interests. Department chairs can accomplish only so much without support from the

institution. Intrainstitutional barriers to research cooperation and mentoring must be overcome. Access

to institutional facilities and financial support must be negotiated on behalf of emergency medicine,

which may be viewed--particularly in more traditional institutions--as an interloper. Lab space, statistical

support, grant writing resources, computer equipment, seed grants, and the like are essential to

research career development in EM just as they are in other disciplines. Grants offices should be

informed about EM-specific sources of funding such as the EMF and the FAEM, and these offices in

turn should inform EM researchers about opportunities for acute care research that may be initially

targeted to other departments. Spending time developing interdepartmental relationships within the

institution or even among multiple institutions may result in cooperative funding agreements and an

enhanced productivity level for all.

The institution should also support networking; though in today’s society this is perhaps an overused

term, the exchange of ideas and opportunities among colleagues is essential in establishing and

maintaining a research career. In academic institutions, networking must cross specialty lines. An

emergency physician researcher cannot expect to be productive in a vacuum, and should seek

colleagues interested in the same areas in other clinical departments, and, if applicable, in basic science

departments as well.

(4) The need for specialized training. In general, residency training in emergency medicine provides

inadequate training in research for one who wishes to make research a significant part of an academic

career. Also in general terms, the optimal training for research is a full-time, two- to three-year

established research fellowship, usually involving pursuit of an advanced degree as well as specialized

research skills that are (hopefully) deserving of independent extramural funding. Unfortunately for the

specialty, very few emergency physicians are interested in following the fellowship route, usually due to

very legitimate concerns about income, career time, etc.

There are several options for less intensive training, but the results are predictably less far-ranging than

those earned via a formal fellowship. Many grant-writing workshops are offered nationally each year;

SAEM periodically offers a workshop more directly applicable to EM researchers at the Annual Meeting,

but one should first look for such opportunities at one’s own institution, where the benefits from

attending may be magnified by the opportunity to network with other budding researchers "at home."

ACEP offers a 13-day (in two sessions, six months apart), intensive Basic Research Skills workshop in

Dallas. Modeled after the highly successful ACEP/EMF Teaching Fellowship, this curriculum offers an

extensive introduction to issues of study design, statistical analysis, protocol formulation, and

grantsmanship. It is pertinent to clinical research only, as there simply is no "one-size-fits-all" approach

suitable for the diverse areas of basic science research pertinent to emergency medicine.

The most important aspect of "training" for research in emergency medicine is identification of a suitable

mentor. It is safe to say that a self-trained "researcher," regardless of his/her energy and enthusiasm,

will be unable to develop research into a career-defining interest without the stable guidance of an

experienced (and funded) mentor. That is not to say that writing papers and answering basic questions

cannot be done on an individual basis, but such activity is otherwise often destined to be "window

dressing" on an academic career.

There is no formula for finding a mentor. Even in highly structured research fellowships, fellows may

work with several researchers before identifying one with whom "the chemistry" and joint interests are

right. Physicians seeking a mentor outside a fellowship setting likely have an even tougher task in this

regard. This is another requirement of a supportive department chairman--the ability (and interest) to

link interested researchers with others in the department, elsewhere in the institution, or even in other

institutions, who will tend and nurture research interests into the opportunity for meaningful

accomplishments. Mentors and networking colleagues may also be sought at specialty society meetings

not usually targeted at emergency physicians, such as the American Thoracic Society if one is

interested in asthma research, or the American Heart Association for resuscitation and cardiologic

issues. Finding a mentor already funded for research with which one’s interest is shared may be an

even more efficient way of getting established in research.

(5) Clinical vs. basic science. This is an issue both of personal preference and institutional capability.

Some institutions simply do not have the physical capacity to support basic science research,

regardless of an individual’s enthusiasm for doing it. Although funding that backs up the enthusiasm

might address the problem in theory, funding agencies are unlikely to award grants to institutions

without pre-existing infrastructure. There are many areas of basic science research that are pertinent to

EM, but if lab work is to be part of one’s career development, one must choose an institution with the

appropriate capabilities. It should also be kept in mind that many techniques used in one area of

laboratory research, even when mastered, may not translate well into other areas of research. This

"subspecialization" can be a barrier to continuing one’s basic science research in the absence of

independent funding. After decreasing during the mid-1980s and 1990s, governmental funding for basic

science research is rising and can be expected to be stable for the next few years.

As opposed to laboratory work, any busy ED can potentially support a clinical research program. Again,

infrastructure--supportive staff, research clerks/nurses, the availability of computers and statisticians--

may be needed to perform clinical research of much substance, but one may "cut one’s teeth" on clinical

research early in one’s career, perhaps even as a resident. Institutional funding may be available for

small projects, especially if there is a quality improvement aspect to the work. Foundations and

governmental agencies (such as the AHRQ, formerly AHCPR, and the CDC) are increasingly interested

in supporting ED-based clinical research, and the opportunities for industry-supported research have

never been greater. Industry support for investigator-initiated protocols can be a boon both to the

researcher and the department, but protocol development and data ownership issues should be clearly

spelled out prior to signing a contract. One’s institution’s research or contracts office can provide

valuable assistance in such negotiations. Participation in industry-initiated trials (the proverbial "drug

studies") may provide needed capital for infrastructure development and may be useful for teaching

residents about informed consent, case report form preparation, and other fundamental research issues,

but rarely result in publication credit for the individual and in most institutions are not helpful in the

promotion and tenure process. Participation in industry-initiated multicenter trials should be considered

only if the researcher’s/department’s answers to each of the following questions is "yes":

Is this study pertinent to EM practice?

Does the disease being studied present to my ED with a predictable frequency?

Is the study scientifically sound?

Is this study one that will generate sufficient sustaining interest in the department

necessary to ensure completion?

Are the resources needed to complete the study either already available (with unmet

capacity) in the department, or are provided by the study?

Is the study budget reasonable to support not only the index study but also other

research activities (particularly those that are currently un- or underfunded) in the

department?

If other clinical departments are involved in execution of the study, are they willing to

participate reliably, and does the budget support payment for their contributions as

well?

Another broad area of potential research interest within EM is population-based or epidemiologic

research. The potential for meaningful contribution in this area is largely unfulfilled. Successful pursuit of

such research mandates a good working knowledge of sampling and statistical analysis techniques and,

typically, the support of colleagues from other specialties and from governmental agencies (such as

health departments).

Clinical research also offers the greatest opportunities for those academic physicians who wish to have

some research "on the CV" but are not interested in being full-time researchers. Active participation in

departmental projects can bring authorship credit as well as interesting and career-expanding

networking opportunities.

(6) Involvement of other specialties/disciplines. It has been emphasized already that very few areas of

research interest within EM do not overlap with interests of other specialties and basic science

disciplines. Furthermore, there is an acknowledged numerical deficit of seasoned mentors and funded

researchers in our young specialty. In most institutions, emergency physicians who are able to establish

research as a, or the, primary cornerstone of their academic careers do so with the assistance of

colleagues outside the ED. Such input should be sought from the very beginning on one’s academic

career.

In summary, the emergency physician who seeks to build a research career requires, first and foremost,

an inquisitive mind, a true and overriding desire to design and execute research plans, and the

enthusiasm, energy, and dedication to support that desire until a sufficient track record can be

generated to "buy down" clinical time and be able to pursue research within the context of a productive

and satisfying academic career. The second requirement is external--an understanding and supportive

(tangible and intangible) chair. This support should be specifically sought during the interview process,

whether for one’s first academic job or for one’s fifth. Given this support--which includes the real

potential for protected time, some infrastructure, perhaps some outside training--one must then develop

one’s interests, identify a potential mentor, and focus one’s enthusiasm on study development and

funding. The successful researcher always has the next two or three protocols--dependent upon the

outcome of the current studies--ready for consideration. The result of this planning and execution can be

job satisfaction, the enjoyment of networking with other physicians who share one’s interests, and

career advancement.

A Blueprint for a Successful Research Program in Emergency Medicine

Authors: W. Brian Gibler and Brian J. Zink

Introduction

The development of a successful research program remains the greatest challenge for any Department

or Division of Emergency Medicine. The patient care and teaching missions of most Emergency

Medicine programs are easier, relatively speaking, to define and achieve excellence in performance.

The purpose of this document is to provide the academic leaders of an Emergency Medicine

Department or Division a blueprint for a successful research program. Establishing a vision, setting up a

research infrastructure, recruiting research faculty, developing collaborations with other departments,

and identifying funding sources will be discussed. As the specialty of Emergency Medicine continues to

evolve as an academic discipline, it is our hope that this effort can provide a framework for a successful

research program in virtually any setting.

Establishing a Vision It is often tempting for a faculty group to pursue a wide variety of research ideas

and projects that reflects far ranging interests and expertise. Unfortunately this haphazard approach to

research results in a lack of Departmental focus and often mediocre research productivity. Establishing

a clear research focus for a Department often results in a more coherent approach to resource

allocation, faculty hiring, and grant writing. Typically every faculty group has one or two individuals that

have been effective in concentrating on a particular research area with resulting success in obtaining

funding, publishing papers, and in bringing national notoriety through presentations of work at national

and international scientific forums. The Chair of the Department, with the support of the rest of the

faculty, can then identify these one or two areas as research focus directions with the successful

researchers as leaders of the effort.

Future hiring of young researchers by the Department should support these newly declared areas of

research focus. Resources allocated by the Department should directly support these initiatives and

members of the faculty and residents should be encouraged to work with the productive researchers to

build programmatic strength. If no senior researcher is present in a newly developed academic unit,

faculty recruiting should be directed toward hiring a productive researcher to build a program around.

It is essential that the Department Chair or Division Chief possess a clear vision for the research focus

area(s) of a program. This vision must be articulated frequently to ensure that the faculty, residents, and

staff of a Department understand the common goal of the research effort. This broad understanding can

then provide support when financial and personnel resources are used to improve research productivity

in an area of focus.

Granting sources such as corporate, foundation, and federal agencies are more likely to provide funding

to organized, focused, and mature research groups. Senior faculty can bring funding to a Department

that includes support for junior faculty, fellows, residents, and support staff. These focused research

efforts also can improve collaborative relationships with other Departments within the medical center

and with other Departments of Emergency Medicine throughout the United States as well as other

countries. Funding sources are familiar with this research focus approach and typically provide monies

to support multiple members of the research team. The junior faculty member can begin to use this

"collateral" grant to develop an independent funding history to become competitive for individual

financial support in the future.

Recruiting Research Faculty The recruitment of junior or senior research faculty requires a clear vision

to determine the training, talents, and interests of the Department of Division. Successful senior faculty

researchers can serve as an effective magnet for junior faculty interested in pursuing a research career.

Most individuals finishing a residency and aspiring to become successful researchers understand that a

mentor is essential to obtain the necessary training to become an independent investigator. Ideally the

junior faculty member will pursue a fellowship position with substantial non-clinical time to learn

research methodology and grantsmanship from an established senior investigator.

The mentor does not need to be a clinician, or even a member of the Department or Division of

Emergency Medicine. A PhD scientist can offer invaluable services as a senior mentor for a young

faculty member. The Department of Emergency Medicine may actually decide to hire a PhD researcher

to lead a particular research focus area. In some instances, hiring successful PhD scientists to lead a

research program may be easier than luring a senior Emergency Medicine clinician scientist from

another program.

Hiring junior or senior level physician scientists to a Departmental research program requires significant

clinical off-load. Typically a load of 24 hours per week is considered the maximum amount of clinical

time for a successful researcher. Further reductions in clinical time can be provided as an incentive for

the researcher that successfully brings significant research dollars into the Departmental coffers. Failure

to provide clinical off-load to prospective candidates for research positions substantially hinders

recruiting efforts, particularly for the most talented prospects receiving multiple faculty offers.

Developing Collaborations with Other Departments After defining a Departmental research vision,

seeking collaboration from other Departments in a medical center can be extremely helpful. Often other

older Departments have established senior investigators with prolific funding histories. Whether an

Emergency Medicine faculty is looking for an established mentor in another Department, or simply

attempting to build a critical mass of researchers in a particular area, inter-departmental collaboration

can be exciting and financially rewarding through successful awarding of grants.

Collaboration with other Departments by emergency physicians also enhances the stature of the

Department or Division of Emergency Medicine in the medical center. Being perceived as intelligent

investigators can improve teaching and patient care relationships with other Departments. A successful

research program that contributes to the medical center research goals can lead to resource allocation

to Emergency Medicine. Presentations at the national and international level with publications in major

journals also enhance the institution’s reputation.

Areas of Focus While research in Emergency Medicine can cover many areas, developing a focus that

is fundable should be the individual researcher and Departmental goal. A number of Departments and

Divisions of Emergency Medicine have received funding in a variety of research areas, however, some

common themes emerge:

Brain Injury/Resuscitation

Heart and Lung Injury/Resuscitation

Infectious Disease

Injury Prevention

Access to Care

Outcomes Research

Environmental Emergencies

There is significant funding available in these major focus areas for Emergency Medicine researchers.

As there is precedent for expertise in Emergency Medicine in these research areas, which has led to

previous corporate, foundation, and federal funding, new research teams may be more likely to be

awarded funds.

Setting Up a Research Infrastructure The development of an infrastructure for research is considered

essential. For a basic researcher, a well equipped lab is necessary to be a productive researcher. In

many cases, a junior Emergency Medicine investigator can work in the lab of a senior scientist from

another Department. This has the dual benefits of being an inexpensive alternative to setting up a lab

prior to obtaining external funding while exposing a fledging Emergency Medicine researcher to a senior

mentor. This training period, while serving as a co-investigator, is usually necessary before receiving the

primary funding essential to build a lab.

For clinical research, the Department or Division can make real investments that can enhance the

likelihood of receiving corporate, foundation, and federal research funding. Hiring a research nurse

coordinator can serve as the nidus for clinical trial funding and investigator-initiated corporate research.

Developing an office for research in a Department or Division can help to coordinate existing trials and

developing grant proposals. As such an office becomes more sophisticated, a research nurse

coordinator and Departmental grants office can be of substantial assistance to investigators. If an

infrastructure works properly, grant submissions, IRB submissions, grant tracking and communication

with sponsors can all be facilitated for the research faculty. Most funding agencies expect a mature

research group to have a research nurse coordinator and grants office to successfully complete clinical

research studies. A minimal infrastructure for clinical research can cost $100,000, which includes

benefits and office space for non-faculty staff. Depending on the complexity of the support staff structure

for research, this cost can be increased 2-3 fold. Ideally, research funds can offset most, if not all, of the

costs of support staff.

Another important consideration in constructing a successful research program is collaboration with a

competent biostatistician. In some circumstances, the Department has to provide funds to pay for

biostatistical consultation for pilot trials or non-funded research. Subsequent grant submissions should

contain funding for data management and analyses by a biostatistics group. Again, funding agencies

expect such expenses in a grant proposal.

Identifying Funding Sources Ultimately Departments and Divisions of Emergency Medicine should

position themselves to obtain federal funded research. These funds for basic and clinical research

awards not only cover Direct or the actual costs of performing the research, but also Indirect funds

which currently total 55% of the Direct costs of the study. Medical school Deans use National Institutes

of Health (NIH) funding of Departments to judge their success as research entities, as well as Indirect

funds to provide an additional source of money to build the research and teaching infrastructure of a

medical center.

Unfortunately, most Emergency Medicine investigators are not competitive for peer-reviewed federal

funding initially. Certainly young investigators are likely not going to be considered qualified to receive

RO-a awards for investigator-initiated original research without a previous track record of publications

and funding in the area under consideration. Training grants such as K-08 for basic research and K-30

for clinical scientist training can be successfully awarded to talented Emergency Medicine researchers,

particularly when combined with an established, well-funded senior investigator. Repetitive submissions

over several grant cycles, with appropriate responses to criticisms of the grant reviewers, are often

necessary to achieve success even with an outstanding research idea.

Corporate funding of investigator-initiated research ideas is an excellent source of initial grant money for

young Emergency Medicine investigators. Such grants can help to provide the publication record

necessary to demonstrate the research focus and success necessary for subsequent peer-reviewed

federal funding such as from the NIH or the Agency for Health Research Quality (AHRQ). Certain

foundations such as Robert Wood Johnson also can be a source of grant support for research.

Foundations also tend to provide peer review of applications and can be quite competitive. Consistent

funding of a focused research area leading to outstanding peer-reviewed publications remains the goal

of any Department and its faculty investigators.

Departmental Standards for Levels of Funding Establishing levels of funding for Departments or

Divisions of Emergency Medicine may be helpful in identifying successful research programs in our

specialty. Currently, there is not a consistent standard for identifying a research program that has

achieved grant money sufficient to be competitive with other similar size Departments or Divisions

across the United States. While this grading scale may be considered somewhat arbitrary, it is likely that

having consistent funding of $500,000 or more can be correlated with a national reputation for research

productivity. This should be prospectively evaluated.

The following amounts of Direct funding from any source, such as corporate, governmental contract,

foundation, or federal agencies, contribute to the following levels of research accomplishment:

Level of Program

Amount of Direct Research Funding

Bronze $250,000 - $499,000

Silver $500,000 - $749,999

Gold $750,000 - $999,999

Platinum $1,000,000 +

These levels of funding are clearly aggressive and should be counted in a given fiscal year. To

ultimately compete with other specialties on an even playing field, Emergency Medicine must have

significant goals for grant awards.

Conclusion In this manuscript, a blueprint for the development of a successful program in Emergency

Medicine has been outlined. This represents a collaborative approach from multiple centers, which

hopefully can assist any Emergency Medicine Department or Division interested in having a productive

research faculty. In the final section, a level of success has identified research grant funding levels

correlating with national recognition for research productivity.

Early Faculty Development

Configuring a Curriculum Vitae for an Academic Career

Author: Mary Jo Wagner

A vital component of career advancement in academic emergency medicine is the preparation of a

comprehensive, professional curriculum vitae (CV). Translated from Latin, the term "curriculum vitae"

means "course of life" and is a detailed chronology of a professional career. It includes a listing of the

physician’s education, clinical, teaching, and research experience, publications and presentations,

awards received and activities in professional organizations. This is in contrast to a resume, which is a

brief overview of qualifications and experiences relative to one’s career objectives. A resume is

generally one or two pages in length and more job specific, focusing on needed skills identified by the

position to which one is applying. A CV is not limited in length, however, and should include detailed

information of the physician’s professional career with an emphasis on the academic components of

research, teaching experience, clinical expertise, and administrative service. Candidates for an

academic position will be asked to submit a CV in place of a job application. In the United States, it is

not uncommon for employers to use the terms CV and resume interchangeably, so one should clarify

the needs of the institution before preparing the document. In Europe, the terminology is reversed – the

resume is generally longer and focuses on one’s academic career and achievements.

A CV can be used to provide a background for prospective employment or promotion, grant applications

or other scholarly activities. Physicians are reticent to sell themselves and this document will provide the

opportunity to demonstrate experience without the need for overt marketing. Developing a CV may also

reinforce the writer’s self-confidence and provide a means for organizing prior experiences in order to

clarify abilities and accomplishments. The CV itself does not have career objectives or goals listed; that

information is included in the accompanying cover letter (see below.

A curriculum vitae is a formal document, and though there is no standard format, a general order and

certain sections are commonly used. (See the guide at the end of this chapter.) Depending upon

institutional convention, Items are often listed in reverse chronological order, i.e., most recent first. The

format must be uniform, with a consistency in the use of bold, italicized, or underlined fonts for section

titles and headings throughout. There should be limited use of abbreviations or acronyms. It is better to

err on the side of convention than to use informal or colloquial titles or expressions.

The first components of a curriculum vitae should be name and title (M.D., D.O.) of the candidate and

contact information. The name should be the one used in formal settings and on professional career

documents. It would be wise to list the legal name with the other basic information for completeness, if

different from the professionally recognized name. Address and contact information should include not

only a telephone number, but a fax number and email, if available. Both home and business addresses

should be included. If prospective employers should not contact the applicant at work nor make any

contact with the current place of employment, this current work information should not be listed here.

Extremely informal or vernacular email addresses might be viewed as unprofessional. Board

certification and state licensure information should conclude the introductory sections.

The next section of a CV typically describes the candidate’s education, also often presented in reverse

chronological order. The location of this section may vary; a more experienced job applicant might

choose to list his or her work experience first, before education, depending on the depth of the

professional experience. A new residency graduate should include college and medical school

graduation information as well as details on residency training. For the recent graduate, it would be

appropriate to mention the undergraduate area of concentration or major, as well as specific

distinctions, such as graduating magna cum laude. If a separate internship year or prior training was

completed in addition to residency, this should also be listed. Any fellowship training or other special

training opportunities of some length should be mentioned here. Professional certifying courses and

other short courses or brief specific training should not be included here. A section for these courses

could be added later in the document. For example, under a section entitled "Certifying Courses,"

"Ultrasound Proficiency Training, beginning and advanced courses (24 hours CME each session)" could

be listed.

Employment usually follows the section on educational background. This information should include the

official job title, institution/corporation name, city, state and inclusive dates of employment. A line may

be added to describe the job if the formal title does not make the responsibilities obvious. It is not

necessary in a CV to indicate the reason for ceasing employment. It is important to include the current

job in this section, including any academic appointment held. If the current employer should not be

contacted until a later stage in the application process, that should be noted here. Finally, individuals

who have received academic appointments from several institutions may decide to make a separate

section, following education, for academic appointments.

Many emergency physicians have practiced at multiple hospital sites, including temporary employment

(moonlighting) during their residency program and early career years. Some professionals have chosen

just to list these hospitals under a section titled "Practice Experience." For example, short-term or part-

time employment would be listed as "ED staff physician: General Hospital, Hamlet, MI 1998; City

Hospital, Village, MI 1997-8; Small-town Hospital, Burgh, MI 1997-8." Full-time career employment

should not be included under this heading, however.

The jobs held during high school and college and odd jobs done for short intervals should not be

mentioned, except for an extraordinary experience. Though an honorable job, bartending part-time

during college, for example, is neither unique nor professionally related and is not necessary to include

in a CV. If one has had limited formal employment, a young professional might put unpaid employment

experiences here, but only long-term, regularly scheduled commitments requiring professional skills

should be used (e.g., volunteer physician at a clinic for indigent patients). Most physicians place these

achievements under "Community and Extracurricular Activities", however. (see below.) As the physician

gains more experience, most non-medical practical experiences should be removed from the CV, unless

they relate directly to one’s career, e.g., computer expertise or basic science research prior to medical

school.

Professional society membership and committee activity section(s) can follow the employment section.

This section can be quite confusing if one belongs to several institutions and medical societies. Care

must be taken to assure an orderly presentation with consistent formatting. Professional organizations

could be listed in order of prestige: international, national, regional or state and local. Some

academicians list the largest organization for their specialty first, then list in decreasing size of

membership. Others may choose to identify first the most career-specific organization (e.g., National

Association for EMS Physicians, for an EMS director applicant); still others begin with the society where

they are most involved. Fellowship designation within a society can be noted in this section as well.

Committee memberships and leadership positions may be listed with the professional societies or under

a separate section, if numerous. Participation on institutional committees, including medical school as

well as hospital committees should also be recorded. Dates of service should be included in all listings.

Honors and awards is another section found routinely on a curriculum vitae. Again, these often listed in

reverse chronological order, ending with distinctive college achievements. Though some creativity may

be used to determine items which may fit in this category, list only merit-based awards and

scholarships. Record the official name of the award, the granting institution and the date presented.

Most of these will need a brief (one sentence) explanation as well, particularly if there are acronyms.

The description can often be derived from the award application, plaque or even letter of

recommendation. For example, "This award was given to the second year resident who best exemplified

compassion to patients and outstanding clinical judgment." Small grants for projects can be placed in

this category as well.

Grants received may be listed separately if there are enough of substantial distinction to merit a

separate heading. Information should include the official title, the granting organization or NIH institute,

the grant number, the principal investigator (and the participant’s role, if not the primary researcher), the

amount, and the date awarded or the timeline for funding, if multi-year. A brief explanation may be

included to clarify the purpose of the grant, although that will usually be self-evident from the title. The

monetary amount awarded should not be a determining factor in including the grant in this section. In

many institutions, it is customary to list only the amount of the award given directly to the investigator,

after the indirect costs (overhead taken by the school or university) have been subtracted. If one is

uncertain, it is entirely appropriate to list both the total and direct monetary value of the award.

For an academic emergency physician’s curriculum vitae, publications and presentations are commonly

listed next. Publications should be written in a standard, accepted format, generally in the style

recommended by the International Committee of Medical Journal Editors and the American Medical

Association.(1,2) This is the same required style found in the National Institute of Health (NIH)

Bibliography Format for its application forms (www.niehs.nih.gov/omhrmb/procedur/bibliog.htm). A

different format is used by some emergency medicine journals. All authors should be listed; some

experts advocate that the CV writer’s name be bolded or underlined. Articles not yet published should

use the phrase "in press" only if they have been accepted by a journal. Articles submitted, but not yet

accepted, may be included but must be listed appropriately (e.g., "submitted"), although in many

institutions, only accepted publications are considered appropriate content for a CV. When there are

sufficient entries, the publication section can be separated by classification. Peer-reviewed articles,

abstracts, book chapters, books, invited reviews, editorials, specialty society publications or opinion

papers, and web-based articles might be some of the categories included here. Letters to the editor, if

listed at all, should be clearly designated separately. Copies of publications should not be submitted

unless specifically requested.

The presentation section should include visiting faculty lectures and other invited speaker opportunities,

as well as abstract presentations. The title of the presentation, the date, and the group addressed

should be indicated. When there are a sufficient number of entries these also should be grouped, with

lectures categorized as international, national, visiting faculty series, regional, local. The list of abstract

and poster presentations should then be included under its own heading. If essentially the same lecture

is given to several different groups, the complete title should be listed once, with the different audiences

and dates noted separately.

It is the custom not to include lectures given locally to one’s own residents and students. By convention,

however, the same lectures given for another residency at the same location, e.g., Internal Medicine

Grand Rounds, are reportable on the CV. The numerous lectures and discussions provided to the local

EM residency need not be ignored, although they are generally more appropriate material for the

teaching portfolio of the clinician-educator (see Chapter on this topic later in this Handbook).

The section "Other Scholarly Activities" may include professional conference planning and development,

or special teaching opportunities (e.g., joint teaching to students in conjunction with a basic scientist).

Consulting engagements could fit in this section, or if the list is lengthy, it may be appropriate to create a

separate one. These items should be related to the medical profession only – the following section is the

one that allows for unrelated, interesting life experiences at institutions where this is deemed

appropriate.

The least regimented section of a curriculum vitae is "Community and Extracurricular Activities." Some

writers leave this information out completely, but many employers look at these activities as an

indication of a well-rounded physician. Chronicling service at a soup kitchen during the holidays would

be a good example of an entry here. Hobbies such as tennis or playing violin in the local orchestra, for

instance, could be included here. It is crucial that this section be written carefully, so as not to include

controversial hobbies or misleading diversions. Better to leave this section out than to appear to be

"padding" one’s CV. Ordinarily, as one develops more traditional academic credentials, this section will

disappear altogether.

Particularly if a curriculum vitae is to be used for a job search, a section on special skills is an important

inclusion. The topics in this section might cover fluency in languages, proficiency in computer

programming or expertise in ultrasonography. If an employer is known to be seeking a faculty member

with specific talents, the incorporation of this skill into a CV may encourage them to look more favorably

at the application.

In general, one’s departmental chair or division chief can advise the junior faculty member on the form

and content of their CV. Many institutions follow a standardized template, which may be required when

submitting a CV to the Promotions and Tenure Committee. It is also worth noting that the configuration

of one’s CV may vary slightly, depending upon the immediate purpose for which it is intended, e.g., a

CV submitted for promotion may look different from a CV submitted to a prospective employer. Similarly,

the CV submitted to accompany a grant application will have yet another focus. All of these issues

require the guidance of a senior faculty member.

Listing references has been discouraged in a professional curriculum vitae. One may leave this section

out completely under the assumption that references will be provided upon request. However, having a

ready list of references with whom future plans have been discussed is important. When references are

requested, they should be provided immediately.

Since the topics for inclusion in a curriculum vitae are not defined, many physicians add sections which

might highlight special talents or opportunities. An emergency physician with extensive experience in

outdoor patient care might have a section of "Wilderness Medical Care Experiences". A physician with a

strong background in education might entitle a section "Mentoring Activities," if the list of academic

advisory activities was indeed a considerable one. The CV should not be padded, but creative

presentation of unique abilities shows initiative to employers as well as highlighting special talents for

which they might be looking. However, because the appearance of "padding" can provide such a

strongly adverse impression, particularly to experienced reviewers, a good rule of thumb in CV

construction is: "When in doubt, leave it out."

Though each document will be individualized, some general techniques for writing a CV should be

followed. The title "Curriculum Vitae" or "CV" should not be written at the top. The nature of the

document should be obvious at first glance and it is more important to have the applicant’s name

prominently displayed and easily read. The applicant’s name should also be placed as a header on

each page, which should be numbered. Specific personal identifying numbers, such as a social security

number or medical license numbers should not be included for security reasons. (Listing the states in

which one is licensed, without giving the specific number, is adequate.) Although date of birth is

optional, one should avoid mentioning any social or personal items, such as ethnicity, religion. A current

photo should not be included unless specifically requested. Such items could be viewed with

discrimination and leaving them off a CV will eliminate any misunderstanding. Disabilities likewise

should be listed only if this would make the application stronger for a specific job. Including marital

status and the number or names of children can leave room for bias, specifically for women. However,

as with date of birth, there is a conflicting opinion about this. Some professionals document this

personal information if they feel it is important to represent their feelings about their family.

Conforming to traditional grammar and style is recommended for this formal document. Slang or jargon

should be avoided. Incorrect spelling or syntax is still possible with the computer "spell-check"

programs, so care should be taken to have the CV proofread several times before submitting it. The

visual layout of the CV is very important, as good first impressions clearly increase opportunities. Easily

read font style (e.g., Times New Roman) and size (12 point) create a more professional document. The

spacing of the items should be consistent, with double spacing between major topics to improve

readability. The document should have generous margins on all four sides of the page and be typed

only on a single side of the paper. There should be clear, distinct section breaks and headings. A CV

that is difficult to read will be more quickly laid aside.

Though using colored heavy stock paper has been recommended in other occupations, white

middleweight stock is most appropriate in academic medicine. Many employers are requesting material

to be faxed or copied and the coarse ivory or gray is more likely to cause difficulty with this technology.

More critical is the use of a laser printer with a new ink cartridge to avoid fading letters and difficult-to-

read type. Sending poor quality photocopies of a CV gives the impression that a mass mailing of these

items has been sent indiscriminately to many potential employers. It is not necessary to use binders,

folders, or cover pages on the curriculum vitae. These can be viewed as pretentious or just bothersome

and are not traditionally used in the medical field. Use of paper with a border or decorative pattern

detracts from the important information on the CV and should be avoided.

Writing a curriculum vitae requires a comprehensive list of all of the subject’s accomplishments. It is

very difficult to remember all the academic and professional activities in which one is involved if some

type of system is not already in place. Use of the Educator’s portfolio, discussed at length elsewhere in

this Handbook,, makes compiling this information much simpler. Once a CV is written, it is easier to

make ongoing changes than to try to update the document only on an occasional basis. The CV should

be updated immediately, for example, to include a paper accepted for publication, an abstract chosen

for presentation, or the selection of one to participate in a specialty society committee.

If the curriculum vitae is used for a job search, a cover letter should accompany this document. This

letter should be created individually for each institution to which one is applying, with specific mention of

local needs or interests. It is here that the applicant should express his or her individuality and unique

talents for a specific job. Obtaining background information about a particular opportunity can guide the

tone and emphasis of the cover letter. As this will be sent with the curriculum vitae, the focus of the

letter should be to highlight job-related accomplishments and skills. It would be appropriate to include

short term and long term goals here, if they match the needs of the organization. Some specific

personal details may also be suitable for this letter; for example, indicating family ties to a specific

geographical region or interest in residing in a particular community. Areas to emphasize in a cover

letter for an academic position in emergency medicine might include academic experiences,

administrative expertise, and research accomplishments. While the letter is a formal document, the style

can be more personal and relaxed. It should be printed on the same type of paper as the curriculum

vitae if possible. The cover letter should summarize, emphasize and personalize successes, not

reiterate items listed on the CV.

A well-organized and clearly written curriculum vitae provides a favorable first impression upon a

reviewer. Whether this document is used for employment, promotion or a grant application, a thoughtful,

carefully crafted CV can increase opportunities for its writer.

References

1. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted

to biomedical journals. Can Med Assn J 1994;150:147-154.

2. American Medical Association. Manual of Style, 9th ed. Baltimore: Williams & Wilkins, 1998.

Further Readings

1. Logan PM and Fraser DB: Constructing a Curriculum Vitae: The radiologist’s resume. AJR 1998;171:

923-925.

2. Yenney SL. The Physician’s Resume and Cover Letter Workbook. Chicago: The American Medical

Association, 1998.

3. http://www.coloradocollege.edu/beta/publications/curriculumvitae/default.htm

Section Guide for Physician Curriculum Vitae

Name and Title

Address and Contact Information

Certification and Licensure

Education

Academic Appointments

Employment

Practice Experience

Professional Society Membership

Committee Activity

Honors and Awards

Grants

Publications

Presentations

Other Scholarly Activities

Certifying Courses

Community and Extracurricular Activities

Special Skills

Understanding the Promotion and Tenure Committee

Author: Edward A. Panacek

The process of promotion and awarding of tenure can appear daunting and mysterious, particularly to

junior faculty. Although the process varies widely among institutions, there are themes that are relatively

universal. Understanding the procedure at your own institution is critical to assuring your success as an

academic faculty member.

Faculty job descriptions and "tracks" can vary substantially among institutions. However, virtually all

institutions have an "academic" faculty series that has a formal promotion process, with or without the

awarding of tenure. This includes a formal period of review for junior faculty, which generally takes place

during the time as an "assistant professor", before being promoted to "associate professor". This period

of review usually lasts for a maximum of eight years. Because the faculty packet for consideration for

promotion is routinely assembled a full year before this period ends, the faculty member’s qualifications

for promotion are actually based on a maximum of seven years of faculty productivity. Even when

faculty have been "decelerated", most institutions have absolute rules governing the maximum period of

time that faculty can serve as an assistant professor in an academic series. At some institutions, the

same rules do not apply to faculty that are in a "clinical" series that does not have a publication or

research requirement.

Assessment Criteria

The process of formal review of a faculty member for promotion, or for the awarding of tenure, includes

activities in four specific categories at most universities. These are clinical competence, teaching,

service activities (both university and public) and research or creative work. Faculty in clinical series that

do not have a publication requirement, are generally judged by assigning greater weight to each of the

first three categories.

Professional competence is generally required for faculty in schools of medicine. This includes

demonstration of distinction in the special competencies appropriate to one’s field. In medicine, this

should include both qualitative and quantitative measures of clinical performance. The quantitative

aspects include billing summaries, RVUs generated, number of clinical shifts or clinical hours, etc. The

qualitative aspects are more difficult to measure, but usually focus on intramural peer review. Credit can

be given for organization of unique or new clinical services. Some institutions use the process of board

certification as one way of assessing clinical competence and most include it as a requirement for

promotion. Recognition or certification by appropriate national professional groups is also often used in

this assessment.

Teaching activities are theoretically highly valued when assessing a faculty member for promotion.

Quantifying the amount of teaching of students, residents, and peers tends to be the focus, since it is

more easily measured. Peer review or evaluations are used to assess the quality of the teaching,

although it is understood that this process is somewhat imperfect. The reality is that while it is easy to

identify faculty who win teaching awards, it is more difficult to identify the mediocre teachers from those

who are solid, above average, teachers. As a result, the quantitative evaluations tend to take

precedence over the qualitative in this category.

Although faculty "service" activities are generally included in packets for consideration for promotion,

they tend to be the least emphasized area. Faculty are expected to function as good citizens and to

shoulder their fair share of the administrative workload. This should be reflected in their list of service

activities recorded in their CV. This includes committees, task forces, and administrative positions held

within the division, department, school, hospital, or university. Peer reviews from colleagues within the

same department are also given some weight in assessing performance in this category. In general,

junior faculty at the assistant professor level are not expected to be given major administrative service

responsibilities.

Other academic activities can include both original research and other evidence of creative work.

Among faculty in the traditional or unmodified academic series the committee is looking for evidence of

a productive and creative mind that is making substantive contributions to the knowledge base of that

individual’s field. Although it is stated that publications, research and other creative accomplishment

should be evaluated on their individual merit and not merely enumerated, this is easier said than done.

Although no absolute numbers are provided regarding the number of publications required for

promotion, there are at least "unofficial" guidelines at many institutions that can be obtained by speaking

with one’s chair or more senior faculty. Although it is always stated that quality should take precedent

over quantity, the reality is that quantity is most easily measured Individuals serving on promotion and

tenure committees are very busy individuals, and it is easier for them to count than to read each article.

The committee is looking for evidence that the faculty candidate in the traditional track is continuously

and effectively engaged in creative activity of quality and significance.. Most institutions now require that

the faculty member, or their department chair, establish as clearly as possible the role of the faculty

candidate in their research efforts. This is particularly important for individuals actively collaborating in

joint efforts with other faculty within their division or department. It is expected that the appropriate

candidate for promotion (and tenure) in the traditional track has demonstrated an ability to function

effectively as an independent researcher. As evidence of this, the faculty applicant is expected to be first

author, or sometimes the last "senior" author, on a significant number of quality publications. Serving as

a "sandwich author" in the middle of the pack on all of the publications, can be problematic. At most

institutions, textbook chapters, review articles, case reports, and other publications that do not involve

original research are considered evidence of scholarly activity, but are not weighted as heavily toward

promotion in the traditional (non-clinical) track. Most institutions consider such publications to be of

greater importance in the clinical track, where teaching ability is weighted heavily.

The successful pursuit of extramural grant funding for research is particularly important for faculty in the

traditional track, and is considered the gold standard in assessing candidates for promotion in any

series that has a strict research requirement. Most tenure track positions fall into this category. Having

NIH grants such as an R01 is evidence of recognition within the field. Extramural appraisals are also

often carefully considered in assessing this area of candidate performance.

Changes in Faculty Series

A change in faculty series or track is an option at many institutions. Such changes are almost always out

of the traditional series with a research requirement and an emphasis on the scholarship of discovery or

application into a clinical series with an emphasis on the scholarship of teaching.

The Review Period

Each review of faculty performance, whether it is for appraisal, merit advancement, promotion, or tenure

includes a formal "review" period. This can be short as 2-3 years for a "merit advancement" at some

institutions. It generally includes a 6-7 year period to advance from assistant professor to associate

professor. Further promotions to full professor often include similar timeframes. Preparation of the

candidate promotion packet is obviously dependent upon the formal review period being considered.

Division heads or department chairs usually have information regarding the relevant period of review.

Extramural Letters

Most universities, at the time of promotion from assistant to associate or from associate to full professor,

solicit extramural letters to assist them in appraising the candidate’s performance. These letters are

solicited from specific individuals chosen from a list of candidates. The department chair may select the

list of extramural reviewers, usually with input from the faculty candidate, or the candidate may submit a

list directly to the P&T Committee. Extramural letters should only be solicited from individuals who are

highly respected in the field, and are already at a faculty appointment level that exceeds that proposed

for the candidate. The reviewer’s academic title, specific expertise, and other credentials should be

clear. These individuals are particularly important in assessing national society service activities and

providing perspectives on the candidate’s scholarly activities.

The Procedure of Promotion and Tenure

The process of identifying faculty candidates for promotion and starting the actual procedure itself

generally begins with a "call for personnel action" from the chair or appropriate review body within the

university. Those faculty who are scheduled to be candidates for consideration for promotion during the

next academic year are identified. The department then puts together the packet with early and close

involvement of the faculty candidate . The candidate should meet with the departmental chair to discuss

the packet and the process as well as identification of potential extramural reviewers.. Most institutions

have a checklist to assist in this process, and some encourage candidates to include their own brief

statement summarizing their activities in each of the four main areas of academics, teaching, clinical

care, and service. It should not repeat what is already obvious in other university files or lists of

publications. Rather, it is designed to give candidates an opportunity to discuss the unique aspects or

special significance of their scholarly career accomplishments that would not be otherwise evident. The

very extensive process of gathering materials documenting scholarly teaching activities (Educator’s

Portfolio, see Chapter 2.8.2.), service activities, clinical productivity, and research activity then begins.

Although the department assists with this process, the vast bulk of the responsibility falls on the faculty

candidate.

After the draft packet has been assembled, the department chair generally provides a cover letter of

recommendation that summarizes the candidate’s qualifications. At some institutions, the candidate can

add a second letter, particularly if they disagree with some of the assessments by the department chair,

although one should be cautious about openly airing disagreements with one’s chair, since this is

typically viewed negatively by P&T Committees. At many institutions, this then goes out to peer vote

within their own faculty group, e.g., those within the same department. At some institutions, only faulty

members with appointments at an equal or higher level are qualified to vote on the candidate’s

qualifications. In other departments, only a special committee appointed by the chair decides on who will

be put up for promotion in a given year. If a vote is held, the results of that vote, and any specific peer

comments, are then summarized in a letter that is generally forwarded to the dean’s office. Ordinarily for

a promotional packet to get to the P&T Committee, it must first pass muster within that individual’s home

department. Virtually all schools have a P&T Committee that is advisory to the dean that does further

detailed assessment of the candidate’s qualifications. This committee generally has broad

representation across all specialties. Unlike the department chair, who is generally the candidate’s

advocate, the P&T committee is designed to be less biased, and may only allow members of other

departments to vote on a given individual’s promotion The P&T committee then makes

recommendations to the dean. The dean typically has authority to make the final decisions regarding

some or most of the actions. At other institutions, there is a larger university committee on promotion

and tenure that is advisory to the chancellor or provost of the university who makes the final decisions.

The amount of feedback information given to the candidate during the process varies greatly among

institutions. At some, the candidate is informed regarding each step from the departmental vote through

the school and university committee recommendations. At other institutions, only the final decision is

communicated. If the candidate disagrees with the decision, all institutions have an appeal process

available. However, such appeals should be carefully considered after discussion with senior faculty,

associate deans, etc. Often, the chair is expected to appear before the committee on behalf of the

candidate to appeal an adverse decision.

Promoting Yourself

Although the process of consideration for promotion and tenure is usually straightforward, problems can

occur. Although the chair’s support is essential, the candidate should not depend upon the department

chair to be their sole source of advocacy. It is the faculty candidate’s own responsibility to appropriately

promote themselves and to ensure that their qualifications are viewed in the best possible light. There

are a number of ways in which faculty can effectively promote themselves:

1. Be punctual and on time with the process. Universities tend to have very strict deadlines for

submission of materials and are intolerant of substantial delays. Get a copy of the schedule and get

your materials in on time.

2. Track the process. The evaluation process can take up to an entire year. It is easy to lose track. Write

yourself reminders and keep a summary of the status of your file at every step. If a problem develops,

you want to know about it immediately, not just at the time of the final decision.

3. Keep extensive records documenting your activities. While your CV usually captures all of your

publications, most of us are not as compulsive about recording all of our teaching and service activities.

For those whose scholarship is centered about teaching, an Educator’s Portfolio is essential (see

Chapter 2.8.2. Set up a file for each to make it easier to track these. Especially for promotion from

assistant to associate professor, it is easy to lose track of activities that occurred three or more years

prior.

4. Write your support letter. At some institutions, this is required, at others it is only optional. Even if you

believe your chairman is a strong advocate for your promotion, there is great value in writing your own

support letter. At the very least, this will serve as a guide for the chair support letter and a reminder to

include items that otherwise might be overlooked

5. Solicit support and evaluation materials. When available, there is value in actively soliciting teaching

evaluations from within the medical school and residency, as well as from national organizations and

other extramural sites. This is particularly true if one has concerns about the quality of teaching

evaluations you have received at your home institution or if your department has not done an effective

job of collating those materials for you.

6. Carefully consider the candidates for your extramural letters. These should be individuals who are

very familiar with your work and are very supportive of you as an individual. If in doubt, there is no harm

in placing a phone call and specifically asking if you can list them as one of the extramural reviewers.

Ask whether they would be willing to write a strong letter of support. Even if you feel that you do not

know the individual very well, you would be surprised at how receptive most prominent faculty are to

such phone calls. If you are unsure whom to list as candidates, consider individuals who have served as

moderators for abstract sessions at which you have presented or associated editors who have handled

manuscripts you have submitted.

7. Ask to review the chair’s support letter before it is finalized. Some chairs are relatively inexperienced

at writing strong support letters; others are simply too busy. Do not take it for granted that your chair will

write a highly supportive and comprehensive letter. Ask to review it yourself and do not be hesitate to

make suggested changes. Many chairs ask the candidates to write a draft support letter themselves. If

given this opportunity, take it.

8. Consider an appeal of any negative decision. If you truly believe you have objective data

demonstrating that you have comparable qualifications to other faculty who have successfully received

promotion or tenure, consider an appeal. Make this decision relatively quickly. The window of

opportunity for an appeal can be relatively short. If you appeal, follow the rules and steps exactly and

track the process very closely. Often it will be the responsibility of the chair to make an appeal to the

committee for reconsideration of a faculty candidate.

9. Know the rules. Even if you are not planning an appeal, you should read your university regulations

regarding the process of promotion and tenure. Do not assume that your department administrator or

chair are highly familiar with these rules. A copy should be on file in your administrator’s office. Read

them while you are starting the process and highlight any elements that you think might particularly

apply to your case. Even if you never need to intervene in the process, you will rest better if you are

familiar with the rules yourself.

The good news is that the system generally works very well and most faculty candidates are

successfully promoted to the next level.

National Perspectives on Promotion and Tenure

Author: Sean O. Henderson

One of the initial steps in career development should be a review of a prospective institution’s policies

and procedures with respect to promotion and the attainment of tenure. An applicant needs to be aware

of the expectations of the department and the school to decide which track (e.g. Clinical, Research,

Tenure) 1) best suits their skill set and 2) will allow the best chance of success. Important issues that

need to be addressed are: the time allotted to complete required tasks, the track record of the

department in advancing individuals on the track that you are being hired into, as well as any other

support available to the newly hired faculty member (faculty development courses, collaborative

partners, mentors, etc.) Given that in many cases, promotion to a higher faculty rank is also

accompanied by an increase in salary, it is important to know what you are getting into on the front end

rather than 4 or 5 years into one’s academic career.

The word "tenure" is defined in the Cambridge Dictionary as "the period of time when someone holds a

job, esp. an official position, or the right to keep a job permanently." Within the setting of academia,

tenure should provide freedom of teaching, research and extramural activities and a sufficient degree of

economic security. This freedom and economic security are indispensable to the success of an

institution in fulfilling its obligations to its students and to society. As there is a cost to the institution of

such a financial obligation, appointment to, and promotion on the tenure track often carries with it a

responsibility to develop alternative funding sources and to excel in research activities, difficult tasks for

those clinical departments that stress patient-care duties.

One way to get a feel for how promotion policies vary from institution to institution is to visit the websites

of prospective employers. Posted under the "Administration" heading at most of these websites will be a

section dealing with Faculty Appointments and Promotion. Some of these sections are deliberately

vague, allowing input from the chairman and the Promotion and Tenure Committee to carry the majority

of the weight, while others are very specific, down to the number of lectures one has to give and the

number of papers written per year. In some cases, there are no options and all the faculty in the

Emergency Department are placed into the Clinical track where attainment of tenure may not be an

option.

Using the CRISP NIH database, a representative sample of the Medical Schools in the country was

taken (top 25%, middle 50%; bottom 25%) and their websites reviewed for Promotion and Tenure

policies. Excerpts from four such sites are listed below with an emphasis on the Clinical

Scholar/Clinician Teacher requirements.

SCHOOL #1

Criteria for Appointment and Advancement

Candidates in the regular Professor series and the Professor in Residence series are evaluated on:

1. Teaching

2. Research and Creative work

3. Professional competence and activity

4. University and public service

For a descriptive statement of each of these criteria see Academic Personnel Manual (APM) Section

210-1 B Instructions to Review Committees*. For discussion of teaching and research responsibilities

see those sections of this Handbook.

Evaluation of Teaching

Teaching is an essential criterion to appointment or advancement; tenure is granted only with clear

documentation of ability and diligence in the teaching role.

Department chairs are charged with gathering evidence of a candidate’s teaching ability at all levels of

instruction, from lower division to graduate courses and dissertation supervision. Such evidence may

include opinions of other members of the department, students, and alumni; the number and quality of

students guided in research or attracted to the campus by the individual’s reputation; and development

of new and effective techniques of instruction.

Departments prepare academic review records for all faculty members under consideration for merit

increases and promotion. The kinds of information on teaching normally included in the academic

review records and students’ evaluations of the faculty member’s teaching, solicited letters from former

students, descriptions of new courses prepared, and lists of Ph.D. qualifying committees chaired and

dissertations supervised.

Promotions: Promotions are based on merit; they are not automatic. Achievement, as it is

demonstrated, should be rewarded by promotion. Promotions to tenure positions should be based on

consideration of comparable work in the candidate’s own field or in closely related fields. The

department and the review committee should consider how the candidate stands in relation to other

people in the field outside the University who might be considered alternative candidates for the

position.

The department chair shall supplement the opinions of colleagues within the department by letters from

distinguished extramural informants. The identity of such letter writers should not be provided in the

departmental letter except by code.

Assessment of Evidence: The review committee shall assess the adequacy of the evidence submitted. If

in the committee’s judgment the evidence is insufficient to enable it to reach a clear recommendation,

the committee chair, through the Chancellor, shall request amplification. In every case all obtainable

evidence shall be carefully considered.

If in assessing all obtainable evidence, the candidate fails to meet the criteria set forth in Section 210-1-

d below, the committee should recommend accordingly. If, on the other hand, there is evidence of

unusual achievement and exceptional promise of continued growth, the committee should not hesitate

to endorse a recommendation for accelerated advancement.

The review committee shall judge the candidate with respect to the proposed rank and duties,

considering the record of the candidate’s performance in (1) teaching, (2) research and other creative

work, (3) professional activity, and (4) University and public service. Mentoring and advising of students

or new faculty members are to be encouraged and given recognition in the teaching or service

categories of:

1. Teaching: Clearly demonstrated evidence of high quality in teaching is an esse4ntial

criterion for appointment, advancement, or promotion.

2. Research and Creative Work: Evidence of a productive and creative mind should be

sought in the candidate’s published research or recognized artistic production in original

architectural or engineering designs, or the like.

3. Professional Competence and Activity: In certain positions in the professional schools

and colleges, such as architecture, business administration, dentistry, engineering, law,

medicine, etc., a demonstrated distinction in the special competencies appropriate to

the field and its characteristic activities should be recognized as a criterion for

appointment or promotion. The candidate’s professional activities should be scrutinized

for evidence of achievement and leadership in the field and of demonstrated

progressiveness in the development or utilization of new approaches and techniques for

the solution of professional problems. It is the responsibility of the department chair to

provide evidence that the position in question is of the type described above and that

the candidate is qualified to fill it.

4. University and Public Service: The faculty plays an important role in the administration

of the University and in the formulation of its policies. Recognition should therefore be

given to scholars who prove themselves to be able administrators and who participate

effectively and imaginatively in faculty government and the formulation of departmental,

college, and University policies. Services by members of the faculty to the community,

State, and nation, both in their special capacities as scholars and in areas beyond those

special capacities when the work done is at a sufficiently high level and of sufficiently

high quality, should likewise be recognized as evidence for promotion. Faculty service

activities related to the improvement of elementary and secondary education represent

one example of this kind of service. Similarly, contributions to student welfare through

service on student-faculty committees and as advisers to student organizations should

be recognized as evidence.

Professor of "Clinical" Series

Teaching: Excellent teaching is an essential criterion for appointment or advancement. Clinical teaching

is intensive tutorial instruction, carried on amid the demands of patient care and usually characterized

by pressure on the teacher to cope with unpredictably varied problems by patient-centered immediacy

of the subject matter, and by the necessity of preparing the student to take action as a result of the

interchange.

Professional Competence and Activity: There must be appropriate recognition and evaluation of

professional activity. Exemplary professional practice, organization of training programs for health

professionals, and supervision of health care facilities and operations comprise a substantial proportion

of the academic effort of many health sciences faculty. In decisions on academic advancement, these

are essential contributions to the mission of the University and students and former students in

academic positions or clinical practice.

Creative work: Many faculty in the health sciences devote a great proportion of their time to the

inseparable activities of teaching and clinical service and, therefore, have less time for formal creative

work than most other scholars in the University. Some clinical faculty devotes this limited time to

academic research activities; others utilize their clinical experience as the basis of their creative work.

An appointee is expected to participate in investigation in basic, applied, or clinical sciences. In order to

be appointed or promoted to the Associate or full Professor rank, an appointee shall have made a

significant contribution to knowledge and/or practice in the field. The appointee’s creative work shall

have been disseminated, for example, in body of publications, in teaching materials used in other

institutions, or in improvements or innovations in professional practice which have been adopted

elsewhere.

Evidence of achievement in this area may include clinical case reports. Clinical observations are an

important contribution to the advancement of knowledge in the health sciences and should be judged by

their accuracy, scholarship, and utility. Improvements in the practice of health care result from the

development and evaluation of techniques and procedures by clinical investigators. In addition, creative

achievement may be demonstrated by the development of innovative programs in health care itself or in

transmitting knowledge associated with new fields or other professions.

Textbooks and similar publications, or contributions by candidates to the professional literature and the

advancement or professional practice or of professional education, should be judged as creative work

when they represent new ideas or incorporate scholarly research. The development of new or better

ways of teaching the basic knowledge and skills required by students in the health sciences may be

considered evidence of creative work.

SCHOOL #2

CLINICIAN TEACHER CRITERIA

Assistant Professor

Teaching

Recognition by peers and students as being among the best teachers of medical students, residents,

fellows, or continuing medical education attendees.

Clinical Service/Scholarship

Evidence of a high level of competence in a clinical area. Use of innovative approaches, technologies,

instrumentation, or systems of patient care in a clinical discipline. Active participation in local, regional,

or national professional clinical organizations.

Publication of clinical observations, analytic studies, reviews, chapters, clinical manuals or treatment

guidelines that organize, synthesize, and convey existing knowledge in a way that enhances the

practice of medicine. Publications should describe state-of-the-art clinical practice, may disseminate

clinical knowledge, techniques, and technologies through syllabi, video and audio learning aids,

computer-based material, or professional communications.

ASSOCIATE PROFESSOR

Teaching

Continuing outstanding contributions to the teaching of medical students, residents, specialty fellows, or

postgraduate students. Recognition of high-quality teaching should be available from formal peer

evaluations, student evaluations, or teaching awards. Impact and value of teaching should be

recognized beyond the local level, as demonstrated by invitations to teach in other hospitals, other

medical schools, programs of professional societies, or continuing medical education courses.

Demonstration of scholarship through continuing development and dissemination of teaching materials,

including new curricular offerings, educational programs, textbooks, syllabi, computer programs, or

videotapes that make a unique contribution to the quality and method of teaching within and outside the

local community.

Clinical Service/Scholarship

Development of a regional or national reputation as an authority in a clinical field as demonstrated by

patient referrals, invited visiting lectureships, and elected membership in professional societies.

Introduction and evaluation of innovative approaches and/or development of standards for patient care.

May play an important role in clinical trials/clinical investigation. An effective role model and mentor for

students, residents, fellows and colleagues.

Demonstration of clinical scholarship through continuing publication of analytic studies, reviews, and

chapters, as well as clinical observations that are recognized as authoritative and that influence the

practice of medicine. May serve as editor of textbook and/or journal. May have continuing dissemination

of clinical expertise by audio and video learning aids and through computer-based material, and/or

evidence of stimulating trainees and colleagues to prepare clinical papers and reviews.

Leadership role in department or hospital, such as section or clinical division head, or medical staff

representative, and/or member of regional national professional organizations.

PROFESSOR

Teaching

Recognition for being an exceptional teacher of medical students, residents, specialty fellows or

continuing medical education participants. Impact of superb teaching should be apparent nationally and

internationally as demonstrated by invitations to serve as visiting professor, named lecturer, or to teach

in specialty societies and national continuing medical education courses.

Impact may also be recognized by success/stature of trainees. Demonstration of outstanding

scholarship by development and dissemination of original teaching materials, such as widely used

textbooks, new curricular offerings, educational programs, syllabi, video materials, or computer

programs.

Clinical Service/Scholarship

National/International reputation for excellence in clinical practice, and as an authority in a clinical field.

Significant leadership role in provision of clinical care in department/hospital/healthcare system.

Development/introduction/evaluation of new approaches to patient care. May have ongoing leadership

role in clinical trails/clinical investigation. Demonstration of scholarship by publication of analytic clinical

studies, clinical observations, comprehensive clinical reviews, or textbooks and chapters that are

recognized as exerting major influence on practice of medicine nationally. May participate in

development of national standards for patient care. May serve as editor of highly regarded and

influential textbooks or journals. May disseminate clinical expertise by audio/video learning aids, and

through computer-based material.

Evidence of being an effective role model and mentor for medical students, trainees, and colleagues.

Demonstration of leadership through active participation in prestigious professional societies, through

other academic recognition or awards, and through playing an important role in department or hospital.

SCHOOL #3

The Department of Emergency Medicine recommends titles of appointment and promotion in two

distinct designations: Assistant Professor, Associate Professor and Professor of Emergency Medicine;

and the modified designation of Assistant Clinical Professor, Associate Clinical Professor and Clinical

Professor of Emergency Medicine. Affiliated Hospital faculty are also eligible for appointment and

promotion. Candidates will be evaluated for academic advancement based on their contributions to

Emergency Medicine in the following areas: clinical service, education, scholarship, administration and

community service. The Instructor designation is reserved for Fellows and Junior Faculty who are

residency trained and not yet Board Certified in Emergency Medicine.

Under special circumstances, occasional individuals who are outstanding contributors to the academic

programs of the department and may be promoted to the unmodified rank with limited objective

evidence of scholarly activities such as publications in peer reviewed journals.

For those individuals strong documentation must be presented of the excellence, continuity and

importance of their unique, academic contributions. Such individuals ordinarily should not be promoted

to Associate Professor until they have served at least five years as an Assistant Professor. In general,

promotions to the Associate Professor rank on this basis are unique and exceptional and are

discouraged; that is, faculty at the rank of Assistant Professor are usually required to develop evidence

of scholarly activity.

Members of the Department of Emergency Medicine with a Ph.D or equivalent research degrees will not

be required to meet the clinical criteria for promotion.

The following guidelines are proposed for appointment and promotion to the two designated tracks.

Assistant Professor of Emergency Medicine Clinical Assistant Professor of Emergency Medicine

1. Board Certification in Emergency Medicine or an equivalent certification in a research discipline, and completion of one year of service in academic Emergency Medicine or equivalent.

1. Board Certification in Emergency Medicine and completion of one year of service in the Emergency Medicine Department.

2. Commitment to and evidence of performance of quality, ethical and compassionate delivery of clinical services

2. Commitment to and evidence of performance of quality, ethical and compassionate delivery of clinical services.

3. Evidence of serious commitment to teaching by participation in departmental education program and teaching ability demonstrated by peer and student evaluations.

3. Evidence of serious commitment to teaching by participation in departmental education program and teaching ability demonstrated by peer and student evaluations.

4. Evidence of commitment to academic emergency medicine as demonstrated by participation in the departmental research program and scholarly work such as initiating a research project and scholarly presentation or peer reviewed journal article. Scholarly work can include public health and health services research, education methods and clinical research.

4. Evidence of commitment to academic emergency medicine as demonstrated by participation in the departmental research program and scholarly work in education methods or clinical issues such as writing a review article, textbook chapter, curriculum, instructional materials and case reports; Research activities are encouraged but not required.

5. Performance of administrative functions within the department, hospital, medical school or involvement in community service project.

5. Performance of administrative functions within the department, hospital, medical school, or involvement in community service.

Associate Professor of Emergency Medicine Clinical Associate Professor of Emergency Medicine

1. A minimum of five years at the rank of Assistant Professor.

1. A minimum of five years at the rank of Assistant Professor.

2. Evidence of excellence in performance and ethical and compassionate delivery of clinical services, documented by evaluations by peers, residents and other providers, and by the findings on department CQI program.

2. Evidence of excellence in performance and ethical and compassionate delivery of clinical services, documented by evaluations by peers, residents and other providers, and the findings on departmental CQI program.

3. Evidence of assuming teaching or mentor-ship responsibilities in the departmental and medical school programs, through 1) activities such as lecturing, bedside teaching, development of curriculum or new teaching methods, videotape, textbook chapters, and 2) teaching excellence on evaluation by students and peers.

3. Evidence of assuming major administrative, teaching or mentorship responsibilities in the departmental and medical school teaching programs, by 1) demonstrating leadership in lecturing bedside teaching, curriculum development, teaching methods, videotape, textbook chapters; and 2) teaching excellence on evaluations by students and peers.

4. Evidence of continued scholarly activity and independence as an investigator demonstrated by a series of at least ten publications, half in peer reviewed journals including several original research articles in which the candidate is first author or a principal collaborator in the creation of the hypotheses, design, and analysis of study.

4. Active participation in departmental research program and five scholarly works in education or clinical issues such as a review article and case reports in peer reviewed journal, chapters in textbooks or published educational methods, videotapes or electronic media.

5. Performance of administrative functions within the department, the hospital, the medical school or community service project or providing leadership and developing novel methods in the performance of administrative functions within the department, the hospital, the medical school or community service project.

5. Performance of administrative functions within the department, the hospital, the medical school or community service project or providing leadership and developing novel methods in the performance of administrative functions within the department, the hospital, the medical school or community service project.

6. Evidence of peer recognition at the regional or national level for scholarly activities as judged by at least three external letters of reference.

6. Evidence of peer recognition at the regional or national level for education or administrative service as judged by at least three external letters of reference.

Professor of Emergency Medicine Clinical Professor of Emergency Medicine

1. A minimum of five years at the rank of associate level.

1. A minimum of five years at the rank of associate level.

2. Continued evidence of excellence in performance and ethical and compassionate delivery of clinical services, documented by evaluations by peers, residents and other providers and by the findings on department CQI program.

2. Continued evidence of excellence in performance and ethical and compassionate delivery of clinical services, documented by evaluations by peers, residents and other providers, and the findings on department CQI programs.

3. Continued evidence of assuming teaching or mentorship responsibilities in the department and medical school programs, through 1) activities such as lecturing bedside teaching development of curriculum or new teaching methods, videotape, textbook chapters and 2) teaching excellence on evaluation by students and peers.

3. Continued evidence of assuming major responsibilities for education administration, teaching or mentorship in the departmental and medical school teaching programs, by 1) demonstrating leadership in lecturing, bedside teaching, curriculum development, teaching methods, video textbook chapters; and 2) teaching excellence on evaluation by students and peers.

4. Evidence of continued scholarly activity as an independent research investigator demonstrated by publishing a series of at least twenty papers, half in peer reviewed journals including five original research articles in which the candidate is first author or a principal collaborator and by receiving external research funding

4. Active participation in departmental research program and ten scholarly works in education or clinical issues such as a review article and case reports in peer reviewed journal, chapters in textbooks or published educational methods and curriculum, videotapes or electronic media.

5. Performance of leadership and administrative functions within the medical school, department, the hospital, or community.

5. Performance of leadership and administrative functions within the medical school, department, the hospital, or community.

6. Evidence of national recognition for scholarly activities as judged by such distinctions as membership in student sections, advisory groups, election to professional societies, and funded research and at least five external letters of reference

6. Evidence of peer recognition at the national level for education or administrative service as judged by such distinctions as awards, invitations as visiting professor, election to professional societies and at least five external letters of reference.

SCHOOL #4

APPOINTMENTS

QUALIFICATIONS AND REQUIREMENTS

Qualifications for appointment, set forth below, are not intended as justification for automatic promotion;

conversely, justified exceptions may be made.

Professor. To be eligible for the rank of professor, a faculty member must have a record of outstanding

performance usually involving both teaching and research, or creativity or performance in the arts, or

recognized professional contributions. The faculty member normally is expected to hold the earned

doctor's degree and have at least nine years of effective, relevant experience.

Associate Professor. To be eligible for the rank of associate professor, a faculty member must have a

record of effective performance usually involving both teaching and research, or creativity or

performance in the arts, or recognized professional contributions. The faculty member normally is

expected to hold the earned doctor's degree and must possess strong potential for further development

as a teacher and scholar.

Assistant Professor. To be eligible for the rank of assistant professor, a faculty member normally is

expected to hold the earned doctor's degree or its equivalent and must possess strong potential for

development as a teacher and scholar.

Instructor. To be eligible for the rank of instructor, a faculty member normally is expected to hold the

master's degree plus substantial additional graduate study, such as having fulfilled the requirements for

admission to candidacy for the doctor's degree.

The qualifications for appointment to positions bearing other titles, such as lecturer or research

professor, are in the Policies and Procedures Manual.

APPOINTMENT PROCEDURES

When the provost, dean, and department chair agree that a vacancy exists, the dean or chair shall

recommend appointment as prescribed in the Policies and Procedures Manual. All vacancies shall be

advertised in accordance with the university's affirmative action policy and state and federal law.

TENURE AND PROMOTION PROCEDURES

The procedures set forth below governing tenure and promotions shall apply to all academic units of the

university. The primary responsibility for the operation of all tenure and promotion procedures shall rest

with the tenured members of the faculty of each academic unit. Final authority for recommending tenure

or promotion to the University Board of Trustees shall reside with the president, and final authority for

approving recommendations of tenure and promotion rests with the Board of Trustees.

ESTABLISHMENT AND REVIEW OF UNIT CRITERIA AND PROCEDURES

The university is committed to achievement in research (including scholarship, visual arts, or performing

arts), teaching, and service. Collectively, the faculty profile of the university and of any academic unit

should reflect performance consistent with that of major research universities. Unit criteria should reflect

the fact that a candidate who is weak in teaching or research, promotion or tenure might not be in the

best interest of the university. Although the tenured members of each academic unit formulate specific

criteria and procedures for tenure and promotion, individual unit criteria and procedures shall be

consistent with the Faculty Manual and shall generally conform to guidelines established by the

University Committee on Tenure and Promotions (UCTP).

Unit criteria for tenure and for promotion of a faculty member shall provide clear standards for the

assessment of past achievements. Criteria for all tenure and promotions decisions should require a

record of accomplishment indicative of continuing development of the faculty member in research,

teaching, and service. Criteria for promotion from associate professor to professor and for tenure at the

rank of professor should require evidence of national or international stature in a field. Unit criteria for

promotion or tenure generally shall require, at a minimum, evidence of excellence in either research or

teaching, accompanied by a strong record in the other areas.

In every instance, the record of teaching, research, and service shall be thoroughly documented, as

suggested in the UCTP guidelines. Unit procedures for the evaluation of the teaching component of the

file must require peer and student evaluations. For units in which the primary focus of the faculty is on

public service, criteria for tenure and promotions shall require evaluation of the quality of the public

service work and the relationship of the service to research or teaching.

Each unit shall submit its proposed tenure and promotions criteria and procedures through the dean to

the provost, who shall forward the proposed criteria and procedures to the UCTP along with his or her

comments. If the UCTP finds that the proposed criteria and procedures are consistent with the general

guidelines in The Faculty Manual and are sufficiently clear, the UCTP shall approve the criteria and

procedures, which then become effective immediately unless otherwise specified. If the UCTP

disapproves the proposed unit criteria and procedures, it shall return them to the unit with an

explanation of the deficiencies. The unit shall then revise and resubmit its proposed criteria or

procedures to the UCTP. Existing criteria and procedures shall be resubmitted to the UCTP for periodic

review on a rotating basis as determined by the provost.

New members of the faculty and persons transferred into tenure track positions will be informed in the

offer of appointment of the tenure regulations applicable to the position. Any change in these regulations

prior to the effective date of the appointment will be communicated to, and receipt acknowledged by, the

new faculty member in writing and made a part of the faculty member's official record. The appointment

of a non-tenured faculty member to an administrative position does not excuse the faculty member from

the unit criteria for tenure and/or promotion. A full-time administrator later appointed as a faculty

member is not excused from the unit criteria for tenure and/or promotions.

The tenured faculty of each academic unit shall serve as that unit's tenure and promotions committee.

Departments or units with fewer than five tenured members are required to submit to the UCTP a policy

for constituting the unit tenure and promotions committee so that the committee has at least five tenured

members. The unit tenure and promotions committee may create subcommittees to assist the full

committee in the performance of its work. Where possible, on matters other than consideration of a full

professor for tenure or consideration of an associate professor for promotion to full professor, a

subcommittee shall include both professors and associate professors.

By April 15 of each year, each unit tenure and promotions committee shall elect a chair for the

upcoming year and report the chair's name to the provost and Faculty Senate office.

UNIT CONSIDERATION OF TENURE AND PROMOTION FILES

At the unit level, all no tenured faculty are considered for tenure, and all faculty members below the rank

of professor are considered for promotion each year. Consideration at the unit level is automatic unless

the faculty member requests in writing that consideration be deferred until the following year (provided

that nontenured faculty cannot defer tenure consideration beyond the penultimate year of their

maximum probationary period). Unless prohibited by unit tenure policies and procedures, candidates for

faculty appointments may be recommended for tenure on appointment by a favorable vote of the

tenured faculty of equal or higher rank in the unit.

However, consistency and durability of performance are relevant factors in evaluating faculty for tenure;

therefore, the length of service which a faculty member has completed in a given rank is a valid

consideration in formulating a tenure recommendation. Faculty members appointed at the rank of

assistant professor who have not previously held tenure-track positions at another college or university

normally will not be recommended for tenure until they are in at least their fourth year. Faculty members

appointed at the rank of associate professor or professor who have not previously held tenure-track

positions at another college or university normally will not be recommended for tenure until they are in at

least their third year.

Potential candidates for tenure or promotion should be advised in writing by the dean, department chair,

or other appropriate administrator by May 1 (or within two weeks of the candidate's date of initial

appointment) of the timetable for the submission and consideration of files. This early notification of

candidates will be in addition to the official notification of potential candidates that is performed by the

dean, department chair, or other appropriate administrator at least one month in advance of the date

when the file is due.

A candidate and the academic unit should follow UCTP guidelines for putting files together. The unit is

responsible for providing a synthesis of evaluations of the candidate's teaching performance and

obtaining at least five outside evaluations of the candidate's research. A majority of the outside

evaluators must be selected by the unit. The unit should include in the file a summary of the

professional qualifications of each outside evaluator or a copy of each evaluator's curriculum vita, along

with a copy of a letter requesting the evaluation and informing the evaluator of the unit's relevant criteria

for tenure or promotion. The dean and the unit chair or other appropriate administrator shall be notified

by the unit committee chair of the pending meeting of the committee.

Each unit shall apply its criteria and procedures to determine whether a candidate qualifies for

promotion, tenure, or both. With regard to tenure recommendations, all committee members of rank

equal to or higher than the candidate shall vote by secret ballot. With regard to promotion

recommendations, all committee members of higher rank than the candidate shall vote by secret ballot.

Each member eligible to vote shall vote "yes" or "no" or "abstain." Whether an abstention vote in units

counts towards the total votes for candidates in determining an appropriate majority shall be decided at

the unit level. A record of the votes is made in all instances and must be forwarded through appropriate

channels. Written justification of all votes at the unit level shall be mandatory and shall state specifically

how the candidate meets or does not meet the unit's criteria.

Recommendations from the unit tenure and promotions committee, including the recording of votes and

all written comments, are forwarded to the unit chair or other appropriate administrator. The unit chair or

other appropriate administrator shall vote "yes" or "no" or "abstain" and shall forward his or her vote with

written justification, along with all other recommendations, statements, and endorsements to the dean.

The dean shall forward the file with his or her recommendation to the provost, who shall forward the file

with his or her recommendation to the UCTP.

A candidate's file will be sent forward if the unit tenure and promotions committee recommends tenure

or promotion. The file of a candidate for both tenure and promotion who is recommended by the unit

tenure and promotions committee for tenure or promotion, but not both, will be sent forward for

consideration of only that aspect favorably recommended by the unit. Upon written request of any

candidate dissatisfied with a negative decision by the unit tenure and promotions committee, the unit

committee shall send that candidate's file through all appropriate channels for endorsement to the

president for appropriate action.

It becomes obvious after a review of the above Policy and Procedures on Tenure and Promotion that

expectations vary greatly from institution to institution. For some, a strict set of defined criteria must be

met within a prescribed period of time. For others, eligibility for promotion is set at the departmental level

and may be tailored to meet the needs of our largely clinical specialty.

The range of expectations and the differences between the Clinical Track and the Tenure track make

the former most attractive to most beginning emergency physicians. There is a common theme however

in all of these that demands some sort of research or creative activity: it will be expected of you so you

should have an expectation of some sort of research / publishing activity as part of your academic

career. Regardless, there is a need for more than simple teaching activities: administration, national

service, creativity and research all play a part in the advancement of a faculty member.

One further point: in the majority of the guidelines for promotion there is mention of some flexibility in

these guidelines, a subjective component which appears to play an important role in the promotion

process. This might seem a beacon of hope for promotion for those of us who have chosen Emergency

Medicine with its need for innovative thinking and its high clinical load. In truth however, there remains a

rather stringent set of guidelines that must be met prior to promotion, especially with regard to promotion

in the tenure track.

In summary, when planning for future promotion, a newly arrived faculty member should expect frequent

evaluation within his/her own department by those who have been successful in promotion on that

particular track in addition to the Department Chair. Having these individuals on your side, for guidance

and support, as well as for realistic evaluations of your performance, will lead to more frequent success

in promotion regardless of the track chosen.

Academic Promotion and Tenure

Authors: Douglas A. Rund & Daniel F. Danzl.

Academic emergency medicine, as the second youngest specialty, is a relative newcomer in the house

of medicine. The American Board of Medical Specialties (ABMS) Assembly recognized the American

Board of Emergency Medicine (ABEM) in 1989 as the 23rd independent specialty board. As a result, at

this juncture in emergency medicine senior level mentors remain at a premium. There are only a handful

of tenured professors of emergency medicine, and a commensurately small number of emergency

medicine faculty who sit on medical school Promotion and Tenure (P&T) committees.

Junior faculty in emergency medicine often fail to consider promotional criteria or various faculty track

options when first entering academics. Steady progress and career development require a clear

understanding of the academic promotion and tenure process.

Institution Specific Criteria

Each University’s governance documents detail specific rules regarding promotion and tenure. The

departmental chair, and in many instances a dean for faculty affairs, will provide an introduction to the

rules of the road for newly appointed faculty. Junior faculty are also well served if they obtain a current

copy of the University’s governance, documents and review the sections on the promotion process and

tenure. Since these rules change occasionally, the latest draft may be available from the Provost or

central administrator or on the University’s web site. The specifics about preparation of the promotion

dossier or portfolio or triptych must be studied in detail during its preparation, but an advanced

understanding of the criteria early in one’s career is also helpful. Certain items such as the need to keep

and record student and resident evaluations of teaching, for example, might not be immediately

apparent at the time of initial appointment but will be necessary for the educator’s portfolio section of the

promotion package.

The faculty senate in many universities has approved governance documents that permit the medical

school unit to employ teaching faculty and clinicians on a variety of "tracks". This flexibility recognizes

the need to recruit clinician-educators in nearly all medical school environments, and particularly in

emergency medicine. In response to such needs, medical schools have gradually introduced various

non-tenure pathways to promotion that recognize clinical skill and teaching excellence.(1,2) Almost 75%

of the LCME-accredited medical schools in the United States have now developed some form of

"clinician-educator" track.

The rules regarding promotion and the possibility of tenure in each track differ from one another and

deserve careful review in both the initial selection of a track and the requirements for promotion.

Common terms for these tracks include "clinical", "regular clinical", "clinician-educator", or "clinician-

investigator". Most of these tracks are for a fixed term of years and are then renewable. A new

permutation is the "rolling term" track that automatically extends in length annually.

Some institutions permit at least one switch from track to track, but switching from the tenure track to the

clinical track may not be allowed once the tenure evaluation process has started after the 5th or 6th

year. The 7th or 8th year is typically the last year of full time employment for the faculty member denied

tenure during the probationary period.

The annual departmental or chair review should provide some indication of progress toward tenure for

eligible faculty. The process (including the interview) is an opportunity for the faculty member to

question and clarify the department’s promotion and tenure policies and to develop a plan for the

coming year. The departmental review may be reported in the form of a letter from the chair to the

faculty member, but is some cases it may be supplemented by a standard departmental evaluation that

reports success in meeting the departmental criteria. In departments sponsoring an emergency

medicine residency program, the program director is required by the national Residency Review

Committee for Emergency Medicine of the Accreditation Council for Graduate Medical Education to

participate in the evaluation process.

Each department and each university has specific policies regarding evaluation categories on faculty

tracks for promotion and tenure. In nearly all instances the mix includes four traditional components:

academics (creativity, innovation, scientific research, scholarly publication), clinical expertise, teaching,

and service.

A central expectation for promotion in most tracks is some scholarly accomplishment, which is

mandatory in the regular tenure track. Promotion criteria commonly considered in this category are

noted in the Box. Traditional research expectation in a science-based discipline such as medicine is that

the faculty member will conduct scientific research and publish the results in peer-reviewed journals.

Evidence of the quality of the research includes funding by agencies outside the university such as the

National Institute of Health (NIH). Other scholarly activity such as authorship of textbooks or chapters is

considered valuable but not at the same level as original contributions, or grant supported research.

In the various newly established clinical tracks scholarship must rightfully be assessed according to

different criteria. Most promotions committees expect fewer peer-review publications from clinician-

educators than from tenure track investigators. Scholarship for a clinician educator has been defined as

"the act of seeking, weighing, formulating, reformulating and communicating knowledge of clinical

practice or teaching".(3)

Teaching criteria commonly considered for promotion include didactic skills, mentoring, developing

educational programs and education research. Although patient care and resident teaching are often

seen as departmental priorities, a central purpose of the medical school itself is the education of medical

students. The dossier for promotion therefore, must supply information about courses taught and the

numbers of students.(4) Evaluation of teaching quality is provided by students who usually rate

instructors in a standard format and by departmental faculty who are provided the opportunity for

didactic observation.(5) Resident teaching is similarly evaluated by both the residents and by other

faculty, especially the program director. Departmental or other teaching awards are also perceived as

valuable indicators of teaching quality.

Excellent patient care and clinical service are nearly always expected of the faculty member. Other

services to the department, school or university can include participation in a committee or the

performance of medical administrative functions (such as Director of EMS or Director of one of the

medical student courses). Departments should protect tenure-track junior faculty from over-involvement

in committees and administrative activities, however, because of the time and effort required to

accomplish the research components of the faculty position. When possible, new faculty should

participate in such activities sparingly, especially in a position where considerable research effort is

required.

Tenure

In the academic setting of the University the term tenure is associated with the concept of academic

freedom. Tenure is, in essence, a status granted after a probationary period that entitles one to hold a

position that is protected from dismissal except for serious transgressions as determined by institutional

due process. The concept of academic freedom dates back centuries in Europe and has survived

various challenges in the United States. Tenure in its American form originated in the 1920’s. An

influential university philanthropist suggested that an economics professor be terminated following an

unflattering historical analysis of the family’s financial affairs.

Academic freedom establishes the right of teachers and researchers to study, conduct research, and

express their views without fear of reprisal or dismissal from the faculty.

The concept implies that the granting of tenure depends on competence as a teacher or researcher.

The maintenance of tenure requires adherence to certain standards of scholarship, teaching

accomplishment, and professional integrity rather then political views or religious beliefs.

In practice a tenured faculty member cannot be terminated arbitrarily by the University. Termination

must be "for cause" and the accused has rights to due process involving a hearing before other

professors at the same institution. The net effect of the process is that it is difficult for an administration

to terminate a tenured faculty member and the faculty member therefore has some degree of security in

maintaining employment at the University.

Most universities in this country have a specific process for granting tenure. A strict process with a

timetable is enforced because without it a faculty member beginning the eighth year of employment, for

instance, might claim de facto tenure; that tenure has, in fact, been granted to the faculty member by

virtue of many years of employment.

The granting of tenure typically involves a detailed assessment of the faculty member’s scholarly and

creative accomplishments, teaching ability, and potential for future achievements. In the traditional

medical school process a faculty member granted tenure should have demonstrated the capacity to

function as an outstanding teacher and an independent scientific investigator whose work has been

critically evaluated by intra-mural and extra-mural experts. The awarding of externally funded research

grants demonstrates favorable external review, as does publication in peer reviewed journals.

The requirements for tenure vary widely among institutions. In the most rigorous setting, the Assistant

Professor applying for promotion and tenure might be expected to demonstrate continuous NIH funding

including support for a new research project grant (RO1), fifteen to forty first author original

contributions, demonstration of outstanding teaching, and at least some service to the University. The

benchmark at many institutions is less stringent.

In the traditional setting, highly regarded important peer-reviewed publications and governmentally

sponsored research grants provide the strongest evidence of one’s capability as an independent

scientific investigator and send the signal that if tenured the faculty member will be able to fund future

research activity including release time, salary support, lab space, lab associates, equipment, supplies

and overhead.

The award of tenure is typically associated with promotion to the rank of Associate Professor, although

in other schools tenure is awarded only to a select number of full professors At some point (eg. before

the beginning of the eighth year of service), the institution must "set the hook" or "snap the line", i.e. the

faculty member on the "tenure track" must be either awarded tenure or terminated if the institution

subscribes to an "up or out" process.

The process of tenure review occurs in stages. The first 6 to 8 years of employment for tenure track

faculty is often termed the "probationary period". Faculty evaluation in the early stages of this period are

typically performed by the departmental chair and involve an annual review concluded by a letter to the

faculty member regarding needs for future growth and prospects for tenure.(6)

As the process evolves the faculty member is reviewed by more tenured faculty, who are organized into

promotion and tenure (P&T) committees. In the final stages of the process, a separate evaluation is

usually required by each successive promotion and tenure committee (department, college, university)

before moving to the next step of the process. In some rare cases the department chair or dean may be

able to forward a recommendation without P&T committee approval but the decision to do so would

have to be clearly justified

Promotion Sequence and the Administrative Process

New residency graduates are hired initially at the instructor or assistant professor level. (Figure 1) Some

institutions base promotion to assistant professor on successful completion of the ABMS board

certification process.

The assistant professor rank is typically a probationary process in tenure track positions. The faculty

member is considered for tenure at the 6th or 7th year of service and must be promoted before the 8th

year of service, which will be the final year of appointment if not granted tenure. Non-tenured faculty

tracks tend to have less rigorous requirements for promotion that can come before or after the seventh

year of service.

The next rank is associate professor and many faculty remain at that rank until retirement. In the

traditional process outlined above, promotion to the rank of full professor usually occurs after some

period of time as an associate professor (eg. seven years), during which the faculty member has

continued to demonstrate excellence in teaching and achieved a national or international reputation as a

scientific investigator (uninterrupted extramural funding, excellent and important peer-reviewed

publications and cutting edge presentations at the major national and international scientific meetings).

Because the details vary from institution to institution, each faculty member should review the specifics

of the appropriate promotion and tenure administrative process to ensure that the proper steps are

followed. In general, however, the process originates in the faculty member’s home department or

division. (Figure 2)

At the proper time for promotion the candidate assembles detailed information on grants, publications,

presentations, numbers of courses taught, numbers of students in each course, resident teaching,

evaluations of teaching, and description of University service and clinical care. In most cases some

external review will be required. Usually the chair or departmental promotion and tenure (P&T)

committee will select several external reviewers who hold faculty ranks superior to that of the candidate.

For promotion from the rank of associate professor to the rank of professor, therefore, external reviews

would be sought from other full professors. The candidate may be able to suggest a portion of the

reviewers. External reviewers may be sent the candidate’s curriculum vitae and in some cases, two or

three of the candidate’s most recent or cited publications. The reviewer should be knowledgeable

enough about the academic field to judge the quality of the candidate’s work and usually provides

written evaluation in the form of a letter to the departmental chair or P&T Committee.

When the dossier and external evaluations are assembled, the application is reviewed by a

departmental promotion and tenure committee. The recommendation of the departmental P&T

committee is accompanied by a letter from the departmental chair to the medical school’s P&T

committee summarizing the applicant’s accomplishments and a recommendation for or against

promotion. The recommendations of the departmental committee, the chair, and the medical school’s

P&T committee are then forwarded to the Dean for consideration. Their decisions are forwarded to the

Executive Committee, and then to the University by the Dean who also provides a recommendation.

Approval by the University P&T committee is usually the final hurdle because approval by the Provost,

President and the Board of Trustees is nearly always based on the recommendation of the University

P&T committee. The entire process takes months. At many medical schools, the promotion process

stops at the level of the school P&T committee’s recommendation to the Dean of the Medical School.

The specifics of the promotion and tenure process vary from institution to institution and track to track

and should ideally be reviewed by the junior faculty member prior to the initial appointment. In nearly all

instances, criteria for promotion will include some mix of the four major areas: academic activity, clinical

expertise, teaching, and service. New developments in the faculty evaluation process will undoubtedly

include greater refinement in evaluating teaching and clinical care. With the development of clinician-

educator pathways rigorous evaluation of clinical ability will become increasingly important.

The aspiring academic emergency physician must plot a course to advance. The nature of this specialty

invites excessive service and teaching loads, which are the most common cause of junior faculty

attrition. Strive for a reasonable load of administrative responsibilities, since they tend to trickle down to

assistant professors and interfere with their research and teaching activities, which are critical and

represent the basis for promotion and academic advancement.

Figure 1

The Academic Ladder

Professor

5-10 years

Associate Professor

(With or without tenure)

Associate Professor

(With or without tenure)

8 year boundary

6-8 yrs

Assistant Professor

1 to 2 yrs or Board Certified

Instructor

(Initial Appointment)

Figure 2

Pathway Toward Promotion

Board of Trustees/Governors

President

Provost (Officer of the University)

University P&T Committee

Dean-College of Medicine

Executive Committee (Department Chairs)

Promotion and Tenure (P&T) Committee (School-wide)

Chair Recommendation

Consideration and vote by departmental peer-review (P&T) committee

1.) Osborn, LM, Sostok, M, Castellano, PZ, Blount, W, Branch, WT, Recruiting and Retaining Clinician-

Educators: Lessons Learned from Three Programs, JGIM, Vol 12, April (supplement 2) 1997.

2.) Branch, WT, Kroenke, K, Levinson, W, The Clinician-Educator-Present and Future Roles, JGIM, Vol

12, April 1997.

3.) Beasley, BW et al. Promotion Criteria for Clinician-Educators in the United States and Canada: A

Survey of Promotion Committee Chairpersons. JAMA, Vol 278:9, pp 723-728, September 3, 1997

4.) Lubitz, RM. Guidelines for Promotion of Clinician-Educator, JGIM, Vol 12 (supplement 2) pp S71-

S78, April 1997.

5.) Jones, RF, Froom, JD, Faculty and Administration Views of Problems in Faculty Evaluation,

Academic Medicine, Vol 69, No. 6, pp 476-483, June 1994.

6.) Jouriles, NJ, Kuhn, GJ, Moorhead, JC, Ray, VG, Rund, DA, Faculty Development in Emergency

Medicine, Academic Emergency Medicine, Vol 4, No 11, pp 1078-1086, 1997.

Developing a Career in the Scholarship of Discovery

Author: Terry Vanden Hoek

Research and Emergency Medicine: an opportunity for a career of discovery

Unfortunately, there is no "research for dummies" book available on the bookstore shelf—I would have

bought a copy immediately if it had been available--and in starting my own research career, much good

advice has unfortunately come only after learning from mistakes that might have been prevented. What

follows are my own thoughts about what has helped me get started on what I dream will become a

successful career of discovery. My hope is that you will be inspired by the possibilities of research,

better appreciate your unique place in the house of medicine and science, and develop some

beginnings of a blueprint for success as you continue your own scientific trek. With more articles like this

from each one of us involved in research in Emergency Medicine, perhaps collectively we can become

"running partners" as we submit manuscripts, grant applications, and make discoveries that can

ultimately make a difference in emergency medical care.

Research induction sequence: good questions, mentoring, and investment

Finding a good research question

How do you induce a promising research career? Your area of research is an important and perhaps the

most fundamental decision to make in your research career. It may determine your level of passion

when you are staying up late at night to get a grant proposal finished; if it is well-honed it will help create

boundaries which will keep you focused on what is most unique about your work; and it may also

determine how well you fit into the overall mission of your section, department, institution, and field. Like

all important decisions, it is well worth the time and investigation you put into it.

1. Take advantage of the unique questions Emergency Medicine faces. Emergency Medicine physicians

are in a position to contribute to world-class research. We have an inherent advantage no amount of

postdoctoral or PhD training can ever give--exposure to a challenging clinical practice, which is filled

with individual research questions that can best be answered by our specialty. Since the Emergency

Department provides medical oversight to emergency medical services in the community and is open to

all who seek care, these questions span many issues of health service and public health not faced by

many of our colleagues. Such research questions include how to break down barriers to healthcare

access, effectively screen and refer patients affected by domestic violence, care for the homeless or

substance abuse patient, improve physician-patient communication, monitor and decrease emergency

department overcrowding, prevent medical errors, improve resource utilization for emergency medical

transport services, and improve readiness for natural and man-made disasters. Also quite unique to our

field are questions of how nightshift work may affect productivity, physician wellness and health, and

patient safety. There are of course a multitude of questions regarding rapid diagnostic and treatment

strategies for medical conditions that span all other specialties within medicine. These questions may

range from better diagnostic algorithms for pulmonary embolism to learning how to resuscitate ischemic

tissue at the molecular and cellular level. Bottom line, there is a gold mine of good research questions in

emergency medicine for those willing to ask them. These questions are keys that can open many doors

at academic institutions to investigators in other fields doing work relevant to that question.

2. Get appropriate research consultation. Emergency Medicine physicians are used to working and

consulting with other healthcare providers to create a diverse team of people tailored to meet the needs

of any given patient. For example, it is not unusual to have discussions with cardiology, neurology, and

orthopedics regarding a patient with atrial fibrillation, new focal weakness, and a hip fracture after falling

at home. These same people-skills can be used to request a "research consult" about an interesting

research question. Thus, for example, it would not be unusual to bring together a team of neurologists,

engineers, paramedics, and emergency medicine physicians to ask whether paramedics could induce

focal brain hypothermia in stroke patients, and perhaps extend the window of opportunity for treatment

with thrombolytics. If we wanted to model such a system in cellular and animal models, veterinarians

and cellular biologists might also become involved. If the question relates to effects of nightshift work,

there are many world-class sleep physiologists and patient safety experts who are waiting to receive a

phone call or visit from an emergency medicine physician willing to ask "how can we better adapt to

night shift work?" If the question relates to how to improve screening and referral for substance abuse,

then a team of social workers, sociologists, and psychiatrists/psychologists might become involved. In

addition, some of the same colleagues we interact with in the Emergency Department during patient

care could become important partners in research. Don’t be afraid to ask these other scientists for input

on your research. Be ready to give a short presentation about your work and your research question (I

like to do a less than 10 slide Powerpoint talk)—this has helped me tremendously in refining my

questions. It’s also fun to hear a completely different perspective on your work. One of the best

experiences I’ve had in giving lectures was talking about cardiac arrest to a group of physics students

and professors. They introduced me to concepts of measuring motion in my cell model--as another

index of what happens during ischemia/reperfusion to the heart--I had never considered.

3. Finding the right question. There are enormous opportunities for finding out what the cutting-edge

questions are in any given research area. Do you wonder why particular types of patients in the

Emergency Department do better and others do worse? Despite the hectic pace and stress of the

emergency department, it is often a rewarding question to ask such questions about at least one patient.

If you can, find out what your clinical consultants know and don’t know. Perhaps they are interested in

the same group of patients, and are doing research to answer some of the same questions you have.

Find out what the literature knows and what it doesn’t, and who in the world is focusing on the problem.

Important websites that may be helpful include PubMed (http://www4.ncbi.nlm.nih.gov/PubMed/). There

are thousands of abstracts of reviews performed by the Cochrane group which can be searched at

http://www.update-software.com/Cochrane/ other helpful links may include general search engines such

as http://www.google.com/ or http://vivisimo.com/ . Ask your colleagues about search strategies they

use. My own research interest began with patients who died despite being fully "resuscitated" back to a

normal blood pressure. Potential answers to this phenomenon did not appear until looking into the basic

science of reperfusion injury and apoptosis.

It’s helpful to make a list of the resources you find most helpful in knowing what is happening in your

research area of interest. Key resources include journals (look at them as scientific catalogues of

research possibilities--most academic institutions have a number of e-journals available, and I have

found it helpful to bookmark the access site to those journals on my computer and try to read each

month what is being published in my areas of interest), seminar series (these are usually posted at

academic institutions weekly or monthly, physically or electronically) and academic interest groups

(usually monthly or quarterly) relevant to your interest can also become important sources of new

insights. It took me over a year on campus as a junior faculty to realize that I was missing a visiting

professor lecture series which included internationally renowned speakers talking to groups of less than

30 people—a great opportunity to talk to some of the world’s brightest scientists. Other meetings I have

found helpful include a mitochondrial interest group (yes, this interest group really does exist at my

institution and has been extremely helpful for me), but for other faculty such meetings may include a

public policy group that meets across campus. Most clinical and laboratory research groups conduct

frequent meetings about research in progress—ask if you can attend some of these if the work being

done is of interest to you. Being interested in someone else’s research is usually considered a great

compliment. Find out what excites you, what feels important to you, and ask a lot of questions. If there

any chances to present your research interest, do it. It will help you refine your thinking about what your

research focus is, and allow others to give feedback. These presentations may include anything from

grand rounds for residents/faculty, to a more informal overhead presentation for a laboratory research

group, or a very brief presentation on a laptop to a fellow researcher on campus.

My own interest in ischemia/reperfusion injury began with talking to investigators at SAEM, the

American Heart Association, and the International Society for Heart Research. Attending at least 2 such

national meetings a year can be very helpful to get a sense of what is happening in your scientific area

of research. Poster presentations at these meetings can be important forums for asking questions about

other people’s work (pick out the posters you want to visit ahead of time, and it may be helpful to write

down your questions before visiting), and is a good way to let other people know who you are as a

person and a researcher. Making connections between other people’s work and your own observations

as a clinician and researcher can be a moment of discovery for both of you. Subsequent emails and

phone calls made possible by these interactions could also save a lot of time as you begin your own

work. My own area of research, preconditioning, was first described by a young investigator in a poster

session at a scientific meeting in the middle of Canada. That work came to life for me at a small

scientific meeting of the International Society for Heart at a hotel in Cincinnati, OH, and talking about

science at the side of a pool. Such meetings are critical for finding new ideas.

4. Look for key judo moves. The beginning of the book "The Road Less Traveled" by M. Scott Peck was

best known for it’s beginning short sentence of truth: "Life is difficult." The same can be said for

research, and even more so for research done alone. One of the key concepts of judo is to gain strength

from the momentum of others. Learning what science is going on around you, and finding a way to

incorporate your interests into that momentum to develop your own novel project leverages your

research time and can benefit everybody. As an example, I had very little expertise in studying

apoptosis, but believed that it played an important role in postresuscitation injury in our heart cell model.

By learning who was working on research in apoptosis at my institution, even though some of the

greatest momentum of that research was focused primarily on pulmonary epithelial and cancer cells, it

was beneficial to everybody to apply those same techniques to a cardiac cell model-- resulting in a

successful NIH grant application.

Learning the science environment may mean talking to other faculty within your department or section to

find out what research focuses exists at your particular institution. If you have a few areas of research in

which you have equal interest, think seriously about pursuing the area which can best "ride the wave" of

departmental and institutional momentum. To find out what funded research is happening at your own

institution, a helpful website is the Computerized Retrieval of Information on Scientific Projects (CRISP)

NIH database, located under "grant topics" on the NIH Office of Extramural Research homepage:

http://grants.nih.gov/grants/oer.htm . You can query this site by multiple search criteria, including new

and old grants funded at your institution, who the Principal Investigator is for each grant, and the

abstract of the research funded. This is a good place to look for opportunities to focus existing

successful research at your institution in new creative ways on an emergency medicine problem. Say

hello and tell them your question.

Mentoring and training

Unless you’ve had quite extensive research training, you will need a mentor to help guide you through

the initial stages (first 3-5 years) of your research career. Mentor in Homer’s Odyssey was a trusted

friend to Odysseus, later symbolizing a wise advisor who imparts the ability to mentate-- to think and

awaken to life. One author described mentoring as a transformational power: "Mentors are guides. They

lead us along the journey of our lives. We trust them because they have been there before. They

embody our hopes, cast light on the way ahead, interpret arcane signs, warn us of lurking dangers and

point out unexpected delights along the way."(1)

Two pathways help to formalize this process, and need to be seriously considered. One pathway

involves fellowship training, and opportunities include Emergency Medicine Research fellowship training

programs, The Robert Wood Johnson Clinical Scholars program (described at

http://www.uams.edu/rwjcsp/ ), or a host of postdoctoral fellowship training grants available through NIH

funding. To get a list of these opportunities at your institution, you can query the CRISP database

(http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket) and enter "training grant" and specify your

institution. Emergency medicine programs that wish to cultivate fellowship training may want to add

some of these postdoctoral training programs onto the list of potential fellowships available for

interested residents. These programs often deal with questions very relevant to emergency medicine,

and often go begging for interested MD applicants. The principal investigator on some of those training

grants may be very interested in making some positions available for emergency medicine residents.

If you are junior faculty already, and wish to pursue a research career, another pathway (which can be

followed after or apart from a fellowship training program) for formalizing a mentorship process involves

the K career development awards via the NIH (outlined at

http://grants.nih.gov/training/careerdevelopmentawards.htm). Particularly the K08 and K23 awards are

useful for the beginning basic science or clinical researcher, and can provide up to $75,000-90,000 per

year for up to 5 years of salary support to work with a mentor and hone your research skills. Unlike the

R01 awards which are more competitive, funding as little as 20% of applications, the K applications

often have over a 50% success rate. Most importantly, these awards focus on the process put in place

to make you a better scientist—the quality of mentor chosen, what other advisors will help oversee your

progress, how much support you will have to train. Given that almost 3,000 K awards were given in the

year 2000, it should be a wake-up call for all of us that Emergency Medicine has only a handful of these

awards. Our success rate in percent applications funded is likely the same as any other specialty, but

for some reason we are not making the first critical move-- applying for these awards. One common

misconception about these awards is that they are only for very junior faculty just out of residency. More

senior faculty are eligible for these awards as well, as long as they have not received independent

federal funding in the past.

The number of submissions of K Award applications in Emergency Medicine is beginning to increase at

some institutions, and it’s an important question to consider when interviewing for a faculty appointment.

Ask how many K awards have been received among Emergency Medicine faculty and ask what support

is given for new faculty to achieve these awards. It’s a fair question to ask, since your own investment

will include significant time (probably well over 25-30 hours/week) spent in doing research and writing

for 1-2 years to compete for about $500,000 of salary support over 5 years. More importantly, this

"partnership" between yourself and your department will result in a training program designed to equip

an Emergency Medicine faculty member with the skills to design and conduct future competitive

research.

Regardless of which pathway you choose, the most important decision to be made is the mentor(s) to

whom you will entrust some of the most formative and important years of your research career. Choose

wisely. Below is a checklist to think about when evaluating a mentor:

1. Track record. Get a list of the former trainees of your candidate mentor, and see if they have become

independent investigators and are now on a career path where you would like to see yourself in a few

years. Mentors who have trained a number of fellows or mentored K Awardees who are now

successfully publishing (check in PubMed) and receiving grants (check on the CRISP database)

themselves are mentors who have the ability to help you do the same.

2. Available time. The best mentor in the world is worthless if she or he is gone most of the time, or is

effectively unavailable and too busy. Will your mentor have the time to meet initially 1-3 times per month

(1-3 hours at a time) to discuss progress? Will they be willing to get into the trenches of reading through

your initial manuscript submissions and grant proposals page by page, and line by line? Having had the

opportunity to work with a mentor who turned some of my initial manuscripts into a sea of red ink, and

another who took his research group (including me) out to his Michigan cabin in order to focus (without

distraction) on drafting one of my first manuscripts, I have come to appreciate the value of focused

attention by a mentor.

3. Personality fit. No matter how good, or how available, you and your mentor need to be able to get

along. Ideally, you need to be able to be comfortable in addressing the greatest fears and concerns of

how you’re doing. There may be "turf" issues which arise regarding research ideas since the mentor

ideally will be doing work somewhat similar and relevant to your own. Ideally you will be working with a

mentor considered by others as having integrity beyond reproach, and having a reputation for being

generous and fair.

4. Who’s going to make sure this relationship works? Some of the strongest marriages I know are

relationships in which both members have a vested interest in seeing that relationship succeed. This is

not unlike the mentor-mentee relationship. Before selecting a mentor, it’s important to ask who above

you and the mentor is invested in your proposed relationship. If for instance there is a stated

commitment between neurology and emergency medicine at the highest level that developing a stroke

research program is a high priority, and that both specialties want to support collaborative work, that will

strengthen your chances of success. Will your department head or section head be willing to make sure

the mentor fulfills his/her obligation, and will you truly receive the 80% protected time promised to the

NIH in return for your K award? These are important questions to ask ahead of time.

5. Stays focused on your research. A good mentor does not ask a mentee to do other work for him not

related to the research. Look for a mentor who is protective of your research time, and does NOT want

to see you picking up multiple administrative or extraneous projects along the way.

There is additional material, which include helpful discussions about mentorship; they are included in

the references (2, 3). Many investigators find it helpful to have more than one mentor, perhaps a senior

mentor and a junior mentor (e.g. someone who just recently completed their K08 award and recently

received funding for their first R01 NIH grant).

Research as an Investment

Good research is the result of investment, not miracles.

In most of life, we all know that something truly significant does not suddenly result from nothing. If it

does, it’s considered a miracle--not an expectation. Successful research careers are not miracles that

arise out of having no protected time and no support. If you value your sanity and your career, you will

find an academic program that wants to develop a research program through faculty investment rather

than faculty miracles performed during off hours. Successful grant applications (even K awards) have an

expectation that the applicant has already been doing some research, has institutional support to do that

research, and has preliminary results that can be presented as a result of that hard work and support.

Cutting edge research within 3 years is not an unreasonable expectation after being provided 3

days/week of protected time to do research, having at least 1 FTE as a helper to accomplish this

research, with the necessary dedicated equipment, space and supplies to do the work. This may easily

cost $300,000 or more, but could be a very small price to pay if it results in a successful research

career, which has the potential for great value. How much money and time should be invested to create

competitive research which has the potential to attract multiple million dollar grants over the course of

years, and generate excitement about Emergency Medicine at your institution among fellow faculty,

residents, medical students, and perhaps grateful patients and potential donors? Look for a program

willing to invest in your career. Help from a Research Director will not be enough—you need your own

protected time and access to good mentors who have their own independent funding and a track record

of training investigators. Of course, milestones need to be met, but you must have a means to get there.

Agree on what should be expected of you—productivity of manuscripts, K Award applications, R01

applications etc.

The value of a successful research career.

There are unparalleled opportunities for the physician-scientist to fill a unique niche and impact the

course of research today. The reasons are many and are highlighted well by others (4). Advances in

science are taking place at an accelerated rate, and yet fewer physicians are available to ask questions

about how to use these advances to improve the care of our patients. More and more physicians are

electing not to pursue a career in research for multiple reasons, not the least of which include the

financial realities of re-paying student loans, and the imposition of more clinical time due to managed

care and thinner operating margins at academic institutions. This is a most unfortunate pattern, as there

will undoubtedly be missed opportunities to advance medicine if physicians don’t actively participate.

The value of such an M.D. perspective is demonstrated by history: since World War II, about half of the

over 120 winners of the Nobel Prize in Physiology or Medicine have been given to M.D.’s. In addition,

the likelihood of success in getting an NIH grant funded is the same for M.D.’s vs. Ph.D.’s,

demonstrating that M.D.’s are capable of bringing a unique and valuable perspective to the research

table. However, fewer M.D.’s, particularly young physicians, are opting to take on a research career.

Hopefully we as a specialty will continue to work at the national level on this issue and join other

specialties in helping our national leadership to understand what is at stake.

The benefits of a successful research career to your own professional happiness and the excitement

and stability within your own department are incalculable. I love seeing patients; I also love designing

and implementing research projects. Although busy, doing such disparate yet related tasks of patient

care and research can be a lot of fun. Faculty having fun in their work are resistant to burn-out, generate

excitement in a program, and tend to stay. These are big benefits for any Emergency Medicine program.

Grants and manuscripts: monitoring your vital signs

As Emergency Medicine physicians, we appreciate how valuable changing vital signs can be in

monitoring how well or poorly our patients are doing. As researchers, there are also key vital signs

important in following how well our science is doing: They include protected time for research,

presentations about that research, abstracts submitted and accepted, manuscripts, and grant

applications. Monitoring these vital signs is important for a number of reasons. They will be important

ultimately for your promotion. From the start, it will be helpful to know what the promotions committee at

your institution will be looking for when you as a physician-scientist are considered for promotion. Do

NOT wait too long to sit down with your chairman to map out how the promotions process works for

physician-scientists, and what is considered "vital" on your biosketch over time for successful promotion.

Scientific vital signs are also worth discussing with your mentor. If a first-authored paper in a high-

impact journal is weighted more heavily than serving 3 years on a hospital committee which requires

considerable time each month, it’s easier to say no to that committee obligation and clear the calendar

on certain days each week to focus on science. The chairman of the department and the Dean’s office

may also have access to examples of individuals who have been promoted in your track—these can be

helpful to get an idea of what a successful CV looks like. Does the committee evaluate numbers of

manuscripts, position of authorship on papers, the impact score of the journal in which you publish?

Each institution weights things differently; it will be important to know what to expect in your promotions

process. Just as with patients who go unmonitored for hours, failure to monitor scientific vital signs each

year invites bad surprises.

Maintaining these vital signs also ensures that you will remain current in your scientific area of interest,

get feedback about your science, and focus on the most important questions relevant to your research

area. It’s a good idea to search each month and read any manuscripts published in your area of

research interest, and file these electronically or in hard copy in a library. These will be very useful when

putting together your next grant proposal. The phrase "no pain, no gain" definitely applies to scientific

endeavors, and some of the best advances in one’s science happen as a result of good (albeit

sometimes painful) critiques at presentations and constructive rejection of one’s work. When I look back

at the work I am most proud of today, that work was the result of multiple rejections and persistence in

trying to respond to the questions and concerns of reviewers. There will always be some unfair reviews,

but almost always there is some helpful critique. The pink review sheets from the NIH, which critique

submitted grant proposals can lay out in significant detail what you need to do to succeed in your

research. The best part of these reviews is that you don’t have to pay any consulting fees for what may

amount to excellent and career-altering advice. You do however have to submit your work for review

and persist in trying to answer good concerns raised. The only way to get this feedback is to submit

manuscripts and grant proposals.

Research maintenance: finding running partners

There are at least a couple types of research "running partners" that can help make your science easier

and more exciting, and give it a greater likelihood of success. I call them running partners because

they’re the type of people who have some interest and stake in you getting out of bed and succeeding in

your research. They complement you in that if there are some things you do not have the time or

needed skills to do—but nevertheless are important to your work—that they can do. They are people

who will hold you accountable when you agree you will submit a particular grant proposal by a particular

deadline. Two types of research running partners include administrative and scientific. Regarding the

administrative personnel, help is important in identifying grant applications and putting together grant

proposals. First of all, you need to know when grant funding relevant to your science is available. Most

institutions have a newsletter available in hardcopy and/or electronically which highlights internal and

external funding opportunities. Make sure you are on that mailing list. It also may be helpful to talk to the

grant office at your institution, to see if they provide any administrative help in letting you know when

particular grant opportunities matching your research interest become available. This type of "research

dating service" can help identify key funding opportunities. Once grant opportunities are identified, other

administrative help is very important for preparing the non-science components of grant applications—

budgets and their justification, description of personnel, assembling needed letters of support,

description of facilities, institutional grant office review and sign-off. An administrative support person

who helps with these additional aspects of grant preparation can be worth their weight in gold, and save

valuable time, which then can be directed at putting together the science of the grant proposal. They

also hold you accountable for helping to get the needed sections of the grant proposal together in a

timely fashion. Having someone in your department who either has these skills or is willing to learn them

from someone else at your institution could be a great help to you and the department.

The other type of running partner is scientific. It can be exceedingly helpful when colleagues at your

institution and elsewhere know you and your work well enough that they are willing to critique your work

at research meetings, and talk to you and send you emails about articles or grant opportunities they just

read relevant to your work. They are scientists doing work similar enough to your own to make it

worthwhile meeting regularly to discuss each other’s work, and perhaps finding ways to collaborate on

joint projects. Such meetings help you get to know the resources available (either within or outside your

own department) that could complement your work and help advance each other’s science. These are

also people who can preview your work prior to submitting it as a manuscript or grant proposal. I will

never forget the person who served as both a mentor and scientific colleague who helped get my first

manuscript regarding cardiac ischemia/reperfusion started. He ultimately insisted that I and my other

Emergency Medicine colleague come out to his cabin 1 hour outside Chicago without our beepers for

the weekend so that we would be less distracted and more focused, since he had an interest in my work

as a cardiac physiology Ph.D. scientist and wanted to see our work published. He reminded me that it’s

easy to get distracted, and of the importance of having other people around who care whether one’s

work succeeds and stays on track. These people can be found at research meetings and grand rounds.

They can be collaborators or former mentors, or new faculty recruited into your department to

complement and expand the research you are already doing. Such a "critical mass" of research running

partners who actually talk to each other and are invested in each other’s work is important for the long

haul of ongoing science. When those first letters of rejection arrive regarding a manuscript or grant

proposal, these research running partners can be very helpful in getting you back out there to finish the

work.

Our successes.

There are more and more examples of success stories in Emergency Medicine in establishing

independent research. As our specialty continues to mature, it will be important that we learn from each

other what works, and what doesn’t in building research careers. I feel like I have a lot to learn yet, and

hope I don’t make too many mistakes along the way. I hope any of your successes will be reported to

SAEM, so that we can all appreciate what research is being done in our field. I also hope others will

write chapters like this to share their own insights into what they’ve learned. Don’t hesitate to email me

about questions or your own insights after reading this chapter; I would love to hear them:

thoek@medicine.bsd.uchicago.edu. And have fun with your own career of discovery…

REFERENCES

1. Daloz LA. Effective Teaching And Mentoring: Realizing The Transformational Power Of Adult

Learning Experiences. San Francisco: Josey Bass, 1986.

2. Chin MH, Covinsky KE, McDermott MM, Thomas EJ. Building a research career in general internal

medicine. J Gen Intern Med 1998;13:117-122.

3. Gray J. Mentoring the young clinician-scientist. Clinical and Investigative Medicine 1998;21:279-282.

4. Rosenberg LE. The physician-scientist: an essential--and fragile--link in the medical research chain. J

Clin Invest 1999;103:1621-1626.

Developing a Career in the Scholarship of Discovery

Author: Terry Vanden Hoek

Research and Emergency Medicine: an opportunity for a career of discovery

Unfortunately, there is no "research for dummies" book available on the bookstore shelf—I would have

bought a copy immediately if it had been available--and in starting my own research career, much good

advice has unfortunately come only after learning from mistakes that might have been prevented. What

follows are my own thoughts about what has helped me get started on what I dream will become a

successful career of discovery. My hope is that you will be inspired by the possibilities of research,

better appreciate your unique place in the house of medicine and science, and develop some

beginnings of a blueprint for success as you continue your own scientific trek. With more articles like this

from each one of us involved in research in Emergency Medicine, perhaps collectively we can become

"running partners" as we submit manuscripts, grant applications, and make discoveries that can

ultimately make a difference in emergency medical care.

Research induction sequence: good questions, mentoring, and investment

Finding a good research question

How do you induce a promising research career? Your area of research is an important and perhaps the

most fundamental decision to make in your research career. It may determine your level of passion

when you are staying up late at night to get a grant proposal finished; if it is well-honed it will help create

boundaries which will keep you focused on what is most unique about your work; and it may also

determine how well you fit into the overall mission of your section, department, institution, and field. Like

all important decisions, it is well worth the time and investigation you put into it.

1. Take advantage of the unique questions Emergency Medicine faces. Emergency Medicine physicians

are in a position to contribute to world-class research. We have an inherent advantage no amount of

postdoctoral or PhD training can ever give--exposure to a challenging clinical practice, which is filled

with individual research questions that can best be answered by our specialty. Since the Emergency

Department provides medical oversight to emergency medical services in the community and is open to

all who seek care, these questions span many issues of health service and public health not faced by

many of our colleagues. Such research questions include how to break down barriers to healthcare

access, effectively screen and refer patients affected by domestic violence, care for the homeless or

substance abuse patient, improve physician-patient communication, monitor and decrease emergency

department overcrowding, prevent medical errors, improve resource utilization for emergency medical

transport services, and improve readiness for natural and man-made disasters. Also quite unique to our

field are questions of how nightshift work may affect productivity, physician wellness and health, and

patient safety. There are of course a multitude of questions regarding rapid diagnostic and treatment

strategies for medical conditions that span all other specialties within medicine. These questions may

range from better diagnostic algorithms for pulmonary embolism to learning how to resuscitate ischemic

tissue at the molecular and cellular level. Bottom line, there is a gold mine of good research questions in

emergency medicine for those willing to ask them. These questions are keys that can open many doors

at academic institutions to investigators in other fields doing work relevant to that question.

2. Get appropriate research consultation. Emergency Medicine physicians are used to working and

consulting with other healthcare providers to create a diverse team of people tailored to meet the needs

of any given patient. For example, it is not unusual to have discussions with cardiology, neurology, and

orthopedics regarding a patient with atrial fibrillation, new focal weakness, and a hip fracture after falling

at home. These same people-skills can be used to request a "research consult" about an interesting

research question. Thus, for example, it would not be unusual to bring together a team of neurologists,

engineers, paramedics, and emergency medicine physicians to ask whether paramedics could induce

focal brain hypothermia in stroke patients, and perhaps extend the window of opportunity for treatment

with thrombolytics. If we wanted to model such a system in cellular and animal models, veterinarians

and cellular biologists might also become involved. If the question relates to effects of nightshift work,

there are many world-class sleep physiologists and patient safety experts who are waiting to receive a

phone call or visit from an emergency medicine physician willing to ask "how can we better adapt to

night shift work?" If the question relates to how to improve screening and referral for substance abuse,

then a team of social workers, sociologists, and psychiatrists/psychologists might become involved. In

addition, some of the same colleagues we interact with in the Emergency Department during patient

care could become important partners in research. Don’t be afraid to ask these other scientists for input

on your research. Be ready to give a short presentation about your work and your research question (I

like to do a less than 10 slide Powerpoint talk)—this has helped me tremendously in refining my

questions. It’s also fun to hear a completely different perspective on your work. One of the best

experiences I’ve had in giving lectures was talking about cardiac arrest to a group of physics students

and professors. They introduced me to concepts of measuring motion in my cell model--as another

index of what happens during ischemia/reperfusion to the heart--I had never considered.

3. Finding the right question. There are enormous opportunities for finding out what the cutting-edge

questions are in any given research area. Do you wonder why particular types of patients in the

Emergency Department do better and others do worse? Despite the hectic pace and stress of the

emergency department, it is often a rewarding question to ask such questions about at least one patient.

If you can, find out what your clinical consultants know and don’t know. Perhaps they are interested in

the same group of patients, and are doing research to answer some of the same questions you have.

Find out what the literature knows and what it doesn’t, and who in the world is focusing on the problem.

Important websites that may be helpful include PubMed (http://www4.ncbi.nlm.nih.gov/PubMed/). There

are thousands of abstracts of reviews performed by the Cochrane group which can be searched at

http://www.update-software.com/Cochrane/ other helpful links may include general search engines such

as http://www.google.com/ or http://vivisimo.com/ . Ask your colleagues about search strategies they

use. My own research interest began with patients who died despite being fully "resuscitated" back to a

normal blood pressure. Potential answers to this phenomenon did not appear until looking into the basic

science of reperfusion injury and apoptosis.

It’s helpful to make a list of the resources you find most helpful in knowing what is happening in your

research area of interest. Key resources include journals (look at them as scientific catalogues of

research possibilities--most academic institutions have a number of e-journals available, and I have

found it helpful to bookmark the access site to those journals on my computer and try to read each

month what is being published in my areas of interest), seminar series (these are usually posted at

academic institutions weekly or monthly, physically or electronically) and academic interest groups

(usually monthly or quarterly) relevant to your interest can also become important sources of new

insights. It took me over a year on campus as a junior faculty to realize that I was missing a visiting

professor lecture series which included internationally renowned speakers talking to groups of less than

30 people—a great opportunity to talk to some of the world’s brightest scientists. Other meetings I have

found helpful include a mitochondrial interest group (yes, this interest group really does exist at my

institution and has been extremely helpful for me), but for other faculty such meetings may include a

public policy group that meets across campus. Most clinical and laboratory research groups conduct

frequent meetings about research in progress—ask if you can attend some of these if the work being

done is of interest to you. Being interested in someone else’s research is usually considered a great

compliment. Find out what excites you, what feels important to you, and ask a lot of questions. If there

any chances to present your research interest, do it. It will help you refine your thinking about what your

research focus is, and allow others to give feedback. These presentations may include anything from

grand rounds for residents/faculty, to a more informal overhead presentation for a laboratory research

group, or a very brief presentation on a laptop to a fellow researcher on campus.

My own interest in ischemia/reperfusion injury began with talking to investigators at SAEM, the

American Heart Association, and the International Society for Heart Research. Attending at least 2 such

national meetings a year can be very helpful to get a sense of what is happening in your scientific area

of research. Poster presentations at these meetings can be important forums for asking questions about

other people’s work (pick out the posters you want to visit ahead of time, and it may be helpful to write

down your questions before visiting), and is a good way to let other people know who you are as a

person and a researcher. Making connections between other people’s work and your own observations

as a clinician and researcher can be a moment of discovery for both of you. Subsequent emails and

phone calls made possible by these interactions could also save a lot of time as you begin your own

work. My own area of research, preconditioning, was first described by a young investigator in a poster

session at a scientific meeting in the middle of Canada. That work came to life for me at a small

scientific meeting of the International Society for Heart at a hotel in Cincinnati, OH, and talking about

science at the side of a pool. Such meetings are critical for finding new ideas.

4. Look for key judo moves. The beginning of the book "The Road Less Traveled" by M. Scott Peck was

best known for it’s beginning short sentence of truth: "Life is difficult." The same can be said for

research, and even more so for research done alone. One of the key concepts of judo is to gain strength

from the momentum of others. Learning what science is going on around you, and finding a way to

incorporate your interests into that momentum to develop your own novel project leverages your

research time and can benefit everybody. As an example, I had very little expertise in studying

apoptosis, but believed that it played an important role in postresuscitation injury in our heart cell model.

By learning who was working on research in apoptosis at my institution, even though some of the

greatest momentum of that research was focused primarily on pulmonary epithelial and cancer cells, it

was beneficial to everybody to apply those same techniques to a cardiac cell model-- resulting in a

successful NIH grant application.

Learning the science environment may mean talking to other faculty within your department or section to

find out what research focuses exists at your particular institution. If you have a few areas of research in

which you have equal interest, think seriously about pursuing the area which can best "ride the wave" of

departmental and institutional momentum. To find out what funded research is happening at your own

institution, a helpful website is the Computerized Retrieval of Information on Scientific Projects (CRISP)

NIH database, located under "grant topics" on the NIH Office of Extramural Research homepage:

http://grants.nih.gov/grants/oer.htm . You can query this site by multiple search criteria, including new

and old grants funded at your institution, who the Principal Investigator is for each grant, and the

abstract of the research funded. This is a good place to look for opportunities to focus existing

successful research at your institution in new creative ways on an emergency medicine problem. Say

hello and tell them your question.

Mentoring and training

Unless you’ve had quite extensive research training, you will need a mentor to help guide you through

the initial stages (first 3-5 years) of your research career. Mentor in Homer’s Odyssey was a trusted

friend to Odysseus, later symbolizing a wise advisor who imparts the ability to mentate-- to think and

awaken to life. One author described mentoring as a transformational power: "Mentors are guides. They

lead us along the journey of our lives. We trust them because they have been there before. They

embody our hopes, cast light on the way ahead, interpret arcane signs, warn us of lurking dangers and

point out unexpected delights along the way."(1)

Two pathways help to formalize this process, and need to be seriously considered. One pathway

involves fellowship training, and opportunities include Emergency Medicine Research fellowship training

programs, The Robert Wood Johnson Clinical Scholars program (described at

http://www.uams.edu/rwjcsp/ ), or a host of postdoctoral fellowship training grants available through NIH

funding. To get a list of these opportunities at your institution, you can query the CRISP database

(http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket) and enter "training grant" and specify your

institution. Emergency medicine programs that wish to cultivate fellowship training may want to add

some of these postdoctoral training programs onto the list of potential fellowships available for

interested residents. These programs often deal with questions very relevant to emergency medicine,

and often go begging for interested MD applicants. The principal investigator on some of those training

grants may be very interested in making some positions available for emergency medicine residents.

If you are junior faculty already, and wish to pursue a research career, another pathway (which can be

followed after or apart from a fellowship training program) for formalizing a mentorship process involves

the K career development awards via the NIH (outlined at

http://grants.nih.gov/training/careerdevelopmentawards.htm). Particularly the K08 and K23 awards are

useful for the beginning basic science or clinical researcher, and can provide up to $75,000-90,000 per

year for up to 5 years of salary support to work with a mentor and hone your research skills. Unlike the

R01 awards which are more competitive, funding as little as 20% of applications, the K applications

often have over a 50% success rate. Most importantly, these awards focus on the process put in place

to make you a better scientist—the quality of mentor chosen, what other advisors will help oversee your

progress, how much support you will have to train. Given that almost 3,000 K awards were given in the

year 2000, it should be a wake-up call for all of us that Emergency Medicine has only a handful of these

awards. Our success rate in percent applications funded is likely the same as any other specialty, but

for some reason we are not making the first critical move-- applying for these awards. One common

misconception about these awards is that they are only for very junior faculty just out of residency. More

senior faculty are eligible for these awards as well, as long as they have not received independent

federal funding in the past.

The number of submissions of K Award applications in Emergency Medicine is beginning to increase at

some institutions, and it’s an important question to consider when interviewing for a faculty appointment.

Ask how many K awards have been received among Emergency Medicine faculty and ask what support

is given for new faculty to achieve these awards. It’s a fair question to ask, since your own investment

will include significant time (probably well over 25-30 hours/week) spent in doing research and writing

for 1-2 years to compete for about $500,000 of salary support over 5 years. More importantly, this

"partnership" between yourself and your department will result in a training program designed to equip

an Emergency Medicine faculty member with the skills to design and conduct future competitive

research.

Regardless of which pathway you choose, the most important decision to be made is the mentor(s) to

whom you will entrust some of the most formative and important years of your research career. Choose

wisely. Below is a checklist to think about when evaluating a mentor:

1. Track record. Get a list of the former trainees of your candidate mentor, and see if they have become

independent investigators and are now on a career path where you would like to see yourself in a few

years. Mentors who have trained a number of fellows or mentored K Awardees who are now

successfully publishing (check in PubMed) and receiving grants (check on the CRISP database)

themselves are mentors who have the ability to help you do the same.

2. Available time. The best mentor in the world is worthless if she or he is gone most of the time, or is

effectively unavailable and too busy. Will your mentor have the time to meet initially 1-3 times per month

(1-3 hours at a time) to discuss progress? Will they be willing to get into the trenches of reading through

your initial manuscript submissions and grant proposals page by page, and line by line? Having had the

opportunity to work with a mentor who turned some of my initial manuscripts into a sea of red ink, and

another who took his research group (including me) out to his Michigan cabin in order to focus (without

distraction) on drafting one of my first manuscripts, I have come to appreciate the value of focused

attention by a mentor.

3. Personality fit. No matter how good, or how available, you and your mentor need to be able to get

along. Ideally, you need to be able to be comfortable in addressing the greatest fears and concerns of

how you’re doing. There may be "turf" issues which arise regarding research ideas since the mentor

ideally will be doing work somewhat similar and relevant to your own. Ideally you will be working with a

mentor considered by others as having integrity beyond reproach, and having a reputation for being

generous and fair.

4. Who’s going to make sure this relationship works? Some of the strongest marriages I know are

relationships in which both members have a vested interest in seeing that relationship succeed. This is

not unlike the mentor-mentee relationship. Before selecting a mentor, it’s important to ask who above

you and the mentor is invested in your proposed relationship. If for instance there is a stated

commitment between neurology and emergency medicine at the highest level that developing a stroke

research program is a high priority, and that both specialties want to support collaborative work, that will

strengthen your chances of success. Will your department head or section head be willing to make sure

the mentor fulfills his/her obligation, and will you truly receive the 80% protected time promised to the

NIH in return for your K award? These are important questions to ask ahead of time.

5. Stays focused on your research. A good mentor does not ask a mentee to do other work for him not

related to the research. Look for a mentor who is protective of your research time, and does NOT want

to see you picking up multiple administrative or extraneous projects along the way.

There is additional material, which include helpful discussions about mentorship; they are included in

the references (2, 3). Many investigators find it helpful to have more than one mentor, perhaps a senior

mentor and a junior mentor (e.g. someone who just recently completed their K08 award and recently

received funding for their first R01 NIH grant).

Research as an Investment

Good research is the result of investment, not miracles.

In most of life, we all know that something truly significant does not suddenly result from nothing. If it

does, it’s considered a miracle--not an expectation. Successful research careers are not miracles that

arise out of having no protected time and no support. If you value your sanity and your career, you will

find an academic program that wants to develop a research program through faculty investment rather

than faculty miracles performed during off hours. Successful grant applications (even K awards) have an

expectation that the applicant has already been doing some research, has institutional support to do that

research, and has preliminary results that can be presented as a result of that hard work and support.

Cutting edge research within 3 years is not an unreasonable expectation after being provided 3

days/week of protected time to do research, having at least 1 FTE as a helper to accomplish this

research, with the necessary dedicated equipment, space and supplies to do the work. This may easily

cost $300,000 or more, but could be a very small price to pay if it results in a successful research

career, which has the potential for great value. How much money and time should be invested to create

competitive research which has the potential to attract multiple million dollar grants over the course of

years, and generate excitement about Emergency Medicine at your institution among fellow faculty,

residents, medical students, and perhaps grateful patients and potential donors? Look for a program

willing to invest in your career. Help from a Research Director will not be enough—you need your own

protected time and access to good mentors who have their own independent funding and a track record

of training investigators. Of course, milestones need to be met, but you must have a means to get there.

Agree on what should be expected of you—productivity of manuscripts, K Award applications, R01

applications etc.

The value of a successful research career.

There are unparalleled opportunities for the physician-scientist to fill a unique niche and impact the

course of research today. The reasons are many and are highlighted well by others (4). Advances in

science are taking place at an accelerated rate, and yet fewer physicians are available to ask questions

about how to use these advances to improve the care of our patients. More and more physicians are

electing not to pursue a career in research for multiple reasons, not the least of which include the

financial realities of re-paying student loans, and the imposition of more clinical time due to managed

care and thinner operating margins at academic institutions. This is a most unfortunate pattern, as there

will undoubtedly be missed opportunities to advance medicine if physicians don’t actively participate.

The value of such an M.D. perspective is demonstrated by history: since World War II, about half of the

over 120 winners of the Nobel Prize in Physiology or Medicine have been given to M.D.’s. In addition,

the likelihood of success in getting an NIH grant funded is the same for M.D.’s vs. Ph.D.’s,

demonstrating that M.D.’s are capable of bringing a unique and valuable perspective to the research

table. However, fewer M.D.’s, particularly young physicians, are opting to take on a research career.

Hopefully we as a specialty will continue to work at the national level on this issue and join other

specialties in helping our national leadership to understand what is at stake.

The benefits of a successful research career to your own professional happiness and the excitement

and stability within your own department are incalculable. I love seeing patients; I also love designing

and implementing research projects. Although busy, doing such disparate yet related tasks of patient

care and research can be a lot of fun. Faculty having fun in their work are resistant to burn-out, generate

excitement in a program, and tend to stay. These are big benefits for any Emergency Medicine program.

Grants and manuscripts: monitoring your vital signs

As Emergency Medicine physicians, we appreciate how valuable changing vital signs can be in

monitoring how well or poorly our patients are doing. As researchers, there are also key vital signs

important in following how well our science is doing: They include protected time for research,

presentations about that research, abstracts submitted and accepted, manuscripts, and grant

applications. Monitoring these vital signs is important for a number of reasons. They will be important

ultimately for your promotion. From the start, it will be helpful to know what the promotions committee at

your institution will be looking for when you as a physician-scientist are considered for promotion. Do

NOT wait too long to sit down with your chairman to map out how the promotions process works for

physician-scientists, and what is considered "vital" on your biosketch over time for successful promotion.

Scientific vital signs are also worth discussing with your mentor. If a first-authored paper in a high-

impact journal is weighted more heavily than serving 3 years on a hospital committee which requires

considerable time each month, it’s easier to say no to that committee obligation and clear the calendar

on certain days each week to focus on science. The chairman of the department and the Dean’s office

may also have access to examples of individuals who have been promoted in your track—these can be

helpful to get an idea of what a successful CV looks like. Does the committee evaluate numbers of

manuscripts, position of authorship on papers, the impact score of the journal in which you publish?

Each institution weights things differently; it will be important to know what to expect in your promotions

process. Just as with patients who go unmonitored for hours, failure to monitor scientific vital signs each

year invites bad surprises.

Maintaining these vital signs also ensures that you will remain current in your scientific area of interest,

get feedback about your science, and focus on the most important questions relevant to your research

area. It’s a good idea to search each month and read any manuscripts published in your area of

research interest, and file these electronically or in hard copy in a library. These will be very useful when

putting together your next grant proposal. The phrase "no pain, no gain" definitely applies to scientific

endeavors, and some of the best advances in one’s science happen as a result of good (albeit

sometimes painful) critiques at presentations and constructive rejection of one’s work. When I look back

at the work I am most proud of today, that work was the result of multiple rejections and persistence in

trying to respond to the questions and concerns of reviewers. There will always be some unfair reviews,

but almost always there is some helpful critique. The pink review sheets from the NIH, which critique

submitted grant proposals can lay out in significant detail what you need to do to succeed in your

research. The best part of these reviews is that you don’t have to pay any consulting fees for what may

amount to excellent and career-altering advice. You do however have to submit your work for review

and persist in trying to answer good concerns raised. The only way to get this feedback is to submit

manuscripts and grant proposals.

Research maintenance: finding running partners

There are at least a couple types of research "running partners" that can help make your science easier

and more exciting, and give it a greater likelihood of success. I call them running partners because

they’re the type of people who have some interest and stake in you getting out of bed and succeeding in

your research. They complement you in that if there are some things you do not have the time or

needed skills to do—but nevertheless are important to your work—that they can do. They are people

who will hold you accountable when you agree you will submit a particular grant proposal by a particular

deadline. Two types of research running partners include administrative and scientific. Regarding the

administrative personnel, help is important in identifying grant applications and putting together grant

proposals. First of all, you need to know when grant funding relevant to your science is available. Most

institutions have a newsletter available in hardcopy and/or electronically which highlights internal and

external funding opportunities. Make sure you are on that mailing list. It also may be helpful to talk to the

grant office at your institution, to see if they provide any administrative help in letting you know when

particular grant opportunities matching your research interest become available. This type of "research

dating service" can help identify key funding opportunities. Once grant opportunities are identified, other

administrative help is very important for preparing the non-science components of grant applications—

budgets and their justification, description of personnel, assembling needed letters of support,

description of facilities, institutional grant office review and sign-off. An administrative support person

who helps with these additional aspects of grant preparation can be worth their weight in gold, and save

valuable time, which then can be directed at putting together the science of the grant proposal. They

also hold you accountable for helping to get the needed sections of the grant proposal together in a

timely fashion. Having someone in your department who either has these skills or is willing to learn them

from someone else at your institution could be a great help to you and the department.

The other type of running partner is scientific. It can be exceedingly helpful when colleagues at your

institution and elsewhere know you and your work well enough that they are willing to critique your work

at research meetings, and talk to you and send you emails about articles or grant opportunities they just

read relevant to your work. They are scientists doing work similar enough to your own to make it

worthwhile meeting regularly to discuss each other’s work, and perhaps finding ways to collaborate on

joint projects. Such meetings help you get to know the resources available (either within or outside your

own department) that could complement your work and help advance each other’s science. These are

also people who can preview your work prior to submitting it as a manuscript or grant proposal. I will

never forget the person who served as both a mentor and scientific colleague who helped get my first

manuscript regarding cardiac ischemia/reperfusion started. He ultimately insisted that I and my other

Emergency Medicine colleague come out to his cabin 1 hour outside Chicago without our beepers for

the weekend so that we would be less distracted and more focused, since he had an interest in my work

as a cardiac physiology Ph.D. scientist and wanted to see our work published. He reminded me that it’s

easy to get distracted, and of the importance of having other people around who care whether one’s

work succeeds and stays on track. These people can be found at research meetings and grand rounds.

They can be collaborators or former mentors, or new faculty recruited into your department to

complement and expand the research you are already doing. Such a "critical mass" of research running

partners who actually talk to each other and are invested in each other’s work is important for the long

haul of ongoing science. When those first letters of rejection arrive regarding a manuscript or grant

proposal, these research running partners can be very helpful in getting you back out there to finish the

work.

Our successes.

There are more and more examples of success stories in Emergency Medicine in establishing

independent research. As our specialty continues to mature, it will be important that we learn from each

other what works, and what doesn’t in building research careers. I feel like I have a lot to learn yet, and

hope I don’t make too many mistakes along the way. I hope any of your successes will be reported to

SAEM, so that we can all appreciate what research is being done in our field. I also hope others will

write chapters like this to share their own insights into what they’ve learned. Don’t hesitate to email me

about questions or your own insights after reading this chapter; I would love to hear them:

thoek@medicine.bsd.uchicago.edu. And have fun with your own career of discovery…

REFERENCES

1. Daloz LA. Effective Teaching And Mentoring: Realizing The Transformational Power Of Adult

Learning Experiences. San Francisco: Josey Bass, 1986.

2. Chin MH, Covinsky KE, McDermott MM, Thomas EJ. Building a research career in general internal

medicine. J Gen Intern Med 1998;13:117-122.

3. Gray J. Mentoring the young clinician-scientist. Clinical and Investigative Medicine 1998;21:279-282.

4. Rosenberg LE. The physician-scientist: an essential--and fragile--link in the medical research chain. J

Clin Invest 1999;103:1621-1626.

The scholarship of integration

E. John Gallagher

In 1922, when T.S. Eliot, who was to receive the Nobel Prize for Literature a quarter of a century later,

published The Waste Land, he was widely criticized for its highly "derivative and unoriginal" features. To

his critics he replied simply: "Good poets don't borrow, they steal." Indeed, Eliot stole with impunity not

just from other works of literature, but also from history, linguistics, religion, music, and philosophy. He

had interwoven allusions to Ovid, Buddha, Wagner, Whitman, Dante, St. Augustine, and Shakespeare,

to list only a few, ending his epic of free verse with a concatenation of fragmentary lines in no less than

five languages. More than a century after his birth, one might argue quite cogently that Eliot, the self-

proclaimed literary thief, was in fact engaged, both literally and literarily, in the scholarship of integration.

Ultimately, his amalgam of seemingly disparate words, disconnected phrases, and diverse ideas, drawn

from a stunning array of sources, was to become one of the most coherent, unique, and enduring artistic

achievements of the 20th century.

Of the four forms of scholarship that constitute the primary organizational axis for this Handbook

(discovery, integration, application, and teaching), that of integration is the most difficult to characterize.

An unfortunate corollary to this is "...of the several forms of scholarly work, the scholarship of integration

has received the least attention." (American Association for Higher Education Eighth Annual Conference

of Faculty Roles and Rewards, February 3-6, 2000. Washington, DC: AAHE.

http://www.aahe.org/FFRR/preview/emphasis3.htm Accessed July, 2001.)

Charles Glassick of the Carnegie Foundation defines the scholarship of integration as "the performance

of serious, disciplined work that seeks to interpret altogether and bring new insights to bear. It is the

capacity to make connections, ... to illuminate... in new and revealing ways... to do scholarship at the

boundaries where fields converge." (Glassick C: How Is Scholarship Rewarded? Address given October

15, 1997. http://www.duc.auburn.edu/administration/horizon/glassick.html Accessed July, 2001.) Thus,

by its very nature, integrative scholarship is difficult to define and recognize. This is presumably

because it operates on the periphery of disciplines at a locus relatively far removed from the central

activity of any one of the several bodies of knowledge upon which it draws.

In the biosciences, the scholarship of integration may encompass work occurring at the edges of two or

more basic sciences, or, more relevant to Emergency Medicine and this Handbook, might bridge the

gap between the basic and clinical realms in a way that is distinct from the scholarship of application.

The latter, which is the trajectory followed by most clinician-scientists, tends to be relatively linear; by

contrast, the scholarship of integration is likely to trace a decidedly nonlinear model of inquiry.

Faculty engaged in the scholarship of integration are rare, not only in medicine, but in other fields as

well. This is not only because comprehension of fundamentally different discipline-specific paradigms is

a prerequisite that is difficult to acquire in the silo structure of traditional academics, but also because

such scholarly activity is considered "risky" to one's career. As Glassick has pointed out:

There is a lack of collaboration in those areas where people develop quantitative measures for

promotion and tenure; that is, ten points for a book and so on. The scholars told us that this leads to

short, safe research projects. They weren't willing to take any chances, and they certainly didn't want to

mess around with other people...(Baird D. Scholarship reconstructed: An interview with Charles

Glassick. Royal Melbourne Institute of Technology University Melbourne, Australia, 1997.)

The scarcity of integrative scholars in Emergency Medicine parallels their low prevalence in other

medical disciplines. Indeed, the Faculty Development Committee was unable to find any academic

emergency physician who felt sufficiently comfortable with the topic to contribute a chapter on the

development of a career in this mode of scholarly endeavor.

Nevertheless, integrative scholarship is extremely important, and is described here by example in the

hope that some young Emergency Medicine faculty may find the concept sufficiently compelling to

explore it further.

Chaos Theory and Nonlinear Dynamic Biological Systems

One example of the possibilities for intellectual satisfaction that the scholarship of integration offers can

be found in the ostensibly implausible link between chaos theory and clinical diagnostic reasoning at the

bedside. Contrary to the conventional meaning of the word chaos, implying complete disorder, the term

is used in mathematics and the physical sciences to describe a specific kind of nonlinear dynamics.

Some recent work in this area has suggested that - contrary to Claude Bernard's longstanding principles

of homeostasis, in which the stability of biological systems is contingent upon their invariance - chaos

theory argues that maintenance of the homeostatic equilibrium characteristic of health may in fact

depend upon continuous, subtle, and apparently erratic fluctuations in baseline state driven by complex

and dynamic interaction between sets of physiologic "oscillators". Data on heart rate variability, which

shows a reduction in normal beat-to-beat variation associated with the onset of serious illness, is

consistent with such an assertion. As a corollary to this, degradation in the biocomplexity of any

interactive physiological system may signal a loss of the internal elasticity needed for an organism to

adapt quickly and efficiently to the broad range of stimuli arising from its external environment. By

extension, clinical bedside diagnosis would then depend upon identification of pathologic states that

decay from the complex interactive variability of health to a simpler, more recognizable kind of

stereotypic linearity, evident to us at the bedside as a pattern of illness. Fortunately, clinicians are not

called upon to make the diagnosis of health - which would be a daunting task, given its biocomplexity -

but rather of disease, which tends to conform to a finite number of less complex and more identifiable

final common pathways.

Much of nonlinearity at first seems counterintuitive because traditional reductionism does not lead to

comprehension of the observed phenomenon, i.e., a meticulous dissection of the component parts of a

nonlinear system may stubbornly refuse to add up. Rather, because many of these components are

"coupled", they are prone to interact in seemingly anomalous ways that do not conform to well-behaved,

linear paradigms. For example, because proportionality is not a feature of nonlinear systems,

remarkably small changes may produce large and unanticipated effects that would not be predicted by a

linear model. Probably the best known example of this is the so-called "butterfly phenomenon", in which

the flutter of a butterfly's wing in, say, Crete produces an almost imperceptible change in nearby air

currents. Over time, these currents alter the state of the proximate atmosphere, extending subsequently

to a distant locale creating, perhaps, a typhoon in the South China Sea, which otherwise might not have

developed. The "butterfly phenomenon" has become a central metaphor for the characteristic loss of

proportionality associated with nonlinear dynamics and "chaos theory".

Descartes’ Error

A second example of integrative scholarship can be found in the dominant theme of a relatively recent

publication, entitled Descartes' Error, by Antonio Damasio, an investigator who has made substantial

contributions to our understanding of the neurobiology of memory and language. Drawing upon prior

work, Damasio provides compelling evidence in support of the interconnectedness of mind and body.

This evidence leads him to conclude that the fundamental error of Cartesian dualism was the axiomatic

assertion that the two are divisible entities. In fact, Damasio argues, their continual interdependent

interaction is fundamental to consciousness and individuality.

Damasio extends his assertions to question a related false dichotomy perpetuated in Neurology and

Psychiatry since the middle of the 20th century. Prior to World War II, these two specialties were

frequently housed under the same academic roof. This conjoint history is reflected today by the fact that

the two disciplines continue to share a single ABMS Board structure (the American Board of Psychiatry

and Neurology). However, as the reigning paradigm for Psychiatry (the mind afflicted by "functional"

illness, dominated largely by psychoanalytic theory) continued to diverge from that of Neurology (the

brain, affected by "organic" disease), common ground eroded, leaving little territory for interdisciplinary

work in psychobiology or neuropsychology. Gradually, as it has become increasingly apparent that

psychiatric disease has a potent genetic and biological substrate, more integrative scholarship is taking

place at the interface between the two disciplines. This has resulted in remarkably salutary

consequences for patients, particularly those with affective disorders. It now seems possible that,

through the scholarship of integration - rather than through further reductionism - we may achieve an

improved understanding and treatment for the most profoundly disturbing and intractable group of

neuropsychiatric illnesses, the thought disorders.

The Compact Disk

Yet another example of the scholarship of integration is offered by Dauphinee and Martin, who borrow it

from the physicist and educator, Geoffery Norman (Dauphinee D, Martin JB: Breaking Down the Walls:

Thoughts on the Scholarship of Integration. Acad Med 2000;75:881-886). It is the story of the

development of the compact disc (CD), which has forever altered the way in which we think about,

transfer, and store information. Norman describes four apparently disconnected discoveries occurring

over widely spaced intervals that ultimately required the ingenuity of scholarly integration in order for the

CD to be "invented":

1. Charles Townes' work in quantum mechanics, for which he received a 1964 Nobel Prize, led to the

discovery of lasers, which read the tiny pits "burnt" into the CD.

2. Einstein's photoelectric effect, for which he received a Nobel Prize in 1921, provided the theoretical

basis for the conversion of light reflected from the CD into electrical signals.

3. Work in semiconductors, for which William Shockley received a 1956 Nobel Prize, led to invention of

the transistor, which made possible the development of integrated circuitry capable of rapid

transmission of complex electronic signals.

4. In spite of this aggregation of 20th century brilliance, there remained the problem of fidelity of data

transfer. The extraordinary amount of information converted from reflected photons into electrons

produced roughly 1,000 errors per second. This problem was solved by application of a redundant

coding system derived from set theory, developed by a French mathematician, Gauloise. This was the

only contribution of the four that did not result in a Nobel Prize. However, Gauloise developed set theory

in the 18th century, and Alfred Nobel did not invent dynamite until the middle of the 19th.

Evidence-based Medicine and The Hierarchy Of Evidence

Finally, and certainly closer to home, the scholarship of integration has been fundamental to the

development of Evidenced-based Medicine. A prototypic example of this is Brian Haynes' pyramid of

evidence, which integrates evidence with bedside care through the marriage of thoughtfully gathered

information with technology (Haynes RB: Of studies, syntheses, synopses, and systems: the "4S"

evolution of services for finding current best evidence. ACP J Club 2001;134:A11-A13). Haynes'

evolutionary hierarchy depicts four tiers of evidence organized in a pyramidal shape. Original studies

published in peer-reviewed journals form the base of the structure. These are followed, in order, by

"syntheses" (systematic reviews or metaanalyses), "synopses" (encapsulations of systematic reviews),

and finally, at the apex of the pyramid, "systems" in the form of computerized decision support systems,

or CDSSs. Individuals who aggregate the information contained in clinical trials (performed by those

engaged in the scholarship of application as clinician-scientists) into critically appraised "syntheses" and

"synopses", to be finally embedded in "systems" that inform everyday clinical decision-making are

functioning as integrative scholars.

Although CDSSs do not yet appear equal to the task of generating a differential diagnosis, their utility

has been demonstrated in drug dosing and preventive care (Hunt DL, Haynes BR, Hanna MA, et al:

Effects of computer-based clinical decision support systems on physician performance and patient

outcomes. A systematic review. JAMA 1998;280:1339-1346). It seems probable that, over time,

increasingly sophisticated evidence-based decision support systems, devised and maintained by

scholars of integration, will come to play an increasingly important role in the provision of care to our

patients and the education of our residents and students.

The Scholarship of Teaching

Choosing Instructional Strategies

Author: Dane Chapman

As professional mentors and teachers of Emergency Medicine, we have come to utilize various

instructional strategies to teach the content and procedural skills of our specialty. Instructional strategy

refers to both the determination of major instructional objectives and the teaching steps used to

optimally fulfill each major instructional objective (1). An instructional system is a prepared set of

instructional materials used to teach instructional objectives according to the instructional strategy for

each objective, using any of a variety of instructional formats such as lectures, small group discussions,

or computer modules.

Instructional Strategies and Instructional Objectives

Two common instructional strategies have been described as the "bucket technique" and the "SOCO"

method (2). Unfortunately the "bucket technique" is still commonly used in medical education and comes

with the assumption that medical school faculty are "all knowing" and that medical student or resident

minds are like empty buckets. The goal of the instructional session is to fill the empty learner "buckets"

with knowledge or "pearls of wisdom" from the faculty. The problem with this method is that it is teacher-

focused, not learner-focused and most often it is associated with the lecture format without clearly

defined, learner-centered instructional objectives. The learner then is expected to regurgitate all the

knowledge in some useful order. Since the knowledge is rarely learned around patient presentations,

recall is difficult when needed in the clinical setting as it has been memorized as a list of facts.

The single overriding communicating objective or "SOCO" method more effectively promotes learning,

Retention, and application of information to new situations. A brief teaching session, such as at the

bedside, might have only one single overriding communication objective (SOCO). A longer session,

such as a Grand Rounds presentation, may have three or four SOCO’s. Such objectives should be

learner-centered, measurable, and appropriate for the level of the medical student or resident. There

may also be "enabling objectives" that must be met before the learner will be able to successfully meet

each single overriding communicating objective.

How Adults Learn

Certain principles of adult learning need to be incorporated into any instructional strategy. Adults learn

best in a supportive environment where they are encouraged and have the opportunity to support one

another. Joining together around a table or bedside with close interaction among all members of the

group facilitates adult learning. Adults especially appreciate teachers who provide learning significance,

ie. the "need to know," and who share the responsibility of learning with the students. By providing clear

goals and objectives, adult learners can "prepare mentally" for the instructional session without hidden

expectations that promote unnecessary anxiety. Adults have a wealth of prior experience that can also

be harnessed and built upon as new information and skills are taught. Adult learners remember best

when they are actively experiencing learning in a problem-based or case-based format, during active,

student-centered instruction with plenty of positive verbal and written feedback. Perhaps these

principles of adult learning are said best in the triplet: "Tell me…I forget; Show me…I remember; Involve

me…I understand." (2).

Studies of learning have demonstrated that only about 7% of information recall is dependent upon the

actual content, and 93% of recall relates to how the content was presented (2). Accordingly,

instructional strategies are most effective when they involve the learner. Since so much of what is

effectively acquired and retained by the learner depends upon how it was presented, principles of oral

communication should be followed closely, especially when using the lecture and small group

discussion formats. The mood for learning can be set by: 1) approaching the class with real excitement

and enthusiasm, 2) adding vocal variety for interest and clarity, 3) including purposeful pauses, 4)

maintaining effective eye contact with each learner throughout the presentation, 5) showing a desire to

communicate without over-dependence on notes, 6) actively involving the learner and, 7) ending using a

strong conclusion with vitality! Being enthusiastic in the presentation is key to effective oral

communication. Compared to written communication, oral speech has more personal references, more

first and second person pronouns, shorter length of thought units, greater repetition, more mono syllabic

words and more familiar words (2).

Instructional Strategy and Teaching Steps

Nine teaching steps or "events of instruction" have been described in the educational literature (1).

These provide the framework for teaching in the classroom, small group discussion or when developing

an instructional system to be adapted as an interactive computer module or simulation (See Table 1).

Utilizing these "events of instruction" or teaching steps gives the mentor or teacher an organized

instructional strategy for optimally transmitting knowledge and assessing competency.

Step 1: Gaining Attention

Gaining attention techniques clearly vary with the type of audience and level of training of the learners.

Techniques include appealing to some learner interest, simply pausing until learner attention has been

obtained, using humor, or asking a question like: "Who wants to learn how to save a life by performing a

cricothyrotomy?"

Maintaining attention is also a key instructional strategy which can be achieved by changing the media

or nature of the activity, referring to a longer-term goal, or referring to an overview or outline to help the

learner keep perspective of the big picture. A sudden change of plans is a useful technique for gaining

or maintaining attention, because it allows the teacher the opportunity to seize upon an unexpected

happening that could illustrate an instructional objective.

Step 2: Goals and Objectives

Informing learners of the instructional objective is only fair as it helps focus students and residents and

guides them through the information or skill to be learned. When defining goals and objectives, the

distinguishing characteristic between them is that a goal is a general statement about what is to be

accomplished in an instructional session. Objectives, however, are statements used to identify key

instructional outcomes and must be measurable in order to determine whether or not they have been

met. Instructional objectives state what the learner will be able to do at the end of the presentation and

are best provided in behavioral and learner-centered terms, appropriate to the learner’s level of

knowledge or skill, and achievable in the time allotted for the learning. Objectives are constructed by

considering what the learner will do, not by focusing on what the teacher will present to the learners.

The key to developing instructional objectives is to complete the sentence, "By the end of this session,

the learner will be able to…."

A goal example would be: "The goal of this chapter on instructional strategies is to enable faculty to

develop their own successful instructional systems, whether lectures, small group, or computer-

assisted, that incorporate adult learning principles."

An objective example would be: "After reading this chapter on instructional strategies, faculty will be

able to: a) formulate the goals and objectives for their own instructional system, b) select an appropriate

media format for presentation, and c) organize the instructional system to include the nine events of

instruction."

Formulating the goal and instructional objectives is considered by some to be the first step in effective

teaching, and occurs during the planning stage of instruction. During the actual teaching sessions,

faculty implement their objectives. Finally, after the teaching session, faculty should assess whether the

instruction has enabled learners to meet the stated objectives. This is also a good time to make notes

about what went well and what needs to be revised in the presentation while learner comments and

performance feedback are fresh in mind. The two most common reasons for failing to meet instructional

objectives are insufficient framing of objectives and misjudging of learner’s prerequisite knowledge level

(2-4).

Step 3: Stimulating Recall of Prerequisite Learning

Stimulating recall of prior learning is especially important for complex knowledge or skills that are built

upon simpler knowledge or component skills. For example, before thoracotomy procedural skills can be

taught effectively, learners must be able to recall important prerequisite anatomy of the thorax (5). The

best instructional systems build upon common knowledge or skill(s) that can be easily recalled by the

majority of learners in the class or group. With that level as the starting point, new information and

skill(s) can be readily integrated, and remembered.

Step 4: Presenting the Stimulus Material

The nature of the stimulus presentation depends upon the type of learning (i.e. facts to be memorized,

rules to be understood, problems to be solved or procedures to be performed). It is best to present only

5-10 paired associates (eg. surgical instrument picture and name) to be memorized at a time. When

presenting information that has order or a relationship, it is useful to provide the learner with the

organizational framework or "advanced organizer" so that the information can be organized in a

meaningful way, aiding both initial learning and later recall (1). Patient presentations serve as a useful

structure for organizing many discrete facts that would otherwise be difficult to recall. When facts are

memorized around a patient presentation (eg. signs and symptoms), learning and recall are facilitated.

Learning can be further facilitated if the presentation includes periodic review or summary statements,

with pacing for interactive questioning and corrective feedback.

When presenting discriminative tasks such as distinguishing congestive heart failure (CHF) from an

acute exacerbation of chronic obstructive pulmonary disease (COPD) in a patient presenting with acute

shortness of breath, the distinctive features of each disease should be pointed out to the learner. Once

the distinctive features are formalized into rules, learners can practice their understanding of the rules

when presented with novel examples for practice and corrective feedback (eg. new patients with either

CHF or COPD).

Step 5: Providing Learning Guidance

Some medical students and residents become more engaged in their own learning when they are given

a problem, and asked to "discover" the solution. Learners tend to remember well what they discover in

this manner because their learning has been an "experience" (ie. experiential learning). When medical

students and residents are assigned to see patients with diseases not previously encountered, they

typically use discovery learning. While this strategy of learning promotes attention and interest among

learners, it can also result in frustration and is a rather inefficient method for learning. The axiom,

"experience is a great teacher, fools will learn in no other way" illustrates this point. If we fail to learn

from another’s experience, we are left to discover truth for ourselves. Faculty can provide various

degrees of guidance through the discovery learning process in order to decrease learner frustration and

make the learning session more efficient. One of the downfalls of problem-based learning (PBL), a form

of discovery learning, is that students do not learn as much information as medical students using a

traditional curriculum. Yet, what they do learn can be better applied to the clinical environment. Learning

is often better retained and generalized to other clinical presentations when instruction follows the PBL

format.

In summary, providing learning guidance by direct prompting is useful for rote memorization. For rule-

using and problem-solving, learning guidance can be provided using a hint or indirect prompt at first,

gradually increasing the directness of later prompts until learners successfully solve the given problem.

Specific types of faculty providing learning guidance for various types of learning (1) are presented in

Table 2.

Step 6: Eliciting the Performance (Formative Evaluation)

After the instructional session using lecture, small group or individualized instruction with a book or

computer simulation it is necessary for learners to demonstrate that they have learned the key concepts

or skills presented. If lists of facts are taught, students and residents should be able to regurgitate the

facts either orally or in writing. If rules or algorithms (e.g. clinical pathways) are presented, then novel

cases can be given to determine whether or not the learner can demonstrate the appropriate application

of the rule. True understanding of a rule requires the demonstration of skills using examples that are

"new" to the learner In order to be sure answers to a few previously given examples have not just been

memorized. For example, if a clinical pathway on the diagnosis and management of acute shortness of

breath had been taught and illustrated using various examples of patients with congestive heart failure,

acute asthma exacerbation, or pulmonary embolism during the instructional session, then, new patient

presentations with these same diagnoses would need to be presented to elicit "rule using" performance

by the medical student or resident. Likewise, when eliciting problem-solving, problems not previously

presented to the learner must be used to determine if problem-solving mastery has occurred.

Regardless of the domain of learning (i.e. cognitive, affective or psychomotor), eliciting the performance

is an important instructional step to assure the learner and teacher that learning has taken place (i.e.

formative evaluation). Otherwise, additional instruction is required to develop competency before the

formal test of mastery occurs (i.e. summative evaluation). For example, in the psychomotor skill

domain, performance of component critical procedural steps need to be elicited separately (e.g.

"opening the chest", pericardiotomy, aortic cross-clamping) (formative evaluation) before the entire skill

(e.g. thoracotomy) is assessed by a test (summative evaluation) (5).

Step 7: Providing Feedback

After the performance has been elicited, learners must receive feedback to know whether it was

performed correctly. This is a key step in learning. Without corrective feedback, learning rarely occurs.

Feedback follows formative evaluation but not summative evaluation. When a performance is only partly

adequate, feedback will help the learner define exactly where additional study or practice is needed.

Step 8: Assessing Performance (Summative Evaluation)

Eliciting the performance (formative evaluation) with corrective feedback may be done several times in

the sequence of learning a single instructional objective. In contrast "assessing" performance is done

only after the learning and instruction have been completed for the entire objective. When assessing

performance, the assessment instrument must be reliable and valid. Since high stakes decisions—eg.

passing a course, graduating from medical school or advancing to the next year of residency—are made

based upon the "assessment", these summative evaluation instruments must be psychometrically

sound. A test is reliable if the results are reproducible or internally consistent. For example, if four

questions on a given test assess the same content area such as acute coronary syndrome, a highly

reliable (internally consistent) test would result in learners responding to all four questions similarly—(ie.

those missing one would likely miss all four, those answering one correctly would likely answer all four

correctly).

Summative assessment instruments also need to be valid—meaning that they are measuring what they

are purported to measure. Resident performance on a valid test of cricothyrocotomy (eg. on a cadaver

model) would be predictive of whether or not the learner would be competent in performing a

cricothyrotomy upon an actual patient in respiratory distress following a failed intubation. Validity can be

measured by correlating the test with actual performance, where a high correlation represents the

presence of validity.

Step 9: Enhancing Retention and Transfer

The last "event of learning" or "teaching step" is to help learners generalize and transfer what they have

learned to new situations. The more learners are able to practice what they have learned, the better

they will recall isolated facts, organized information, or skills. Moreover, as learners apply what they

have learned to a range of practical situations, they are more likely to retain that knowledge or skill.

In medicine, experts in clinical decision-making use pattern-recognition and decision-making algorithms

and clinical pathways, rather than the more mentally taxing hypothetico-deductive reasoning process

(6). As a result, discrete facts previously memorized about particular diseases are often forgotten by the

expert who easily retains the ability to diagnose and manage patients efficiently, but must struggle to

maintain "the edge" in factual recall. Clearly organized information or information memorized around a

structural framework like rules or algorithms are easier to recall and transfer to new situations than are

isolated facts. Psychomotor skills like critical emergency medicine procedural skills are easily retained

once sufficiently practiced. Yet, it remains unclear how many procedures must be performed to achieve

mastery. There is some evidence to suggest that 10-12 procedures performed correctly may be a

sufficient number to achieve mastery of complex psychomotor procedural skills like emergent

thoracotomy and cricothyrotomy (7). It is less clear how frequently such procedures must be performed

to maintain skill proficiency (7,8).

Optimizing Instructional Formats

This section addresses the pros and cons of various instructional formats of lecture, small-group

discussion, workshop and individualized instruction.

Lectures

Lectures are one of the most efficient of all teaching formats where large numbers of learners can

receive instruction simultaneously. Unfortunately, one of the greatest determinants of whether

knowledge is acquired depends on the degree of interaction between the learner and the teacher (2).

Using this format, it is difficult, but not impossible, to involve the audience effectively (2-4). The

instructor can for example, direct questions to the audience throughout the lecture, use handouts with

questions to be answered during the presentation, and roleplay (3,4). An effective method is to organize

medical information around a meaningful case that can then be applied directly to the clinical

environment. Too often medical information is discussed during medical school as lists of facts without

much thought to how the information could be used to help diagnose a patient’s problem.

Information not organized around a patient’s presenting signs and symptoms is much more difficult to

learn and to retain. Accordingly, good lectures often begin with an interesting unknown case that

illustrates some aspect of the content to be discussed in the body of the lecture. As the case unfolds,

decision points can then be amplified and differential diagnoses discussed with special attention being

given to those distinguishing signs, symptoms, or diagnostic study results that differentiate the correct

diagnosis from a long list of differential diagnoses that have some of the same signs, symptoms, and

diagnostic study results in common with the correct diagnosis.

The downside of lectures is primarily the difficulty in actively involving the learner throughout the

presentation (2). The learner has a special challenge of maintaining attention and it is quite easy to fall

asleep during lectures when the lighting is turned down for slides. The instructor typically does not

engage learners with enough interaction to keep all learners attentive and interested. However, when

the instructor is engaging, lectures can be very effective (3,4).

Small Group Discussions

The optimum size for small group learning has been found to be a maximum of twelve learners per

group (2). Twelve or fewer learners can interact reasonably well with a single instructor such that all are

kept involved and engaged in active learning. The disadvantage of small group learning is that it

requires more teachers or discussion group leaders than the lecture format. However, if the instructor

can train one or more group members to be group facilitators, then this is a very effective method of

teaching. Focus groups utilize this method in discovery learning to create a solution to a common

problem. The small group format is also optimal for teaching procedures.

Small group discussions have been used successfully in medicine in the form of medical and surgical

attending rounds. A patient presentation is given that forms the basis for instruction. Using this case-

based approach, medical educators have successfully taught trainees to memorize common

presentations or "disease frames" that can later be drawn upon to make diagnostic and therapeutic

decisions (6,9). Key elements of the small group method are interactivity and involvement of the learner.

Workshops

Workshops typically include both lecture and small group break out sessions to take advantage of the

efficiency of the lecture format in presenting facts, and the small group discussion format in teaching the

application of those facts presented during the lecture session. For example, the latest development in

anti-platelets, thrombolytic therapy and cardiac catheterization could be presented in a Grand Rounds

lecture format, with break-out sessions directed toward the application of principles learned to novel

cases presented in a small group format. Typically, workshops provide a standard learning exposure for

a limited content or skill area that can be fully presented in 2-5 hours.

A sample workshop for faculty development was recently undertaken to enhance the questioning skills

of faculty and residents (3). A basic discussion of thinking skills and a review of various types of

questions is presented in a lecture format. Next, in small groups, participants critique previously

produced videotape vignettes that demonstrate good and poor questioning techniques. The workshop

concludes with a paper case where participants are able to apply what they had learned by writing

questions directed toward different levels of learning . These are then discussed in a larger, combined

group interactive forum.

Computer-Assisted Instruction (CAI)

CAI can maximize learner involvement, which translates into more active learning and better retention of

information or skills presented. Learners have the advantage of learning when they feel most like

learning—provided they have access to the CAI systems. The CAI format maximizes interactivity, but

falls behind the lecture and small group format in efficiency. A combination of CAI and small group study

has been shown to optimize both methodologies and learners appear to learn better from CAI when

they study in groups of 2-3 rather than alone (9).

Becoming the Optimum Teacher

Instructional strategies provide a useful framework for any form of instruction and involve clearly

defined, learner-centered instructional objectives and teaching steps. Principles of adult learning have

been presented as they relate to instructional strategies. However, application of these principles alone

will not allow us to become the best teachers that we can be. To become our best teacher is to discover

the teacher within us, to be who we really are, to be ourselves (10). As we are more willing to be

ourselves in front of our medical students and residents, willing to admit our weaknesses and

inadequacies, learners will respond to our humility with their own willingness to learn. They will feel a

genuine respect for us because they will know that we care more about them than we care about our

reputation or our image. Such high regard for students triggers similar feelings in return. Ample

research has demonstrated that when students value their teacher, their commitment to learning is

enhanced (10).

In contrast, when teachers are more concerned about their own image in front of the group, they

insulate themselves from personal involvement with their students’ lives. To them, the teaching role is

defined solely in terms of the teacher’s performance. Such teacher-centered faculty will find that the

greater they try to control their students or residents, the more superficial will be learner commitment.

The more they try to motivate, the less motivated learners will become. The more elegant their lectures,

the more sporadic will be the attendance (10).

Learner-centered teachers humble themselves before their students and unpretentiously perform the

highest form of teaching. They use instructional strategies to serve and uplift, not to control or

manipulate. They engage the learner in a mutual obligation to learn and they worry less about being

seen as "experts" or "authorities." Learner-centered teachers place learners in control of their own

learning, serving as facilitators of the instructional session. As academic pride is stripped away, such

teachers humbly influence students’ lives for good and become master teachers (See Table 3). Master

teachers focus upon the students’ need to learn well rather than upon their own need to teach well. May

we each allow ourselves to be such teachers as we discover the teachers within us!

TABLE 1: INSTRUCTIONAL STRATEGY TEACHING STEPS TO OPTIMIZE LEARNING

1. Gaining attention of learner

2. Informing the learner of the objective

3. Stimulating recall of prerequisite learning

4. Presenting the stimulus material (new content, skill, etc.)

5. Providing "Learning Guidance"

6. Eliciting the performance from the learner

7. Providing feedback to learner about performance correction

8. Assessing the performance

9. Enhancing retention and transfer of content or skill learned

TABLE 2: LEARNING GUIDANCE APPROPRIATE FOR VARIOUS TYPES OF LEARNING*

Type of Learning Outcome

Form of Guidance to Learning

Discrimination Point to distinctive features of objects to be discriminated

Concrete Concepts Give cues to identifying attributes

Defined Concepts Provide codes or memory bridges

Names and Labels Provide codes or memory bridges

Facts Provide meaningful context

Organized Knowledge Provide prompting in context of the organizational framework

Rules Show how component concepts make up the rule

Problem-Solving Provide minimum cues needed to lead learner to select and apply applicable rules

Motor Skills Stimulate recall of sequence of acts; provide practice with feedback

Attitudes Establish respect for human model; show his behavior and how he is reinforced

*adapted from Briggs, 1977, page 211.

Table 3: The Master Teacher*

Invites rather than compels

Acts in the best interest of students, leading them to truth and clarity, and away from confusion

Focuses on residents as individuals, not on content or skill being taught

Teaches out of high regard for the student rather than from duty

Identifies the life demand or driving force that will motivate residents to receive truth

Has traveled the path so can help refine an idea, polish a skill, and give honest feedback; but, is sensitive to each residents’ limit to handle the feedback

Is okay with guiding students to the correct path and letting them discover the solutions themselves

*Adapted from Osguthorpe, RT. The Education of the Heart. Covenant Communication, Inc, American Fork, UT, 1996, pp 83-101.

Acknowledgements

I would like to acknowledge Debra Palecek for her wonderful help in preparing this manuscript almost

single handedly.

References

1. Briggs, LJ. Designing the strategy of instruction, Chapter 7 in Briggs, LJ (ed) Instructional Designing

Principles and Applications, Educational Technology Publications, Englewood Cliff, NJ, pp 179-218,

1977.

2. Kelliher, GT, et.al. Effective Teaching: Improving Your Skills. Workshop presented by the Office of

Education, Medical College of Pennsylvania/Hahneman University. June 3-7, 1996.

3. Sachdeva, AK. Use of effective questioning to enhance the cognitive abilities of students. J. Cancer

Education

4. Kelliher, GT, Sachdeva, AK, Fleetwood, J. Preserving the best of the art of teaching. Acad Med

1996;71:248-250.

5. Chapman, DM, Marx, J, Honigman, B, et al. Emergency Thoracotomy: Comparison of medical

student, resident and faculty performance written computer and animal model assessments, Acad

Emerg Med 1995;1:373-381.

6. Chapman, DM, Char, DM, and Aubin, C. Clinical Decision-Making, Chapter 10 in John A. Marx

et.al.,(eds). Emergency Medicine: Concepts and Clinical Practice (5th Edition), Mosby Publishing Co,

2001.

7. Chapman, DM and Cavanagh, SH. Using receiver operating characteristics (ROC) analysis to

establish previous experience for critical procedural competency. Acad Med1996;71:57-59.

8. Long, DM. Competency-based residency training: The next advance in Graduate Medical Education.

Acad Med 2000;75:1178-1183.

9. Chapman, DM, Calhoun, JG, Davis, WK, et al. Acquiring clinical reasoning competency: Group

versus individual practice using patient management computer simulations. Acad Emerg

Med1997;4:511-512.

10. Clark, DC. The Teacher Within: A Voyage of Discovery. Orem Utah: Granite Publishing and

Distributing, 2000 pp. 17-23.

The Educator's Portfolio

Author: Gloria Kuhn, D.O., Ph.D., FACEP

The Educator's Portfolio (also known as a teaching portfolio or teaching dossier) is a tracking device for

collecting materials that document and demonstrate excellence as an educator. The Portfolio can serve

many different functions in its capacity for demonstrating teaching expertise. This article will discuss the

many uses of the portfolio, creating a portfolio, and finally how to create a portfolio that can be submitted

to a Promotion/Tenure (PT) Committee.

Uses of the Educator's Portfolio

Promotion and Tenure

Many institutions are using the Portfolio in the P&T process. This enables the P&T Committee to see,

and therefore, judge, the accomplishments of a faculty member applying for promotion. Faculty

members frequently forget to record the many and varied educational activities in which they have been

engaged over the years of their career or they may not feel that the activities are "important" enough to

record. They cannot subsequently include supporting materials about these activities in a file that is

submitted to a P&T committee. While these activities may not have great weight individually, in

aggregate they reveal the many and varied talents of the educator and the valuable role that the

individual plays in the growth of the institution. Because the Portfolio provides an ongoing methodology

for collecting materials as they are generated, preparing a document for a P&T committee is easier,

faster, and more accurate. Trying to remember past activities and collect documentation at the time the

decision is made to apply for promotion leads to frustration and a sparse file that cannot represent the

value of the educator fairly.

Evaluation

Department Chairs can use the Portfolio when performing periodic evaluations of their department

members. The Portfolio aids the faculty member and Chair to put past accomplishments in perspective

when used for this purpose. Future goals and activities can then be planned which will build upon the

knowledge gained during past activities. It aids the Chair in determining the productivity of department

members and in generating a report to the Dean of the productivity of the whole department. From the

perspective of the faculty member it makes preparing for periodic evaluations very easy as all of the

material is already assembled.

New Positions

The faculty member can use the Portfolio when applying for a new position to demonstrate scholarly

accomplishments and experience. This was the original purpose of portfolios as used by artists and

architects to display his/her best work to a potential patron or client. Many teachers use the Portfolio

they have assembled when looking for a new job or applying for a promotion. One of the most valuable

uses is to assist a faculty member in rapidly updating and keeping current his/her curriculum vitae, an

activity that is necessary for any application.

Reflection on Teaching

Many of those who have assembled a Portfolio have stated that it has aided in their growth as an

educator. The very act of looking at past accomplishments and activities has led them to examine what

actions have been successful and why, what they would change in the future, and what direction their

career has taken. This act of self-reflection often results in growth as a teacher and leads to a higher

level of ability. Educators who have assembled Portfolios state that when instructional activities have

been less than successful the Portfolio has helped to make this apparent to them. They then have had

the opportunity to devise methods that have proven more successful in accomplishing their teaching

goals. It has been argued that this reflection-on-teaching and the resultant growth in ability as an

educator is the most valuable aspect of the Portfolio.

The Portfolio as Incentive and Reward

Most educators in medicine are highly motivated. They do not wish to have an empty Portfolio. The very

existence of the Portfolio acts as an incentive towards accomplishing goals. The self-reward occurs

when the educator is able to look at past activities and see the many accomplishments and career goals

that have been attained.

Creating the Educator's Portfolio

The contents of the Portfolio will vary because of the many activities in which educators are engaged.

One of the easiest ways to create a Portfolio is to use a tabbed three-ring binder. The Portfolio should

contain the following sections: 1) Activities, 2) Philosophy of Education, Accomplishments, and Future

Goals, 3) Recognition of Excellence and, 4) Courses and Study to Increase Expertise as an Educator.

The materials gathered for each of these sections will be highly individualized to reflect the activities of

the educator. It is critical to determine if your institution has guidelines on how the portfolio should be

structured so that you can follow them.

The Activities Section should include the educational activity, any materials generated as a result of the

activity, and any evaluations by peers or learners. Examples of activities might include courses taught,

lectures given, a list of students advised, committees or panels upon which the educator was asked to

serve, and any clinical supervision given to medical students or residents. Publications and authored

educational materials such as educational software may be included in this section. It is important to

remember that many institutions require national and even international recognition for promotion to full

professor. Educators may want to have separate areas in their Activities Section for national and

international endeavors.

The section dealing with your Philosophy of Education may be the hardest to generate. But doing this

early in your career will pay huge dividends in the future. The end of the academic year is a perfect time

to look through the contents of the Activities Section and reflect on what has been accomplished and

what still needs to be done. At this time, it is relatively easy to write a short statement as to how you feel

you can best teach, what motivated the activities in which you were engaged, what value you feel these

had to the institution, how these activities implemented your philosophy of education, and what your

future goals are (place a copy of the lithe list of goals for the coming year in a new Portfolio which will be

filled in the coming academic year). The discussion should only take a few pages but it needs to

articulate your beliefs and activities as an educator. This statement is then placed in the Philosophy of

Education Section. This is also a good time to look at both activities and evaluations to determine if they

are in line with your career goals. This section should be re examined periodically so that it can be

modified to reflect changes in your teaching philosophy and methods. It is this re examination that

allows for "reflection upon action" which is so important for expertise in an area to develop. In fact, many

who have studied the use of teaching portfolios consider this act of reflection to be the most important

use of the portfolio.

The Section for Recognition of Excellence will depend on how you have been recognized during the

year. Include any awards or honors, whether national, local, or institutional. Recognition by residents

and medical students for excellence in teaching is of great value. Do not forget to include any thank you

letters received as a result of educational activities from course directors or students you have

supervised, mentored, or advised. While these are not formal awards, they document your excellence in

teaching from a variety of sources.

Listing self-study and formal courses taken to increase your expertise in teaching is of great value. It

demonstrates your commitment as an educator and the credentials you have accumulated in the area of

education.

Generating a Portfolio is of most value when the contents are kept for future use. All of the materials

collected during the academic year is saved, either in a file or the three-ring binder, and a new Portfolio

is begun for the new academic year.

Preparing a Portfolio for the P&T Committee

The first step should be to examine the contents of the Portfolios that you have archived. Read the

statements you wrote for the Philosophy of Education Sections and then spend some time thinking

about your accomplishments, your goals, and how your activities and actions have benefited your

students, residents, and the institution.

After this reflection you are ready to begin preparing a Promotion Portfolio. Include the activities that you

feel best represent your accomplishments. Compose a narrative of three to eight pages that discusses

your philosophies, your accomplishments, your growth as an educator, and activities of which you feel

proud. You can include tables or graphs that display your successes. Include samples of educational

materials you have generated in labeled appendices. Make it easy for the members of the P&T

committee to understand what you wanted to achieve and how you went about ensuring your success in

these endeavors.

It is often of value to ask someone who has prepared a Promotion Portfolio to look at your Portfolio and

give you advice. You may want to ask members of your Departmental Peer Review Committee to look

at the Portfolio prior to its official submission to them to see if there are any suggestions as to contents

or format. Use their suggestions to strengthen the document. You may want to let some time pass and

reexamine the Portfolio to be sure that it is complete, reflects your best work, and adequately represents

you as an expert educator.

Finally, pretend that you are a member of the P&T committee of your institution and that the Portfolio

belongs to a stranger. Is it easy to read and does it demonstrate expertise? Is it the Portfolio of

someone whom you feel deserves promotion? If the answers are "yes", submit it. If the answers are

"no", keep working.

The following references are recommended if you would like to learn more about Portfolios. Those that

are starred show examples of Portfolios. The examples they contain are varied and demonstrate the

creativity used to document expertise.

Recommended Bibliography

1. Beasley, B., S. Wright, et al. (1998). "Promotion criteria for clinician-educators in the United States

and Canada." JAMA 278(9): 723-8.

2. Beecher, A., J. Lindemann, et al. (1997). "Use of the educator's portfolio to stimulate reflective

practice among medical educators." Teaching and Learning in Medicine 9(1): 56-9.

3. Carroll, R. (1996). "Professional development: A guide to the educator's portfolio." Am J Physiol

271(6P&T 3): S 10-13.

4. Roth, L. (1998). "Teaching portfolios: Reflecting upon and improving teaching." J Cancer Educ 13(4):

194-6.

5. Seldin, P. (1997). The Teaching Portfolio. A practical guide to improved performance and

promotion/tenure decisions. Bolton, MA, Anker Publishing Company Inc. *

6. Shulman, L. (1990). "The Educator's Portfolio." Presentation at Conference on Assessment in Higher

Education.

7. Simpson, D., A. Beecher, et al. (1998). The Educator's Portfolio. Milwaukee, WI. Medical College of

Wisconsin. *

8. Speer, A. and D. Elnicki (1999). "Assessing the quality of teaching." Am J Med 106(4): 381-4.

9. Zubizarreta, J. (1999). "Teaching portfolios: An effective strategy for faculty development in

occupational therapy." Am J Occup Ther 53(1): 51-5.

Developing a Career in the Scholarship of Teaching as a Clinician-Educator

Author: Stephen R. Hayden

Introduction

Clinical bedside teaching is nothing new. It was Hippocrates (circa 400 BC) who abandoned temple

based medicine for a practice that valued direct observation, the exact recording of the features of

disease, and adherence to the principal that "You must go to the bedside, it is there alone that you can

learn disease." In his address to the New York Academy of Sciences, Sir William Osler stated that there

should be "No teaching without a patient for a text, and the best teaching is that taught by the patient

himself." Despite this legacy there has been gradual erosion in time spent teaching at the bedside.

Thirty years ago over 75% of medical teaching occurred at the patient's bedside. Several authors have

recently examined the time devoted to attending rounds on inpatient medical services. They estimated

that only 16 - 20 % of the time devoted to attending rounds was spent in the presence of the patient. In

other studies using direct observation or videotaping it was found that the average time spent at the

bedside was only 2 - 3 minutes compared with approximately 60 minutes in the classroom. In 25 % of

instances teachers never saw the patient at all, whether during the case presentation or afterward.

Although a number of studies have shown that approximately 85 % of patients preferred bedside

rounds, only 35 % of attending physicians did so, 4 % of students, and 2 % of house staff.

The emergency department (ED) has always been regarded as a rich environment for clinical teaching

with the wealth and diversity of diseases that present to our doors. Yet most academic emergency

physicians are experiencing intense pressure from external sources to improve the efficiency,

documentation, and cost effectiveness of emergency medicine (EM) practice. I have heard many of my

colleagues lament that this results in less time for teaching residents and students in the ED. If you

believe that the best teaching occurs in the doctors workstation, conference room, or lecture hall then it

is understandable that you would feel this way. I'm going out on a limb here, however, and suggesting

that recent external forces that require attending EM physicians to personally see and examine all

patients in the ED may be the best thing that has happened to clinical teaching in EM. We have been

handed a golden opportunity. As a faculty physician you now need to be there anyway, take a resident,

or student, by the hand and lead them with you back to the bedside where a multitude of teaching

moments can occur.

In this chapter we will discuss characteristics of good clinical teachers, perceived obstacles to effective

bedside teaching, strategies to overcome them, the components of good bedside teaching, and a

number of practical models to use in clinical instruction.

Characteristics of Good Clinical Teachers

There are a number of characteristics that great clinical teachers in medicine share:

Teachers are knowledgeable

Presentations are clear and well organized

They are enthusiastic and able to interact skillfully with students and residents

Provide simultaneous teaching and clinical supervision

Demonstrate clinical skills to learners

Model professional characteristics

Good clinical teachers also display numerous intangible qualities such as:

Being available

Being approachable

Having infinite patience

Staying calm in difficult situations

Osler described this as equanimity, and suggested "In the physician or surgeon no quality takes rank

with imperturbability."

Superb clinical teachers also use effective teaching skills including:

Explaining concepts at the learners level

Providing timely feedback

Modeling their behavior for students

Illuminating how their thought process works

Instructing in small digestible "teaching bites"

Guiding learning with questions

This last item bears repeating: Good clinical teachers guide learning with questions. This means asking

questions that require synthesis and interpretation of information and evidence rather than simple

regurgitation.

Examples of such high yield questions are:

Why do you believe that to be true?

How did you reach that conclusion?

What lead you to that decision?

Why is X approach better than Y?

Why is that information important?

What will happen if you don't do X?

What is the association between X and Y?

Obstacles to Effective Clinical Teaching

Concern for the Privacy and Well-being of the Patient

The argument is often made that to present case histories and physical findings in front of patients, and

possibly their families, would prove embarrassing or uncomfortable to them. On the contrary, the

available evidence suggests that patients are in fact appreciative of the attention being devoted to them

by so many health-care professionals. When conducted tactfully and empathetically bedside

presentation is not a traumatic emotional experience but rather educates and reassures patients. The

overwhelming majority of patients feel that they understand their illness better and have a better

opportunity to get their questions answered. Patients want the attending physician to introduce

themselves, to state the purpose of bedside rounds, and to be sensitive to the need to translate medical

jargon into terms that they can understand.

Medical Chauvinism

Some doctors believe that it is not appropriate to involve patients in the process of making major

decisions regarding their health-care. Consequently this may be responsible for moving case

presentations and discussions away from the bedside. These physicians also do not want to display

weaknesses in front of patients or families in discussing their own problems associated with data

collection, interpretation, and synthesis. Again, the available evidence would indicate that active

involvement of the patient, as well as the patients observation of our deliberations, can lead to an

honest, open, and mature doctor patient relationship where both the physician and patient assume

appropriate responsibility for decisions made.

Passive View of Education

Here the old idiom that education is the transfer of knowledge from teacher to student is applicable. This

view purports that teaching on rounds means a series of mini-lectures by the attending on topics that

happened to arise, often followed by a more lengthy discussion in the doctors workstation, conference

room, or classroom. Trainees support this arrangement since it requires little active work on their part

and conforms to their prior educational experiences as passive listeners in a lecture hall. They are used

to the doughnuts and coffee, the comfort of sitting around a conference table or at a work desk, and the

cloak of early morning or post-meal semiconsciousness. In order to combat this, the skilled emergency

medicine faculty will know how to actively engage the student or resident by guiding learning with

appropriate questions. The attending facilitates group or individual learning by assisting the trainees to

discover for themselves the important clinical issues and develop a strategy to solve the clinical

problem.

Emergency Medicine Faculty Discomfort at the Bedside

Many teachers are uncomfortable discussing subject matter in which they feel less than expert. The

bedside is avoided where the reality of the patient's situation or difficult questions might draw them on to

intellectually thin ice. They prefer the workstation, the conference room, or even worse the hallway,

where they can turn the discussion to subjects with which they are far more comfortable. There will be

no patient and no family in attendance to ask embarrassing questions that force us to say, "I don't

know." Furthermore, there is our discomfiture with physical diagnosis. All of these barriers may be easily

overcome. Create a safe and comfortable environment for asking questions and discussing answers.

Become comfortable with saying, "I don't know but here is how we will find out." If you don't know the

answer to a specific question, tactfully turn the question to other members of the group. If none of the

group members know the answer, then an individual may be assigned to search for the answer. Such

questions generated at the bedside during the course of patient evaluation and care are the most useful

and relevant questions for teaching purposes; encourage rather than avoid them. Even without specific

expertise with the particular disorder presented, other skills may be taught at the bedside, including

history taking, demonstration of interpersonal skills, and teaching trainees to be skilled observers. The

bedside teacher's role is transformed into one that focuses attention and generates clinical inquiry.

Lack of Interactive Skills

Faculty physicians themselves may be uncomfortable interacting with certain types of patients. This may

be especially true in the emergency department. In fact some studies have found that most teachers go

to the bedside only to check on abnormal physical findings. As a consequence, bedside time may be

kept to a minimum and trainees may lose the opportunity to observe an experienced clinician in action

with the patient.

Social learning theory emphasizes the learning that occurs by observation and imitation of role models.

From this viewpoint, the quality of the interaction between the attending physician and the patient is

likely to be imitated by the resident in interactions with their own patients. Faculty should practice what

they preach and model the kind of communication patterns they expect residents to use with patients.

Bedside teaching fosters a wonderful link with the past. Trainees watch you as carefully as does a child

his parent; they watch you attend to the patient, watch you observe. They observe your powers of

diagnosis, the respect you hold for other human beings, your attitude, and your caring. Students witness

your own dignity, and the love and enthusiasm you have for medicine and teaching. And so true

mentoring begins.

Components of Good Clinical Teaching

Figure 1

As depicted in Figure 1, the process of clinical teaching can be thought of as two connected cycles each

with a number of components. When teaching at the bedside, the experience cycle will come before the

explanation cycle. The preparation phase involves preparation by both the teacher as well as the

student. Think about what you expect your students/residents to be able to do when you take them to

the bedside. What are they ready for? What is their ability level? These are important considerations

when you plan what you hope to accomplish at the bedside. Learning must be targeted at the level of

ability and knowledge of the student/resident; your teaching goals will be different for learners at

different stages in their clinical training. This may seem obvious, but it is all too often forgotten.

Faculty need to prepare themselves for the experience cycle. First target your learner, and assess their

learning needs. Have a focused, and feasible teaching goal for each clinical encounter. In a busy

emergency department keep these goals simple and do not attempt to teach everything in one

encounter; one or two teaching goals per clinical encounter is appropriate. Save other specific teaching

objectives for the next patient experience. You may have to do a little homework yourself prior to

teaching regularly at the bedside. Refresh your own physical diagnosis skills, develop a set of index

cards or use your Palm Pilot to keep important diagnostic criteria, key references, or specific numbers at

your fingertips. You may even decide to do "theme days" where you may pick a specific physical finding

(type of heart murmur, back pain exam, etc.) or a clinical presentation (cough, abdominal pain, sore

throat, etc.) to focus your teaching on that day. It is then much easier to review appropriate physical

examination techniques, lookup relevant references, and prepare briefly for teaching on your next shift.

The next step in the experience cycle is briefing. Briefing prepares both the patient, and the

student/resident for the clinical encounter. The patient can make a considerable contribution to a

teaching session. As a clinical teacher, set a good example and introduce yourself to the patient and

give the patient a brief indication of the purpose of the bedside encounter. Something as simple as the

following will set the stage with the patient for the rest of the clinical encounter: "Hi, I'm Dr. Hayden and

I'm the doctor in charge of the emergency department today. We're making rounds right now to see how

you are doing. I'm going to have Dr. Sloane tell me briefly what he has learned from you so far and then

we will ask you a few more questions and examine you further. If there is anything you don't understand

just let us know and we will be happy to explain it to you, and feel free to ask questions, or clarify

something for us at any time." All the studies of bedside teaching consistently report that patients prefer

clinical teachers to introduce themselves in such manner, to inform them what the bedside session is all

about, and to translate medical jargon so that they can follow the discussion.

Briefing the student/resident is likewise important. This can be done at the doctor's workstation or just

outside the patient's room. Instructions can be given on what is expected, the rules about what to do

and what not to do, and limits set about how far to go in the encounter. How much does the patient

know about his or her condition? What may or may not be said in front of the patient or family?

Negotiate the rules; what will the resident do? What will the faculty do? If a procedure is to be

performed, the student's familiarity with the technical and cognitive skills may be assessed. What

uncertainties are there in the student/residents' minds, and what questions do they have? Briefing will

make the subsequent clinical encounter go much more smoothly.

During the clinical encounter there are a multitude of teaching goals that may be achieved. Focus

specific goals on the learner's level of experience and limit your teaching to just one or two points. One

of the major goals of bedside teaching is to cultivate the skills of acute observation. As Florence

Nightingale once said, "the most important practical session that can be given is to teach students what

to observe, how to observe, what symptoms indicate improvement and which the reverse, which are of

importance and which are not." Interpretation comes into play only after the features have been carefully

observed and described. The role of the clinical teacher during a clinical encounter is quite variable, yet

however that role is seen, some of the most powerful teaching flows from your own modeling of

politeness, concern, discretion, gentleness, honesty and specific techniques of history taking and

physical examination. The environment should be one of openness and encouragement to both ask

questions and to voice ideas. The teaching skills in this setting lie principally in:

Guiding communication with the patient and explaining clearly to the students/residents

Demonstrating a variety of clinical signs and symptoms and how to elicit them

accurately

Supervising performance and providing gentle but firm feedback

Questioning and challenging interpretations of the data

Modeling professional style with the patient and persistence in obtaining the necessary

clinical information

Before leaving the bedside, solicit questions from the patient about what just happened and what their

understanding is of the diagnostic and management plan.

Debriefing after the clinical encounter allows the clinical teacher to review with the learners what went

on to the bedside. It provides an opportunity to talk about the experience, to express to the teacher how

the clinical interaction was understood, and to raise questions. Additionally, debriefing checks that

appropriate information has been recognized and interpreted accurately. Learning from the case can be

synthesized giving the student a sense of achievement, ensuring resolution of any feelings aroused

during the clinical encounter, and devising learning plans for future interactions.

The explanation cycle begins with reflection, where the teacher and student literally step back from the

immediate experience to link practice with theory, and other evidence that can shed light on the clinical

events. The shift is from "What went on?" to "What did it mean?" Reflection is the time for learners to

think aloud and the teacher's purpose at this stage is to allow free flow of their thoughts, which you help

clarify and link to other learning. Reflection connects this patient with other patients, and with previous

learning.

Explication can be described as a search for how the questions of practice can be helped by biomedical

science and current best evidence. The purpose is to link the clinical experience with theory and

research relevant to the case. Explication may come from journals, textbooks, and clinical experiences

of the teacher and other experts. The rule is that the most current, best available evidence is sought. It

is also valuable at this stage to make assignments for obtaining necessary information including

questions to be asked of the medical literature, or further history from other sources such as family or

private physicians.

The last step in the explanation cycle is the derivation of clinical working knowledge from the clinical

experience. In other words it is "What would I do next time?", "What practical ideas have I picked up

from thinking about this patient?", "What could I have done differently?" The learners create working

rules, or rules of thumb, for use in future practice and clinical teachers guide them through this process.

This practical knowledge then contributes to the preparation for the next patient, which brings us to the

beginning of the next experience cycle.

The Five-minute "Microskills" Model of Clinical Teaching

You are probably saying at this point that this kind of clinical teaching is all well and good but there is no

time in the ED to do this. In an ideal teaching setting, maybe during a "teaching shift" or the equivalent,

all phases of the experience and explanatory cycles can be done in their pure form. In a busy ED,

however, a more condensed version is necessary that still retains key elements of the clinical teaching

process. Such a five-minute model has been developed:

Get a commitment

Probe for supporting evidence

Discuss a "teaching pearl"

Reinforce what was done right

Correct mistakes

Getting a commitment up front involves asking the learner to interpret or synthesize the clinical

information obtained from the patient encounter. It allows the teacher to immediately diagnose the

learner's needs, and gives you a sense whether the student/resident is in the ballpark regarding this

patient's situation. Examples of this are "What do you think is going on with this patient?", "Why do you

think the patient is noncompliant?", "Which of the many complaints will you focus on this visit?" Probing

for supporting evidence takes this a step further by getting learners to reveal their thought processes. It

allows you to identify their knowledge gaps. You might ask "What findings led to your diagnosis?",

"What else did you consider?"

Discussing a teaching pearl gives you the opportunity to introduce key elements of the case in question.

This may include important diagnostic features, appropriate diagnostic testing, a variety of management

issues from an emergency medicine perspective, and current best evidence that pertains to the specific

clinical situation. This pearl, or "teaching bite" should be focused, easily digestible, and targeted to the

learners level of understanding. Examples may include "The key features of this case are...", "In the ED,

when a patient presents with X, your top three priorities are..."

Reinforcing what was done right solidifies the behavior you want from learners. Give specific, and timely

feedback. "Sandwich" constructive criticism between two layers (statements) of positive feedback.

Correcting mistakes is extremely important at this stage. Omissions, errors, misinterpreting data, will

become habit and part of "muscle memory" if not corrected at the time they occur. This should be done

in an appropriate setting. It may not be suitable to correct serious errors in front of patients, nursing

staff, or other students/residents. For example, "Next time that happens, try the following...", "I agree the

patient may be drug seeking, but it is still important to do a careful history and physical examination"

You may not even be able to use this five-minute model on every patient encounter in the ED. Be

selective, choose a limited number of patients of the greatest teaching value during a given shift. You

can listen for clues during the case presentation to select such patients; inconsistencies or confusing

aspects of the history, abnormal findings described on the physical examination, may be clues that this

patient can provide a "teachable moment". Alternately you can ask the student/resident which of their

patients they want to see with you at the bedside making teaching learner-centered. An additional

strategy is to grab one resident (this works with either a senior or junior EM resident) during a given shift

and do periodic bedside rounds on the patients they are responsible for.

Evidence Based Emergency Medicine at the Bedside

Evidence based medicine (EBM) can be defined as asking a focused, relevant clinical question and

answering it based on the best most current evidence available. It is often stated that the place for EBM

is in journal clubs or in reading articles in the library and that there is no time for this approach in a busy

ED. A skilled clinical teacher, however, can bring elements of EBM to the bedside in a busy ED.

At the bedside in the ED, use questions about the history and physical examination for teaching basic

principles of EBM. Take a single item of history or examination and think of it as a "diagnostic test."

Take a combination of history and physical examination features as a clinical prediction rule. It is an

opportunity to discuss concepts such as pretest probability, precision (simple agreement, kappa) and

accuracy (likelihood ratio, positive (PPV) and negative predictive value (NPV)) of diagnostic tests, utility

of diagnostic tests, and using these properties to move from pretest probability estimates to posttest

probability of disease.

Start with pretest probability, use the HPI to establish baseline probability of a given condition. Discuss

where pretest probabilities come from; ideally from well done published studies, or quality assurance

studies done in your own ED, or based on clinical experience. Next focus on the specific elements of the

history or examination. For example, meningismus, Murphy's sign, effort syncope, etc. In your briefing

session review how to elicit the specific findings prior to assessing the patient. After assessing the

patient, review these key elements of history or examination; discuss interrater, and intrarater reliability.

Highlight the difference between simple agreement, and the agreement beyond that due to chance

alone (kappa). You do not have to calculate a likelihood ratio, or PPV/NPV at the bedside to discuss the

accuracy of a diagnostic test. Do your homework and have these numbers immediately available and

show how to use a likelihood ratio to modify the pretest odds and derive a posttest odds of disease that

can then be converted back into posttest probability. Question learners on how further diagnostic testing

will alter disease probability and guide treatment and disposition decisions. For residents at higher

training levels discuss the accuracy of combinations of signs and symptoms derived during a patient

encounter and the management implications of clinical decision rules.

The skilled clinical teacher will not attempt to get through all of these teaching goals for every patient.

Take one concept that seems most relevant to the current patient, and save other concepts for

subsequent similar patients seen in the course of the shift. Choose clinical conditions that you

commonly see in the ED to prepare for. We all see suspected appendicitis, pharyngitis, exacerbations of

asthma, and many other such conditions on a daily basis. The medical literature is replete with articles

on clinical findings for various diseases. When searching the literature use terms such as "physical

examination", "medical history taking", "observer variation", or "interrater reliability". JAMA has a series

called the Rational Clinical Examination that contains this information for many common disease

presentations. Have the likelihood ratios or sensitivity/specificity of various signs and symptoms readily

available for these common conditions. Then when the teachable moment arises you'll be ready to

pounce.

Conclusions

External forces, such as recent CMS regulations, have pushed academic EM faculty into a situation

where we need to spend a great deal of time personally evaluating patients. Rather than lament the loss

of teaching time in the doctors workstation, grease board, or conference room, this is a unique

opportunity to go back to the bedside with our residents and students and teach them firsthand medical

history taking, physical examination skills, clinical acumen, and model professional interpersonal skills

with patients.

This paradigm shift requires that academic EM physicians refine their clinical teaching skills. Learn to

recognize and seize the "teaching moment." Have a number of "teaching bites" readily available to use

when such moments arise. Become skilled at recognizing your learner's knowledge gaps and exploit

them for teaching. Guide learning with high yield questions that require synthesis and interpretation.

Most of all, enjoy the opportunity to learn from your students/residents at the bedside as much as they

learn from you. As Osler stated in his farewell address to The Johns Hopkins Hospital in 1905, "By far

the greatest work of The Johns Hopkins Hospital has been the demonstration to the profession and to

the public of this country how medical students should be instructed in their art. Personally, there is

nothing in life in which I take greater pride than in the introduction of the old-fashioned methods of

practical instruction. I desire no other epitaph than the statement that I taught medical students on the

wards, as I regard this by far the most useful and important work I have been called upon to do."

Suggested Reading

1. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching [see

comments]. J Am Board Fam Pract. 1992;5:419-24.

2. Stone MJ. The wisdom of Sir William Osler. Am J Cardiol. 1995;75:269-276.

3. Cox K. Planning bedside teaching--1. Overview. Med J Aust. 1993;158:280-282.

4. Cox K. Planning bedside teaching--2. Preparation before entering the wards. Med J Aust.

1993;158:355-357.

5. Cox K. Planning bedside teaching--3. Briefing before seeing the patient. Med J Aust. 1993;158:417-

418.

6. Cox K. Planning bedside teaching--4. Teaching around the patient. Med J Aust. 1993;158:493-495.

7. Cox K. Planning bedside teaching--5. Debriefing after clinical interaction. Med J Aust. 1993;158:571-

572.

8. Cox K. Planning bedside teaching--6. Reflection on the clinical experience. Med J Aust.

1993;158:607-608.

9. Cox K. Planning bedside teaching--7. Explication of the clinical experience. Med J Aust.

1993;158:789-790.

10. Cox K. Planning bedside teaching--8. Deriving working rules for next time. Med J Aust. 1993;159:64

11. Sapira JD. The Art And Science Of Bedside Diagnosis. Williams & Wilkins, 1990, Baltimore, MD

Mid-Career Faculty Development

Developing a Career in the Scholarship of Teaching as a Clinician-Educator

Author: Stephen R. Hayden

Introduction

Clinical bedside teaching is nothing new. It was Hippocrates (circa 400 BC) who abandoned temple

based medicine for a practice that valued direct observation, the exact recording of the features of

disease, and adherence to the principal that "You must go to the bedside, it is there alone that you can

learn disease." In his address to the New York Academy of Sciences, Sir William Osler stated that there

should be "No teaching without a patient for a text, and the best teaching is that taught by the patient

himself." Despite this legacy there has been gradual erosion in time spent teaching at the bedside.

Thirty years ago over 75% of medical teaching occurred at the patient's bedside. Several authors have

recently examined the time devoted to attending rounds on inpatient medical services. They estimated

that only 16 - 20 % of the time devoted to attending rounds was spent in the presence of the patient. In

other studies using direct observation or videotaping it was found that the average time spent at the

bedside was only 2 - 3 minutes compared with approximately 60 minutes in the classroom. In 25 % of

instances teachers never saw the patient at all, whether during the case presentation or afterward.

Although a number of studies have shown that approximately 85 % of patients preferred bedside

rounds, only 35 % of attending physicians did so, 4 % of students, and 2 % of house staff.

The emergency department (ED) has always been regarded as a rich environment for clinical teaching

with the wealth and diversity of diseases that present to our doors. Yet most academic emergency

physicians are experiencing intense pressure from external sources to improve the efficiency,

documentation, and cost effectiveness of emergency medicine (EM) practice. I have heard many of my

colleagues lament that this results in less time for teaching residents and students in the ED. If you

believe that the best teaching occurs in the doctors workstation, conference room, or lecture hall then it

is understandable that you would feel this way. I'm going out on a limb here, however, and suggesting

that recent external forces that require attending EM physicians to personally see and examine all

patients in the ED may be the best thing that has happened to clinical teaching in EM. We have been

handed a golden opportunity. As a faculty physician you now need to be there anyway, take a resident,

or student, by the hand and lead them with you back to the bedside where a multitude of teaching

moments can occur.

In this chapter we will discuss characteristics of good clinical teachers, perceived obstacles to effective

bedside teaching, strategies to overcome them, the components of good bedside teaching, and a

number of practical models to use in clinical instruction.

Characteristics of Good Clinical Teachers

There are a number of characteristics that great clinical teachers in medicine share:

Teachers are knowledgeable

Presentations are clear and well organized

They are enthusiastic and able to interact skillfully with students and residents

Provide simultaneous teaching and clinical supervision

Demonstrate clinical skills to learners

Model professional characteristics

Good clinical teachers also display numerous intangible qualities such as:

Being available

Being approachable

Having infinite patience

Staying calm in difficult situations

Osler described this as equanimity, and suggested "In the physician or surgeon no quality takes rank

with imperturbability."

Superb clinical teachers also use effective teaching skills including:

Explaining concepts at the learners level

Providing timely feedback

Modeling their behavior for students

Illuminating how their thought process works

Instructing in small digestible "teaching bites"

Guiding learning with questions

This last item bears repeating: Good clinical teachers guide learning with questions. This means asking

questions that require synthesis and interpretation of information and evidence rather than simple

regurgitation.

Examples of such high yield questions are:

Why do you believe that to be true?

How did you reach that conclusion?

What lead you to that decision?

Why is X approach better than Y?

Why is that information important?

What will happen if you don't do X?

What is the association between X and Y?

Obstacles to Effective Clinical Teaching

Concern for the Privacy and Well-being of the Patient

The argument is often made that to present case histories and physical findings in front of patients, and

possibly their families, would prove embarrassing or uncomfortable to them. On the contrary, the

available evidence suggests that patients are in fact appreciative of the attention being devoted to them

by so many health-care professionals. When conducted tactfully and empathetically bedside

presentation is not a traumatic emotional experience but rather educates and reassures patients. The

overwhelming majority of patients feel that they understand their illness better and have a better

opportunity to get their questions answered. Patients want the attending physician to introduce

themselves, to state the purpose of bedside rounds, and to be sensitive to the need to translate medical

jargon into terms that they can understand.

Medical Chauvinism

Some doctors believe that it is not appropriate to involve patients in the process of making major

decisions regarding their health-care. Consequently this may be responsible for moving case

presentations and discussions away from the bedside. These physicians also do not want to display

weaknesses in front of patients or families in discussing their own problems associated with data

collection, interpretation, and synthesis. Again, the available evidence would indicate that active

involvement of the patient, as well as the patients observation of our deliberations, can lead to an

honest, open, and mature doctor patient relationship where both the physician and patient assume

appropriate responsibility for decisions made.

Passive View of Education

Here the old idiom that education is the transfer of knowledge from teacher to student is applicable. This

view purports that teaching on rounds means a series of mini-lectures by the attending on topics that

happened to arise, often followed by a more lengthy discussion in the doctors workstation, conference

room, or classroom. Trainees support this arrangement since it requires little active work on their part

and conforms to their prior educational experiences as passive listeners in a lecture hall. They are used

to the doughnuts and coffee, the comfort of sitting around a conference table or at a work desk, and the

cloak of early morning or post-meal semiconsciousness. In order to combat this, the skilled emergency

medicine faculty will know how to actively engage the student or resident by guiding learning with

appropriate questions. The attending facilitates group or individual learning by assisting the trainees to

discover for themselves the important clinical issues and develop a strategy to solve the clinical

problem.

Emergency Medicine Faculty Discomfort at the Bedside

Many teachers are uncomfortable discussing subject matter in which they feel less than expert. The

bedside is avoided where the reality of the patient's situation or difficult questions might draw them on to

intellectually thin ice. They prefer the workstation, the conference room, or even worse the hallway,

where they can turn the discussion to subjects with which they are far more comfortable. There will be

no patient and no family in attendance to ask embarrassing questions that force us to say, "I don't

know." Furthermore, there is our discomfiture with physical diagnosis. All of these barriers may be easily

overcome. Create a safe and comfortable environment for asking questions and discussing answers.

Become comfortable with saying, "I don't know but here is how we will find out." If you don't know the

answer to a specific question, tactfully turn the question to other members of the group. If none of the

group members know the answer, then an individual may be assigned to search for the answer. Such

questions generated at the bedside during the course of patient evaluation and care are the most useful

and relevant questions for teaching purposes; encourage rather than avoid them. Even without specific

expertise with the particular disorder presented, other skills may be taught at the bedside, including

history taking, demonstration of interpersonal skills, and teaching trainees to be skilled observers. The

bedside teacher's role is transformed into one that focuses attention and generates clinical inquiry.

Lack of Interactive Skills

Faculty physicians themselves may be uncomfortable interacting with certain types of patients. This may

be especially true in the emergency department. In fact some studies have found that most teachers go

to the bedside only to check on abnormal physical findings. As a consequence, bedside time may be

kept to a minimum and trainees may lose the opportunity to observe an experienced clinician in action

with the patient.

Social learning theory emphasizes the learning that occurs by observation and imitation of role models.

From this viewpoint, the quality of the interaction between the attending physician and the patient is

likely to be imitated by the resident in interactions with their own patients. Faculty should practice what

they preach and model the kind of communication patterns they expect residents to use with patients.

Bedside teaching fosters a wonderful link with the past. Trainees watch you as carefully as does a child

his parent; they watch you attend to the patient, watch you observe. They observe your powers of

diagnosis, the respect you hold for other human beings, your attitude, and your caring. Students witness

your own dignity, and the love and enthusiasm you have for medicine and teaching. And so true

mentoring begins.

Components of Good Clinical Teaching

Figure 1

As depicted in Figure 1, the process of clinical teaching can be thought of as two connected cycles each

with a number of components. When teaching at the bedside, the experience cycle will come before the

explanation cycle. The preparation phase involves preparation by both the teacher as well as the

student. Think about what you expect your students/residents to be able to do when you take them to

the bedside. What are they ready for? What is their ability level? These are important considerations

when you plan what you hope to accomplish at the bedside. Learning must be targeted at the level of

ability and knowledge of the student/resident; your teaching goals will be different for learners at

different stages in their clinical training. This may seem obvious, but it is all too often forgotten.

Faculty need to prepare themselves for the experience cycle. First target your learner, and assess their

learning needs. Have a focused, and feasible teaching goal for each clinical encounter. In a busy

emergency department keep these goals simple and do not attempt to teach everything in one

encounter; one or two teaching goals per clinical encounter is appropriate. Save other specific teaching

objectives for the next patient experience. You may have to do a little homework yourself prior to

teaching regularly at the bedside. Refresh your own physical diagnosis skills, develop a set of index

cards or use your Palm Pilot to keep important diagnostic criteria, key references, or specific numbers at

your fingertips. You may even decide to do "theme days" where you may pick a specific physical finding

(type of heart murmur, back pain exam, etc.) or a clinical presentation (cough, abdominal pain, sore

throat, etc.) to focus your teaching on that day. It is then much easier to review appropriate physical

examination techniques, lookup relevant references, and prepare briefly for teaching on your next shift.

The next step in the experience cycle is briefing. Briefing prepares both the patient, and the

student/resident for the clinical encounter. The patient can make a considerable contribution to a

teaching session. As a clinical teacher, set a good example and introduce yourself to the patient and

give the patient a brief indication of the purpose of the bedside encounter. Something as simple as the

following will set the stage with the patient for the rest of the clinical encounter: "Hi, I'm Dr. Hayden and

I'm the doctor in charge of the emergency department today. We're making rounds right now to see how

you are doing. I'm going to have Dr. Sloane tell me briefly what he has learned from you so far and then

we will ask you a few more questions and examine you further. If there is anything you don't understand

just let us know and we will be happy to explain it to you, and feel free to ask questions, or clarify

something for us at any time." All the studies of bedside teaching consistently report that patients prefer

clinical teachers to introduce themselves in such manner, to inform them what the bedside session is all

about, and to translate medical jargon so that they can follow the discussion.

Briefing the student/resident is likewise important. This can be done at the doctor's workstation or just

outside the patient's room. Instructions can be given on what is expected, the rules about what to do

and what not to do, and limits set about how far to go in the encounter. How much does the patient

know about his or her condition? What may or may not be said in front of the patient or family?

Negotiate the rules; what will the resident do? What will the faculty do? If a procedure is to be

performed, the student's familiarity with the technical and cognitive skills may be assessed. What

uncertainties are there in the student/residents' minds, and what questions do they have? Briefing will

make the subsequent clinical encounter go much more smoothly.

During the clinical encounter there are a multitude of teaching goals that may be achieved. Focus

specific goals on the learner's level of experience and limit your teaching to just one or two points. One

of the major goals of bedside teaching is to cultivate the skills of acute observation. As Florence

Nightingale once said, "the most important practical session that can be given is to teach students what

to observe, how to observe, what symptoms indicate improvement and which the reverse, which are of

importance and which are not." Interpretation comes into play only after the features have been carefully

observed and described. The role of the clinical teacher during a clinical encounter is quite variable, yet

however that role is seen, some of the most powerful teaching flows from your own modeling of

politeness, concern, discretion, gentleness, honesty and specific techniques of history taking and

physical examination. The environment should be one of openness and encouragement to both ask

questions and to voice ideas. The teaching skills in this setting lie principally in:

Guiding communication with the patient and explaining clearly to the students/residents

Demonstrating a variety of clinical signs and symptoms and how to elicit them

accurately

Supervising performance and providing gentle but firm feedback

Questioning and challenging interpretations of the data

Modeling professional style with the patient and persistence in obtaining the necessary

clinical information

Before leaving the bedside, solicit questions from the patient about what just happened and what their

understanding is of the diagnostic and management plan.

Debriefing after the clinical encounter allows the clinical teacher to review with the learners what went

on to the bedside. It provides an opportunity to talk about the experience, to express to the teacher how

the clinical interaction was understood, and to raise questions. Additionally, debriefing checks that

appropriate information has been recognized and interpreted accurately. Learning from the case can be

synthesized giving the student a sense of achievement, ensuring resolution of any feelings aroused

during the clinical encounter, and devising learning plans for future interactions.

The explanation cycle begins with reflection, where the teacher and student literally step back from the

immediate experience to link practice with theory, and other evidence that can shed light on the clinical

events. The shift is from "What went on?" to "What did it mean?" Reflection is the time for learners to

think aloud and the teacher's purpose at this stage is to allow free flow of their thoughts, which you help

clarify and link to other learning. Reflection connects this patient with other patients, and with previous

learning.

Explication can be described as a search for how the questions of practice can be helped by biomedical

science and current best evidence. The purpose is to link the clinical experience with theory and

research relevant to the case. Explication may come from journals, textbooks, and clinical experiences

of the teacher and other experts. The rule is that the most current, best available evidence is sought. It

is also valuable at this stage to make assignments for obtaining necessary information including

questions to be asked of the medical literature, or further history from other sources such as family or

private physicians.

The last step in the explanation cycle is the derivation of clinical working knowledge from the clinical

experience. In other words it is "What would I do next time?", "What practical ideas have I picked up

from thinking about this patient?", "What could I have done differently?" The learners create working

rules, or rules of thumb, for use in future practice and clinical teachers guide them through this process.

This practical knowledge then contributes to the preparation for the next patient, which brings us to the

beginning of the next experience cycle.

The Five-minute "Microskills" Model of Clinical Teaching

You are probably saying at this point that this kind of clinical teaching is all well and good but there is no

time in the ED to do this. In an ideal teaching setting, maybe during a "teaching shift" or the equivalent,

all phases of the experience and explanatory cycles can be done in their pure form. In a busy ED,

however, a more condensed version is necessary that still retains key elements of the clinical teaching

process. Such a five-minute model has been developed:

Get a commitment

Probe for supporting evidence

Discuss a "teaching pearl"

Reinforce what was done right

Correct mistakes

Getting a commitment up front involves asking the learner to interpret or synthesize the clinical

information obtained from the patient encounter. It allows the teacher to immediately diagnose the

learner's needs, and gives you a sense whether the student/resident is in the ballpark regarding this

patient's situation. Examples of this are "What do you think is going on with this patient?", "Why do you

think the patient is noncompliant?", "Which of the many complaints will you focus on this visit?" Probing

for supporting evidence takes this a step further by getting learners to reveal their thought processes. It

allows you to identify their knowledge gaps. You might ask "What findings led to your diagnosis?",

"What else did you consider?"

Discussing a teaching pearl gives you the opportunity to introduce key elements of the case in question.

This may include important diagnostic features, appropriate diagnostic testing, a variety of management

issues from an emergency medicine perspective, and current best evidence that pertains to the specific

clinical situation. This pearl, or "teaching bite" should be focused, easily digestible, and targeted to the

learners level of understanding. Examples may include "The key features of this case are...", "In the ED,

when a patient presents with X, your top three priorities are..."

Reinforcing what was done right solidifies the behavior you want from learners. Give specific, and timely

feedback. "Sandwich" constructive criticism between two layers (statements) of positive feedback.

Correcting mistakes is extremely important at this stage. Omissions, errors, misinterpreting data, will

become habit and part of "muscle memory" if not corrected at the time they occur. This should be done

in an appropriate setting. It may not be suitable to correct serious errors in front of patients, nursing

staff, or other students/residents. For example, "Next time that happens, try the following...", "I agree the

patient may be drug seeking, but it is still important to do a careful history and physical examination"

You may not even be able to use this five-minute model on every patient encounter in the ED. Be

selective, choose a limited number of patients of the greatest teaching value during a given shift. You

can listen for clues during the case presentation to select such patients; inconsistencies or confusing

aspects of the history, abnormal findings described on the physical examination, may be clues that this

patient can provide a "teachable moment". Alternately you can ask the student/resident which of their

patients they want to see with you at the bedside making teaching learner-centered. An additional

strategy is to grab one resident (this works with either a senior or junior EM resident) during a given shift

and do periodic bedside rounds on the patients they are responsible for.

Evidence Based Emergency Medicine at the Bedside

Evidence based medicine (EBM) can be defined as asking a focused, relevant clinical question and

answering it based on the best most current evidence available. It is often stated that the place for EBM

is in journal clubs or in reading articles in the library and that there is no time for this approach in a busy

ED. A skilled clinical teacher, however, can bring elements of EBM to the bedside in a busy ED.

At the bedside in the ED, use questions about the history and physical examination for teaching basic

principles of EBM. Take a single item of history or examination and think of it as a "diagnostic test."

Take a combination of history and physical examination features as a clinical prediction rule. It is an

opportunity to discuss concepts such as pretest probability, precision (simple agreement, kappa) and

accuracy (likelihood ratio, positive (PPV) and negative predictive value (NPV)) of diagnostic tests, utility

of diagnostic tests, and using these properties to move from pretest probability estimates to posttest

probability of disease.

Start with pretest probability, use the HPI to establish baseline probability of a given condition. Discuss

where pretest probabilities come from; ideally from well done published studies, or quality assurance

studies done in your own ED, or based on clinical experience. Next focus on the specific elements of the

history or examination. For example, meningismus, Murphy's sign, effort syncope, etc. In your briefing

session review how to elicit the specific findings prior to assessing the patient. After assessing the

patient, review these key elements of history or examination; discuss interrater, and intrarater reliability.

Highlight the difference between simple agreement, and the agreement beyond that due to chance

alone (kappa). You do not have to calculate a likelihood ratio, or PPV/NPV at the bedside to discuss the

accuracy of a diagnostic test. Do your homework and have these numbers immediately available and

show how to use a likelihood ratio to modify the pretest odds and derive a posttest odds of disease that

can then be converted back into posttest probability. Question learners on how further diagnostic testing

will alter disease probability and guide treatment and disposition decisions. For residents at higher

training levels discuss the accuracy of combinations of signs and symptoms derived during a patient

encounter and the management implications of clinical decision rules.

The skilled clinical teacher will not attempt to get through all of these teaching goals for every patient.

Take one concept that seems most relevant to the current patient, and save other concepts for

subsequent similar patients seen in the course of the shift. Choose clinical conditions that you

commonly see in the ED to prepare for. We all see suspected appendicitis, pharyngitis, exacerbations of

asthma, and many other such conditions on a daily basis. The medical literature is replete with articles

on clinical findings for various diseases. When searching the literature use terms such as "physical

examination", "medical history taking", "observer variation", or "interrater reliability". JAMA has a series

called the Rational Clinical Examination that contains this information for many common disease

presentations. Have the likelihood ratios or sensitivity/specificity of various signs and symptoms readily

available for these common conditions. Then when the teachable moment arises you'll be ready to

pounce.

Conclusions

External forces, such as recent CMS regulations, have pushed academic EM faculty into a situation

where we need to spend a great deal of time personally evaluating patients. Rather than lament the loss

of teaching time in the doctors workstation, grease board, or conference room, this is a unique

opportunity to go back to the bedside with our residents and students and teach them firsthand medical

history taking, physical examination skills, clinical acumen, and model professional interpersonal skills

with patients.

This paradigm shift requires that academic EM physicians refine their clinical teaching skills. Learn to

recognize and seize the "teaching moment." Have a number of "teaching bites" readily available to use

when such moments arise. Become skilled at recognizing your learner's knowledge gaps and exploit

them for teaching. Guide learning with high yield questions that require synthesis and interpretation.

Most of all, enjoy the opportunity to learn from your students/residents at the bedside as much as they

learn from you. As Osler stated in his farewell address to The Johns Hopkins Hospital in 1905, "By far

the greatest work of The Johns Hopkins Hospital has been the demonstration to the profession and to

the public of this country how medical students should be instructed in their art. Personally, there is

nothing in life in which I take greater pride than in the introduction of the old-fashioned methods of

practical instruction. I desire no other epitaph than the statement that I taught medical students on the

wards, as I regard this by far the most useful and important work I have been called upon to do."

Suggested Reading

1. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching [see

comments]. J Am Board Fam Pract. 1992;5:419-24.

2. Stone MJ. The wisdom of Sir William Osler. Am J Cardiol. 1995;75:269-276.

3. Cox K. Planning bedside teaching--1. Overview. Med J Aust. 1993;158:280-282.

4. Cox K. Planning bedside teaching--2. Preparation before entering the wards. Med J Aust.

1993;158:355-357.

5. Cox K. Planning bedside teaching--3. Briefing before seeing the patient. Med J Aust. 1993;158:417-

418.

6. Cox K. Planning bedside teaching--4. Teaching around the patient. Med J Aust. 1993;158:493-495.

7. Cox K. Planning bedside teaching--5. Debriefing after clinical interaction. Med J Aust. 1993;158:571-

572.

8. Cox K. Planning bedside teaching--6. Reflection on the clinical experience. Med J Aust.

1993;158:607-608.

9. Cox K. Planning bedside teaching--7. Explication of the clinical experience. Med J Aust.

1993;158:789-790.

10. Cox K. Planning bedside teaching--8. Deriving working rules for next time. Med J Aust. 1993;159:64

11. Sapira JD. The Art And Science Of Bedside Diagnosis. Williams & Wilkins, 1990, Baltimore, MD

The Role of the Chair in Promotion

Author: Bill Barsan

Introduction

The departmental chair plays a critical role in facilitating promotion at any academic medical center. It is

fair to say that the chair's responsibilities for a) clearly defining the criteria for promotion and b)

objectively evaluating faculty members each year, will be the key elements in achieving promotion. This

applies to promotion in not only the research or tenure track but the clinician educator track as well. In

this chapter, I have defined the key roles played by the chair as determination of department balance,

recruitment, resource allocation, evaluation and support for promotion. Although other chairs may

define the roles somewhat differently, I think that most would include all of these areas somewhere in

their summary of key roles.

Determination of Departmental Balance

In overseeing the entire department, the chair should attempt to determine the appropriate balance

between research or tenure track faculty and clinician educator faculty. Some of the factors, which will

impact this balance, would include not only the individual needs of the department but also the

academic milieu in which the department exists. In general, it is advisable to have the Department of

Emergency Medicine look similar to other academic departments within the medical school in regard to

the proportion of tenure track and clinical track faculty. Currently, this is not always the case. A survey

from 1997 showed that only about one-third as many emergency medicine faculty members are

tenured compared with faculty members in other specialties at the same institutions. The department

chair also has to consider the different administrative roles to be performed within the department. In

general, roles with heavy administrative responsibilities are not going to be appropriate for faculty

working towards tenure as these responsibilities will not enable enough time for the faculty member to

pursue any meaningful research program. The other issue of departmental balance relates to any

specific research interests for prospective faculty. In general, it is preferable to match up research

interests with research expertise. For example, if a prospective faculty member had research involving

neuronal cell cultures and nobody in the institution or the department had any experience with neuronal

cell cultures, that faculty member's chance for success in that research area would be limited. Ideally,

the chair should try to recruit young faculty with similar research interests to experienced researchers

already in the department or in the institution.

The Recruitment Process

The chair's role is obviously critical and pivotal in the recruitment process. In addition to selecting the

prospective faculty member on personal, clinical, research and balance concerns, the chair also needs

to clearly define where a prospective recruit fits in. Specifically, the chair should identify during the

recruitment process whether the prospective faculty member will likely be a clinical track or tenure track

faculty member. The chair will also have to give the prospective recruit the definitions and factors

critical to achieving promotion in the different tracks. The chair can't assume that a recruit will have any

automatic understanding of these issues. The criteria for promotion and tenure and the different tracks

available vary widely from institution to institution and need to be clearly defined in each individual

circumstance. At the completion of the recruitment process, both the chair and the prospective faculty

member should have a clear idea of the prospective faculty member's role in the department, which

academic track they will pursue and the critical elements for success in that particular track.

Provision of Resources

The area of resources is frequently cited as the most important responsibility of the chair toward faculty

promotion. The most important resources provided by the chair for faculty are financial support for

research, adequate time and mentors.

The amount of financial resources committed towards an individual faculty member will depend on the

academic track as well as the specific area of research. In general, clinician educator faculty members

typically need little, if any, allocation of financial resources over and above traditional commitments of

CME monies. For faculty members pursuing a tenure track, a commitment of financial resources is

critical. The general approach taken by many academic departments at the University of Michigan is

that the department is responsible for providing financial resources to pay for the first two years of a

faculty member's research, after which period of time the faculty member should start to procure some

extramural funding to support further research. For people involved in laboratory research, this

commitment of two years funding may be quite expensive. Additionally, laboratory researchers will

need a laboratory to perform their research and adequate facilities in the lab to conduct the type of

research to be performed. In some circumstances this may mean fully outfitting a departmental

laboratory and in other circumstances, the faculty member may be able to work in laboratories with

individuals from other departments.

Providing adequate time for faculty to meet their requirements for promotion and tenure is critical and

has always been a hot topic in academic emergency medicine. Although there are no hard and fast

rules, it is generally assumed that working more than 22-24 clinical hours per week will not be

compatible with achieving promotion in the research track. Besides this limitation in clinical hours, the

chair needs to make sure that the faculty member is not loaded up with other duties during their non-

clinical time. The faculty member in the tenure track should for the most part limit their non-clinical

activities to pursuing their research and should not assume major departmental roles like assistant

program director, EMS director, operations director, etc. The chair should be responsible for working

with the faculty member to limit these other responsibilities. Another way to increase a faculty

member's efficiency with limited time is to provide some ancillary support. This may be in the form of

secretarial support or laboratory technical support or providing monies to hire students or others for

tasks such as data entry, chart abstraction, etc.

Perhaps the most important item that a chair can provide to a young faculty member is a mentor.

Particularly for individuals in the research or tenure track, a mentor or mentors play a very important

role. These individuals can advise and direct the young faculty member on their research as well as

help them with grant writing and development of new areas for research. The mentor should be a

senior faculty member at the associate professor level or higher and one who has significant expertise

and hopefully evidence of extramural funding in the faculty's area of research. Although some faculty

members are able to identify their own mentors, it is critically important that the chair help them find a

mentor if they don't already have someone in mind. One of the common practices in emergency

medicine is to team up young faculty with mentors exclusively in your own department. Because

emergency medicine is still a relatively young field and there is a paucity of tenured faculty members, it

is advantageous to locate mentors outside of the department as well. In most major academic medical

centers, there are a number of tenured faculty members in other departments with research interests in

different areas. Many of these individuals are more than willing to serve as mentors for junior faculty

from EM. The quality of research and personal characteristics of the mentor are far more important

than the department in which they have their primary appointment. For faculty in the clinician educator

track, it is usually easier and makes more sense to have mentors from within the department. Often this

may end up being the chair but could easily be other senior faculty members as well.

Evaluation

After the faculty member clearly understands the requirements for promotion and is equipped with

appropriate mentorship and any needed start up money, the faculty member's job is to try to fulfill the

needed requirements for promotion. The chair's role in this process is to perform timely evaluations

either once or twice a year and help the faculty member track his/her progress toward achieving

promotion. A yearly conference is an opportunity for the chair to work with the faculty member to set

goals for the coming year and track whether or not the faculty member is appropriately progressing

towards completion of his or her goals in eventual promotion. If a faculty member is having difficulty in

meeting the goals that have been set, the chair needs to work with the faculty member to decide

whether the goals are unrealistic, there is a resource issue, or other issues affecting the faculty

member's performance. It is important that these yearly assessments be realistic and the goals

reachable. Particularly for instructional or tenure track faculty members, it's extremely important for the

chair to let the faculty member know whether or not they are on track for eventual promotion at the end

of the required time or whether this will be difficult or impossible.

The Promotion Process

Ultimately, the department chair will have to make the determination of when a faculty member should

be put up for promotion. This is obviously not a unilateral decision and will need the input of the

individual faculty member as well. The yearly evaluations of the faculty member should usually include

long term plans for when promotion will be sought so that the decision of when to go for promotion is

not a surprise. In addition to determining whether or not the faculty member is ready for promotion, the

chair typically will have to write a support letter that highlights the ways in which the faculty member

has reached the criteria necessary to be promoted. It is ultimately the chair's responsibility to make

sure that supporting documentation is present in the promotion packet as required by the institution.

Request for promotion will typically be reviewed by a departmental promotions committee prior to

review by the institution's promotions committee. The department chair needs to be sure that the

departmental committee has knowledgeable individuals who can sufficiently evaluate each promotional

recommendation. Because emergency medicine is a new specialty and there may be a relative lack of

senior faculty members, it may be advisable to have one or two "guest" members from other

departments who have more extensive knowledge and experience of the promotions process in that

institution.

If the chair believes that a given faculty member is worthy of promotion and this is supported by the

departmental committee, there may be occasions where the institution's promotions committee will vote

not to promote the individual. In cases where the chair believes that the institution's promotions

committee is overlooking some important information, he or she should not be reluctant to appeal the

committee's decision. In circumstances where a faculty member is being heavily recruited elsewhere

and the decision not to promote could affect a decision to stay, most promotions committees will take

this under serious consideration in their decision.

In cases where promotion is denied, the promotions committee will typically give their reasons for

denial. In those cases, it is the chair's job to work with the faculty member to try to correct the

deficiencies present prior to resubmitting for promotion.

Conclusion

While the specifics of the promotion process may vary from institution to institution, the chair will play a

key role in helping faculty to achieve promotion. The faculty member's responsibility is to work with the

chair and develop a plan, which will be successful. The chair's job is make sure the faculty member

clearly understands the requirements for promotion, has the necessary resources to perform the work

required and advice on the progress and timing of promotion.

Advanced Degrees for Academic Emergency Physicians

Author: Gregory P. Conners

Why would an academic emergency physician want a graduate degree? Phrased differently: will the

career enhancement be worth the investment of time and money? The pressures of day-to-day life can

make obtaining a graduate degree difficult. Clinical and family schedules may seem overwhelming and

inflexible; additional tuition bills will certainly be unwelcome. The ultimate answer, of course, will vary for

each individual. The purpose of this chapter is to help you determine the right answer for yourself.

Medical school and residency provide excellent foundations for the clinical practice of emergency

medicine. However, although expectations vary, the academic physician is typically expected to be not

only a top-notch clinician, but an excellent teacher, a productive researcher, and to take on various

administrative assignments. While any and all of these may be learned on the job, an advanced degree

is a way to rapidly develop proficiency in one or more of these areas. Less obviously, being a graduate

student provides contacts with graduate faculty and other students. This networking may lead to new

ideas, collaborations, and other opportunities. Finally, having an advanced degree may serve as an

additional credential, providing credibility in a competitive academic world. Similar arguments may be

made about fellowship; in fact, it is not uncommon to pair fellowship with pursuit of an advanced degree,

such as an M.P.H.

Graduate study requires a considerable investment of time, money, and energies, whether full- or part-

time. Graduate programs require reading, homework, studying for tests, and, often, preparation of final

projects. The vagaries of grades may be ego-challenging. We can always find another way to

productively use our time, our most precious resource, whether it is in enhancing our academic careers,

moonlighting, or spending time with our families and friends. On the other hand, investing in graduate

study now may make the career-oriented time we spend in the decades to follow more productive. For

example, graduate training may allow us to approach and smoothly and effectively complete a complex

project or goal that previously might have been difficult or even impossible.

Location and availability of graduate training are also important considerations. Those working in a

university setting or a large city may have easy access to a wide variety of relevant graduate programs;

others may not. Fortunately, high-quality distance learning programs are now available in many fields,

and are growing steadily. Judging relative quality of graduate programs, whether distance learning or

traditional, is difficult. Annual rankings compiled by the U.S. News & World Report, while imperfect, may

be of interest http://www.usnews.com/usnews/edu/beyond/bcrank.htm; the website also offers links to

some ranked programs.

Some strategies have emerged from academic emergency physicians who have successfully obtained

graduate degrees. First and foremost, you will need to focus. Just as in medical school, you will need to

marshal your energies when it is sometimes difficult, and will need family or other social supports.

Having an idea of your ultimate goal, whether it is a successful career in academic emergency medicine,

commanding a military hospital, or a medical school or hospital leadership position, can help keep you

motivated. Those who successfully obtain graduate degrees while conducting academic careers

typically describe having made their commitment to graduate study an important part of their lives.

Although a few become full-time students, most try to carve out time for part-time study while a full-time

faculty member (or fellow). This is probably most easily accomplished when you are beginning a new

job, and still apportioning your time to various areas. However, the benefits of graduate training are not

limited to those beginning their careers or changing jobs. In fact, it is not uncommon to initiate graduate

training a few years into an academic career, spurred perhaps by realizing that, while you are truly

interested in having a successful academic career, it is not going as well as you would like. Academic

physicians may believe that proposing graduate study will be negatively received by departmental or

medical school leadership. However, department chairs and deans may develop an interest in training

to properly conduct the large-scale projects that their positions now make available.

Another important strategy is to remember that not all the time and money to be invested must be your

own. Some academic positions offer tuition benefits as a standard benefit (when it is job-related, tuition

benefits are not subject to federal income tax, at least right now). Whether you are just starting out,

changing jobs, or even if you are an established faculty member, consider negotiating, along with salary

and other considerations, a graduate degree package, typically including such features as clinical

flexibility or tuition reimbursement. A sabbatical, perhaps funded by the SAEM Scholarly Sabbatical

Grant, may also provide an opportunity for graduate education. Remember, your department chair and

dean sincerely want you to succeed, and a graduate degree may make the difference. Be sure to point

out how your new degree will enhance your academic career and the department in general; no chair

will want to spend scarce discretionary funds to help you make more money in industry.

A third strategy is to make school work do double or triple duty. For example, if you take a course on

decision analysis, use it to analyze an important clinical problem, then present your work at a national

meeting and publish it in the medical literature, while improving your own practice. If you do a research

thesis, use it as a way to learn new techniques, to work with accomplished senior collaborators, and to

publish at least two papers (a literature review based on the background information you have gathered,

and an original research paper). Many who adopt this policy are surprised to find their academic

productivity actually going up while obtaining an advanced degree, due to the focused, deadline-driven

nature of the course work. Similarly, if supervised teaching is part of your graduate degree program, try

to teach a course that will meet faculty teaching requirements, or at least enhance your standing with

your department chair or dean. If your initial negotiations for financial or time backing with your

department chair were unsuccessful, a few such academic successes may provide an opportunity for re-

negotiation.

A final strategy: try to do something you enjoy. If you are uncertain, try enrolling in a course or two

before committing to a degree program. You may find yourself drawn to unexpected areas, and may

ultimately dramatically alter, and enhance, your career. If you dislike it, at least you can get out early!

Discussion of three areas of particular interest, public health, administration, and education, follow. They

offer general as well as specific ideas in those areas. Reading this chapter may offer insights to those

interested in pursuing any of these or even a different field all together. Because the time commitment

required to earn a doctoral degree is typically difficult (but not impossible!) to reconcile with an ongoing

academic career, the majority of the discussion is geared to those seeking certificate or Master's degree

training, but the information will also be of interest to those considering doctoral programs. Those who

have further questions after reading the discussions should seek advice from others who have earned

graduate degrees. Degree program directors often have experience and insight regarding the

application of their training that is unavailable elsewhere; it is always worth meeting with a potential

program director well before formally applying to a program.

Public Health

The most common graduate degrees obtained by academic emergency physicians are probably in

public health. Most popular is the Master of Public Health (M.P.H.) degree, but there are many

variations, including Master of Health Science (M.H.S.), Master of Science in Public Health (M.S.P.H.),

Master of Science in Clinical Epidemiology (M.S.C.E.), or Master of Science in Health Services

(M.S.H.S.). Doctoral programs in such related areas as epidemiology, health services research, and

health policy are also widely available. Certificate programs are also available, leading to non-degree

training in specific topics.

The variety of master's level programs in public health and related areas is incredible, especially for

those more familiar with lock-step M.D. and residency programs. From general surveys of public health

to those with a specialized area of focus and requiring a thesis, the M.P.H. degree can represent a wide

spectrum of training. This allows great freedom for emergency physicians to study what interests them

the most. Programs will typically have core courses in biostatistics, epidemiology, environmental health

sciences, health services administration, and social and behavioral sciences; these are the five areas of

knowledge considered basic to public health and required for accreditation by the Council on Education

for Public Health (CEPH). Enrolling at an M.P.H. program that is accredited by CEPH (or its equivalent

in related fields) is preferable, as accredited programs must maintain demonstrated high quality to meet

the standards. Advanced coursework is typically available in all these five areas as well, along with

other upper-level courses that reflect the strengths of each program. These may include such diverse

areas as informatics, public policy, international health, ethics, maternal & child health, health care

policy, and many more. Spending some time at the CEPH web site, www.ceph.org, which has links to

accredited programs, will provide insight into what is available both in your area and around the United

States.

The tendency go directly from residency to an academic faculty position can put emergency physicians

at a disadvantage when competing in the academic realm. Having an M.P.H. can help you overcome

some of these disadvantages, both by actual improvement in academic skills and by having an

additional credential. Since so many academic emergency physicians do clinical research without

specific training, an advanced degree in public health can pay off by providing important skills in the

design and conduct of clinical research. This will lead to better research which is likelier to lead to actual

improvements in the field of emergency medicine. Grant proposals made by an emergency physician

with an M.P.H. are also likelier to be funded, both because of the additional formal credential and

because formal or informal training in grant-writing may be part of the curriculum.

Although mentorship is crucial to academic success, many academic emergency physicians have

trouble finding suitable mentors. Public health training provides access to successful medical scholars,

some of whom will be willing to collaborate with and mentor an emergency physician working to

establish an academic career. Also, do not forget that fellow students may also be looking for

collaborators; many are already accomplished in their specific areas, or may be members of successful

research teams that would love to add a hard-working academic emergency physician with public health

training to their group. Their access to patients in the acute phases of illness make emergency

physicians attractive to many research efforts; those with abilities in research design and conduct are

especially valuable.

There are two typical venues for studying public health: graduate schools of public health, and graduate

programs in community health/preventive medicine. The latter are typically based in a department of a

medical school; some are based in a school of health and human services, allied health, or the like.

National rankings of public health school-based programs may be found at the U.S. News & World

Report website, www.usnews.com/usnews, by clicking the "education" tab, then looking at graduate

school rankings for public health. Given their scale and focus, the schools of public health usually offer a

richer array of public health programs. Smaller-scale programs, however, should not be overlooked, as

they may offer excellent educational opportunities in areas of specific interest, and lots of flexibility. For

those at a distance from any programs, quality distance learning programs, such as the "career MPH"

offered by the Rollins School of Public Health at Emory University, are available

www.sph.emory.edu/CMPH/index.html.

Management and Leadership

As much as any medical specialty, and more than most, emergency medicine requires physicians to be

adept clinician-managers. There are numerous opportunities for those interested in going beyond

patient-level management to take on a variety of Emergency Department administrative tasks, such as

clinical directors, division chiefs, department chairs, EMS director, and quality managers, as well as

hospital- and medical school-level leadership positions. As emergency medicine matures, an increasing

number of leadership positions will go to those with management experience and specific training. Many

of these will be physicians whose academic careers have led them to leadership positions for which

they would like to become better-trained; thus, a mid-career investment in a management degree is

becoming increasingly common.

There are numerous benefits to formal management training. Although there is a role for a combination

of innate ability and on-the-job training in management and leadership, graduate training is widely

available and perhaps a more reliable path to successful leadership, whether specifically in Emergency

Medicine or elsewhere in health care. Far from learning how to sell used cars or take advantage of HMO

customers, management training focuses on such areas as understanding systems, budgeting

resources, strategic planning, and aligning incentives. Academic emergency physicians address these

sorts of issues regularly, giving even the most general business management training a feeling of

relevance and immediate usefulness in daily academic practice. However, a caveat often mentioned by

management authorities is worth repeating here. Those seeking to escape from the business aspects of

the practice of modern medicine by going into health care leadership will almost certainly be even more

dissatisfied with management jobs. Therefore, those seeking leadership / management will be happiest

and the most successful if they do so as a means of achieving a goal rather than avoiding the pressures

of clinical practice.

Graduate training in administration and leadership is available at two levels. A wide variety of non-

degree "certificate programs" offer introductions to management principles for health professionals or

instruction in specific health-related leadership or management topics. These programs are typically

offered at university medical schools, business or management schools, or schools of public health.

They are generally expensive. Most offer CME credits; some double as introductory courses for formal

degrees. Notable examples of certificate courses include the wonderful offerings in health care

leadership of the Harvard University School of Public Health www.hsph.harvard.edu/ccpe/. Although

most are site-based, several distance learning programs are available. For example, the University of

South Florida has a distance learning Business of Medicine Certification Program for physicians, which

may be extended into a distance learning executive M.B.A. for physicians program

www.coba.usf.edu/programs/docs/.

It is important for potential physician managers to be aware of The American College of Physician

Executives (ACPE). This organization of more than 12,000 physician managers offers a wide variety of

distance learning and conference-based educational programs in medical management. Distance

learning formal degrees are also available to its members. These include the Master of Medical

Management (M.M.M.) degree, in conjunction with either the University of Southern California, Tulane

University, or Carnegie Mellon University www.acpe.org/Degrees/index.htm. A Master of Science in

Administrative Medicine (M.S.A.M.) program is also available, in association with the University of

Madison-Wisconsin Medical School www.medsch.wisc.edu/adminmed/.

Formal management degree programs, both health care specific and in general management, are

widely available. Most common is the Master of Business Administration (M.B.A.), which may be general

or have a health care concentration. Several other health care management degrees are also available,

depending on the curriculum and university preference. These include the M.M.M. or M.S.A.M. degrees

as noted above, Master in Health Administration (M.H.C.A.), and the like. An interesting variation is the

Master of Public Administration (M.P.A.), Master in Health Care Administation (M.H.C.A.), and the like.

An interesting variation is the Master of Public Administration (M.P.A.) degree; New York University, for

example, has a highly-regarded M.P.A. program with a specific focus in Health Policy and Management

(see www.nyu.edu/wagner/programs1.html). A national ranking of programs in health care

administration is available at http://www.usnews/com/usnews click on the "education" tab, then search

the graduate schools listings. Many physicians seeking management training, however, prefer to enroll

in programs without a specific health care focus, either in general management (usually an M.B.A.) or

with an emphasis in another area, such as marketing or finance (M.B.A. or M.S. degree). For some, this

is a specific decision to obtain more flexible, general training; many find that such a program may simply

be the most convenient.

Since a full-time degree is often impractical and part-time study may take several years, the two-year

executive M.B.A. format has become popular for physicians. Both general M.B.A. and health care-

oriented executive M.B.A. programs are available. For example, the Olin School of Business at

Washington University offers both general and health services management executive M.B.A. programs

www.olin.wustl.edu/execed. Classes typically meet on Fridays, alternate weekends, or some similar

schedule, and have significant team-based non-class assigned projects. Although they are rigorous,

graduates of executive programs often speak highly of their training.

Education

The role of the Clinician-Teacher in the academic medical center is being increasingly recognized.

Curriculum re-design and sophisticated educational objectives and assessments are becoming

common. As the rewards for medical school teaching excellence and leadership slowly become greater

and more apparent, more academic physicians are finding formal graduate training in education an

attractive choice. Those with formal educational training are in an excellent position to conduct research

into educational interventions and their assessments. The wide variety of teaching methods and the

availability of learners at all levels in academic medical centers offer many opportunities for research

that can truly improve medical education and practice. Formal educational training may make those

seeking administrative advancement especially good candidates for clerkship or residency directorships,

or even dean-level positions, both at the medical school and university levels.

Master's degrees in education are widely available, and vary widely in quality. Along with general

educational offerings, university schools of education typically offer specialized training that may be of

particular interest to academic physicians, such as the M.S. in administration with a concentration in

higher education available at the University of Rochester's Warner School of Education and Human

Development www.rochester.edu/Warner/programs/elhigher1.html. Those seeking excellent short-

course experiences may be interested in the Harvard Macy Institute Program for Physician-Educators

and Program for Leaders in Medical Education www.hms.harvard.edu/oed/macy/. Additionally, many

medical schools and universities offer faculty development seminars in teaching the adult learner, an

area in which many of us can improve.

Summary

Advanced graduate education has much to offer the academic emergency physician, but requires time,

energy, and commitment. Those interested in more rewarding or effective academic careers and those

seeking administrative advancement may find a formal graduate degree program an enjoyable and

effective tool in achieving these goals. Along with the degree itself, the process of graduate education,

such as interactions with other students and faculty, will be beneficial. The academic emergency

physician with well-established goals and an advanced degree is in an excellent position for future

academic success.

Acknowledgments: Thanks to E. John Gallagher, M.D, Sandra M. Schneider, MD, and Frank L.

Zwemer, Jr., MD, MBA for critical readings of drafts of this chapter.

Making the Move From Regional to National Prominence

Author: Arthur L. Kellermann

What is "national prominence"?

Many promotion and tenure committees require candidates for promotion to the rank of Associate

Professor level to achieve "national prominence" in their field. Virtually all promotion and tenure

committees require achievement of "national prominence" for promotion to the rank of Professor.

Unfortunately, there are no explicit criteria for what constitutes "national prominence". Perhaps the

best definition for "national prominence" is the one given by Justice Hugo Black of the U.S. Supreme

Court when he was asked to define the term "pornography" – "I know it when I see it".

How is "national prominence" determined?

Since national prominence is subjectively defined, identifying it requires the concurrence of a majority

(if not a consensus) of the group of individuals who is tasked with the responsibility of weighing the

merits of faculty promotions at your institution. At most hospitals or universities, this group is known as

the "Promotions and Tenure (P&T) Committee", or some closely related term.

When you are ready for promotion, you will be asked to prepare a packet of information that includes

an up-to-date CV, perhaps a copy of your teaching portfolio, and 2-5 representative reprints of articles

you have authored or co-authored. This packet will be accompanied by a "Chairman's letter" that

presents a succinct case for why you merit promotion. If you belong to a "Division" or a "Section" of

Emergency Medicine in another clinical department rather than in an autonomous academic

department of EM, your division or section chief will most likely write this letter for your department

chair. The task of writing this letter will be much easier if you can provide concrete evidence that you

have made, and are making, an impact on Emergency Medicine at a national level.

The vast majority of the members of institutional Promotions and Tenure (P&T) committees are drawn

from departments other than the candidate's own. To validate your chair's assertion of the value of

your contributions, most P&T committees will ask senior EM faculty at other institutions to

independently evaluate the significance of your work, and your prominence in your field. This creates a

paradox for most EM chairs and faculty members. While the demands of academic EM are great

(clinical shifts, student and residency lectures, mentoring, and departmental and hospital committee

work) these efforts don't count as much as they should when it comes time for promotion. The blunt

truth is that giving an excellent lecture given at a national meeting or another medical school counts far

more towards establishing your "excellence in teaching" and "national prominence" than giving the

same excellent lecture at your own institution! This leads to the following warning: if you spend all of

your professional time and energy working inside your institution for your own department, and are not

well known outside your own institution, you may encounter difficulty gaining promotion beyond the

rank of Assistant Professor. As a department chair, I can assure you that it is very hard to claim that a

member of my faculty has achieved "national prominence" in his/her field if the faculty member has not

taken the time to become visibly involved in specialty activity at a national level.

What do you need to do to achieve "national prominence"?

Fortunately, achieving national prominence in Emergency Medicine is not as hard as it sounds.

Academic EM is still a fairly small club. There is plenty of room for anyone who wants to get involved in

organizational activities at a regional or national level. The number of "alphabet soup" national EM

organizations (e.g., ACEP, SAEM, ABEM, CORD, AAEM, NAEMSP,) is large, and insures ample

opportunities for you to get involved. . Given the meritocracy of Emergency Medicine at the national

level, anyone with talent, energy and commitment can quickly gain entry to the national scene.

There are several ways you can achieve regional and/or national prominence:

1. Show up – Given the crazy schedules that most Emergency Physicians work, it takes a

considerable amount of effort to cluster your free days together in order to attend a state, regional or

national meeting. Do it. You won't get known outside your institution if you don't make an effort to meet

your colleagues at regional and national professional meetings.

2. Speak up – If you have something to say at a meeting, say it. If you have a special interest or

expertise that an EM organization can use, offer it. At academic meetings like SAEM, making periodic

trips to the microphone to ask cogent questions or offer useful insights is a good way to increase your

visibility and become engaged in the intellectual discourse of the meeting. Like anything else, this can

be overdone. Don't hog the microphone!.

3. Volunteer – Committee assignments can be a blessing, or a curse. Service on a national committee

or task force is a great way to meet colleagues from around the country and become better known. If,

however, you are not careful, committee work can become a tremendous drain on your time and

energy. Beware of becoming overextended by volunteering for too many assignments, or getting

drawn into a long or complex project that has little hope of success. If you are unsure of what to do,

consult a senior colleague or ask your chair.

4. Network – It is fairly easy to get placed on a committee or task force; all you have to do is submit a

written expression of interest within the time frame requested by the organization. You can enhance

your chances by asking your chair, chief, or a key faculty colleague to lobby on your behalf, or by

contacting the chair of the task force directly. If you know a board member of the organization, they

may be able to speak on your behalf. Emergency Medicine is a remarkably egalitarian organization.

Those of us who are fortunate enough to have reached a position of leadership within EM haven't

forgotten what it was like to be a resident or a new faculty member. We are very approachable. If you

don't know a colleague who are active at a national level, the odds are great that your chair, chief, or a

faculty colleague does – work through them to secure the support you need.

5. Produce – It is not enough to show up and volunteer. You also have to produce. If you undertake a

research project, produce high quality work. If you accept assignment to a national committee, you are

duty-bound to follow through on your assignments and responsibilities, including showing up at the

meeting and participating in conference calls. If you don't, the likelihood that you will be picked for

future service will be markedly diminished. Committee and task force chairs are generally selected

from the ranks of committee members who have logged the time, followed through on their

assignments, demonstrated initiative, and acquired the experience they need to be effective leaders.

6. Focus – Emergency Medicine, by its very nature, is broad. In addition to maintaining your clinical

and teaching skills, you should try to develop concentrated expertise in one or at most a very limited

set of topics. Most of the leading figures in academic EM are respected for their expertise in a

relatively focused area of knowledge. Figure out what you want to be known for, and develop your skill

and/or expertise in that topic or area of endeavor. Once you have acquired in-depth knowledge of the

issue, you will be ready to publish one or more high-quality case reports or review articles on the topic,

give national-quality lectures at other programs or national venues, and initiate research to expand

your (and the specialty's) understanding of the issue.

7. Present your work – Presenting a research abstract at a national meeting is fun and ego-enhancing.

It is also a great way to earn a spot on your program's "traveling squad"! Preparing interesting didactic

sessions at SAEM or a strong course at ACEP Scientific Assembly, Winter Symposium, or another EM

organization's annual meeting is a great way to boost your visibility and add "national talks" to your

CV. Don't overlook opportunities to present at International meetings. While they carry a particular

mystique and often impress P&T committees, it is typically easier to get a paper accepted at one of

them than it is at a competitive national meeting like SAEM! The reason this is true is that the

organizers of these meetings are often highly dependent on registration fees to fund the event. Since

they know that few people will incur the time and expense to fly across the ocean to simply "attend"

their meeting, they generally accept most (if not all) submitted papers to boost attendance. The

downside for you (and your program) is cost. Don't be surprised if your chair has a stroke when you

ask for program support to present a paper at a meeting in Europe or Asia. My advice is to float the

idea in advance.

8. Publish your work – Presenting papers and posters at national meetings is fun, but the effect is

transient. The only way you will make a lasting contribution to Emergency Medicine is by publishing

your work in a peer-reviewed journal. The same can be said for the written product(s) of many

organizational committees and task forces. If one of the objectives of your committee is to produce a

report, position paper, or other document, make sure you make enough of a contribution to warrant

inclusion as a co-author, if not the lead author. In addition to raising your national visibility, publications

are essential to meet another criterion for promotion – demonstrating at least "adequacy" in

scholarship (see related chapter: Why do Research?).

9. Persist – Few of us were lucky enough to succeed the first time out. Don't be discouraged if your

first abstract or manuscript is rejected, if you lose an election (all of us have), or you are passed over

for a committee or task force. Learn what you can from the experience, be gracious in defeat, and try

again. .

10. Maintain balance – If you want to succeed in academic emergency medicine, you have to stay in it

for the long haul. High-quality research can take years to produce. Leadership roles in EM

organizations can take even longer. If you try to take on too many projects, or tackle too much too

soon, you will burn out and abandon the quest.

11. Help others along the way – As you begin to climb the ladder of academic success, don't overlook

opportunities to advise, mentor or help others. Remember all of the favors done for you, and extend

the same courtesy for those who come behind you. Seek to advance the careers of your colleagues,

whether they work at your institution or at another program. By helping others freely and willingly, you

will advance the interests of emergency medicine, and make countless friends. Someday, they (or

their friends) may be in a position to repay the favor. One more thing – if you achieve national

prominence in EM, the day will come when you will be asked by a "Promotions and Tenure"

Committee from another institution to provide written comments on the merits of promoting a worthy

colleague. If that happens (and once it does, it will happen again and again) give this and all

subsequent requests the same level of care and attention that senior EM colleagues gave your

promotion.

12. Don’t forget your colleagues back home – Once you achieve a measure of national recognition,

don't be surprised if this stirs jealousy or resentment among your colleagues back home. To minimize

the likelihood of this happening, freely acknowledge their role in your success, make sure you carry

your share of the load, and use your newly won recognition for the good of the program. If you are a

"name" that applicants to your program will recognize, make sure you help on interview days. If you

get time off to attend a national EM meeting, make a point of repaying your colleagues when they

need time off for special trips or family activities. If you are rewarded with a reduced clinical load

(a.k.a., "protected time") to conduct research or participate in national activities, make sure that you do

your fair share of nights, evenings and weekends.

13. Don’t forget your family at home – Travel is exciting and service to national organizations is a real

ego trip, particularly when both are new. There is a great danger, however, in letting success go to

your head. Take the time to count the number of nights and weekends that you spend traveling, and

add them to your night and weekend shifts. This is the amount of time you are away from your family.

Too many organizations expect their leaders to sacrifice their families or their most important

relationships to the job. It is a bogus and self-defeating expectation. It is up to all of us to redefine the

terms of "success" so that gifted academic emergency physicians can contribute to the specialty and

achieve "national prominence" without sacrificing those who make it all worthwhile.

Conclusion:

Academic Emergency Medicine rarely pays as well as comparable efforts in private practice, but it

offers rewards that more than offset this economic difference. One of them is the satisfaction of

teaching – whether it involves medical students, EM residents, rotating house staff from other

specialties, paramedics, or professional colleagues through continuing education. Another reward is

the opportunity to push the boundaries of the specialty through basic and applied research. A third is

the opportunity to travel, both nationally and internationally, with the attendant opportunity to interact

with energetic and visionary colleagues who share your values and ideals. Finally, academic EM offers

an opportunity to make a difference – whether it is locally, regionally, nationally or internationally – and

in the process, earn recognition for your contributions. In short, academic EM offers a ready path to

achieving "national prominence" in your field – along with the satisfaction, and the opportunities, that

this brings. .

Opportunities for Faculty Development in National Organizations

American Academy of Emergency Medicine

Author: Robert McNamara

Introduction

The American Academy of Emergency Medicine (AAEM) was founded in 1993 primarily to address the

needs of the clinical emergency physician and to promote the importance of Board Certification in

Emergency Medicine. Our current membership is approximately 3,500 and we have expanded our

mission by providing educational offerings, political representation, and practice assistance to

emergency physicians. There are numerous opportunities for faculty and leadership development

available to the academic emergency physician.

Educational Programs

AAEM offers a yearly Scientific Assembly that is geared to the level of the practicing board-certified

emergency physician. For example the 2002 offering included:

1. Airway Management Course - covers difficult airway, new techniques and equipment.

2. Ultrasound Course - comprehensive 11.5 hour course with live models.

3. Pediatric procedures course - advanced techniques, hands on instruction.

4. Tour of a CA vineyard - designed to enhance your status at medical staff dinners.

Teaching Opportunities

AAEM offers another venue for national speaking engagements at our Scientific Assembly. In addition,

we have partnered with the European Society for Emergency Medicine to initiate biannual conferences

in the Mediterranean region. The first held in Stresa, Italy in September 2001 was a huge success.

Currently, we are planning a conference for 2003 in Barcelona. Opportunities also exist for teaching at

our board review courses.

Publications

AAEM has recently created, in conjunction with Emedicine, an internet-based textbook for laypersons

where authorship roles are available. The Journal of Emergency Medicine is our official journal. In

addition to traditional scientific articles we seek articles and editorials related to the AAEM mission. As

an example, JEM recently published an article about our joint effort with SAEM and CORD regarding

resident moonlighting. Our national newsletter, Common Sense, and the California chapter's California

Journal of Emergency Medicine are also open for submissions. AAEM periodically publishes

monographs for the membership and is willing to review ideas for such products.

Leadership Roles

Promotion committees are always impressed with national society leadership roles and such roles can

raise one's stock in the eyes of the medical school leadership. AAEM is notable for its open path to

leadership roles. Through our one member, one vote system open pathways exist for leadership in

national AAEM and our state chapters (currently organized in CA, TX, LA, WI and starting in FL and

OH). We have a standard complement of the requisite committees and pride ourselves on responding to

member input by quickly formulating task forces to address specific items. For example, we recently

created a task force to examine the use of thrombolytics in acute stroke. A message to info@aaem.org

is all it takes to be considered for these roles. On the more traditional side, AAEM appoints two

Associate Editors for the Journal of Emergency Medicine and an Editorial panel for our newly developed

charting template.

Appointment/Liaisons

As a national organization, we receive frequent requests to send representatives to interdisciplinary

meetings/working groups and rather than select from an "insider" pool we generally solicit nominations

directly from the members via e-mail.

Other Opportunities

1. Annual resident research forum - members participate as abstract reviewers and judges.

2. State Chapter creation - if ambitious we are always looking for folks to create new state chapters. We

have laid out the requisite steps in a document you can request.

American Board of Emergency Medicine

Author: Robert Hockberger

THE AMERICAN BOARD OF MEDICAL SPECIALTIES

The concept of board certification in medical specialties (ie, the administration of a single standardized,

nationwide examination to graduates of training programs in a specific medical discipline) began in the

United States with the establishment of the American Board of Ophthalmic Examinations in 1917. The

specialties of Otolaryngology, Dermatology and Obstetrics and Gynecology soon followed suit. In 1933,

representatives from these specialty boards participated in a conference with the American Hospital

Association, the Association of American Medical Colleges, the Federation of State Medical Boards, the

American Medical Association Council of Medical Education, and the National Board of Medical

Examiners. As a result of that conference, the American Board of Medical Specialties (ABMS) was

founded with the mission of "maintaining and improving the quality of medical care by assisting member

boards in their efforts to develop and utilize professional and educational standards for the evaluation

and certification of physician specialists."

By 1949, all existing medical specialties were represented within the ABMS. In 1969, the ABMS

introduced the concept of periodic recertification, i.e., periodic retesting to assess continued

competence over time. In 1999, the ABMS organized an effort of its member boards to develop the

components of a maintenance of certification program to promote lifelong learning and improvement in

clinical practice over time. The components of the program are:

1. Evidence of professional standing.

2. Evidence of a commitment to lifelong learning and involvement in a periodic self-assessment process.

3. Evidence of cognitive expertise.

4. Evidence of evaluation of performance in practice.

Each board is currently developing its own maintenance of certification program using these

components. Individual boards may implement their programs as early as 2003.

THE AMERICAN BOARD OF EMERGENCY MEDICINE

The American Board of Emergency Medicine (ABEM) became the 23rd member-board of the ABMS in

1979. This was accomplished with the support of the American College of Emergency Physicians, the

University Association for Emergency Medicine (now the Society for Academic Emergency Medicine)

and the American Medical Association. Over the past two decades, ABEM has become a recognized

and respected member of the ABMS due to its development of both oral and written examinations that

are based upon a scientific analysis of the practice of emergency medicine (i.e., the Emergency

Medicine Core Content), its use of high-quality research to assess and improve the validity and reliability

of its examinations, and its willingness to play a leadership role in innovations pioneered by the ABMS.

ABEM plans to implement its maintenance of certification program, termed the Emergency Medicine

Continuous Certification (EMCC) Program, in 2004.

Mission and Purpose

The mission of ABEM is "to protect the public by providing and sustaining the integrity, quality, and

standards of training in and practice of emergency medicine."

To accomplish that mission, the purposes of ABEM are scientific and educational and include

the following:

To improve the quality of emergency medical care;

To establish and maintain high standards of excellence in the specialty of emergency

To improve medical education and facilities for training emergency physicians;

To evaluate specialists in emergency medicine applying for certification and

recertification (soon to be continuous certification);

To grant and issue to qualified physicians certificates or other recognitions of special

knowledge and skills in emergency medicine and to suspend or revoke same;

To serve the public, physicians, hospitals, and medical schools by furnishing lists of

those diplomats certified by ABEM.

To accomplish these purposes, ABEM participates in the following endeavors:

The development and administration of certification, recertification and residency in-

service examinations.

The development of a continuous certification program with an expected

implementation date of 2004.

The conduct of research to assess and improve the reliability and validity of its

examinations.

The performance of an ongoing longitudinal study of emergency physicians to

determine those factors that promote and detract from a successful and satisfying

career in emergency medicine.

The annual publication of demographic information about emergency medicine

residency programs.

The contribution of proposed changes to the Special Requirements for Emergency

Medicine that are used by the Emergency Medicine Residency Review Committee to

accredit training programs.

The analysis of proposals to develop combined training programs and subspecialties

within the field of emergency medicine.

The participation in joint endeavors with other emergency medicine organizations to

benefit the field of emergency medicine.

Opportunities for Involvement

Item Writer

ABEM annually administers certification, recertification and residency in-service examinations using a

databank of approximately 7,000 items (questions) that is constantly being updated and expanded by a

team of item writers. Item writers are expected to write 24 questions per year. They meet with the exam

editors and staff each summer at a retreat where new item writers are trained and all item writers are

given feedback on their performance during the previous year.

Item writers are appointed by the Test Development Committee, based upon recommendations of

committee members; however, individuals are welcome to send CVs and letters of interest to the

committee for consideration. To be eligible for appointment one must 1) have successfully completed an

ACGME-or RCPSE-approved emergency medicine residency, 2) be an ABEM diplomate for at least 5

years, and 3) be actively involved in the practice of clinical emergency medicine. Experience and

background in medical writing is also considered. Item writers are appointed for a 3-year term, and may

seek reappointment for a total of 2 terms.

Oral Examiner

ABEM annually administers two oral examinations using a pool of trained examiners. The qualifications

for appointment as an oral examiner are the same as those for item writers. Nominations most often

originate as suggestions from current examiners and directors of the board; however, individuals may

apply directly by submitting a letter of interest, current CV and brief description of their clinical practice

to the chair of the Test Administration Committee. For a nomination to be considered it must be

supported by a current or senior director of the board.

Oral examiners are appointed for a 3-year term, and may seek re-appointment for a total of 3 terms.

During the appointment period, examiners are expected to be available to participate in at least one of

the two 4-5 day examinations that are administered annually in the spring and fall. Examiners are

provided with training and feedback about their performance, and also participate in the data collection

phase of the board’s ongoing quality control of its examination.

Oral Examination Team Leader

Team leaders supervise a "team" comprised of 8-12 examiners at each oral examination. They train

their team to administer the examination cases, monitor the performance of those individuals, and

provide them with appropriate feedback. They also participate with the chief examiners and staff in

reviewing the cases at the end of each examination. To be selected as a team leader an examiner must

have 1) participated as an examiner on all 3 examination teams, 2) received consistently good

evaluations for their performance as examiners, and 3) exhibited a high level of medical knowledge and

leadership skills through their participation as examiners.

Senior Oral Case Reviewer

Senior oral case reviewers are periodically selected to review, update and edit oral examination cases.

They often present their recommendations to a case review panel that convenes at each oral

examination. These individuals are selected from the current pool of oral examiners.

Case Selection Panel Member

The Test Administration Committee selects one team leader each year to participate in the selection of

cases to be administered at the following year’s examinations.

Case Development Panel Member

The board periodically selects several individuals to participate with members of the Test Development

Committee in developing new cases for the oral examination. These individuals are selected from the

current pool of team leaders and oral examiners. Each participant is expected to develop several cases

using real patient encounters from their own practice and the board’s guidelines for case development.

All panel members then participate in a meeting to discuss, modify and finalize the cases, which are

then field tested at subsequent examinations.

Subspecialty Subboard or Examination Committee Member

ABEM has collaborated with several other boards to develop subspecialties in Medical Toxicology,

Pediatric Emergency Medicine, Sports Medicine, and Undersea and Hyperbaric Medicine. ABEM

appointees to subboards or subspecialty examination committees must be board certified in the

particular subspecialty. Nominations are usually submitted by the individual subboards or by ABEM

directors. Sub-board members develop the examinations for subspecialty certification and

recertification, review candidate subspecialty applications, and recommend examination and training

standards.

Director

Individuals selected to be ABEM directors must be residency-trained and board certified in emergency

medicine and, in the opinion of current board members, possess the knowledge and expertise

necessary to help the board accomplish its mission and purpose. New directors are elected by current

board members from a slate of nominees submitted from either a sponsoring organization (ACEP,

SAEM or the AMA) or by the ABEM Nominating Committee.

Directors are elected for a 4-year term, and are eligible for reelection for a second term. They are

expected to serve on one or more of the board’s committees or task forces, and to attend the semi-

annual 5-day board meetings that take place in the summer and winter. Some of the directors serve as

liaisons to the sub-boards, many participate as team leaders and chief examiners for the examinations,

and most participate in presenting the "ABEM Presentation to Training Programs (PTP)" to emergency

medicine residencies throughout the country.

ABEM’s major committees include the Credentials Committee, the Test Development Committee, the

Test Administration Committee, and the Academic Affairs Committee. ABEM’s current task forces

include the Oral Examination Task Force, the Maintenance of Certification Task Force, and the

Presentation to Training Programs Task Force, the Longitudinal Study Task Force, and the Residency

Information Task Force. Directors serve as ABEM’s representatives on joint task forces with other

emergency medicine organizations in efforts to advance the specialty. Recent examples include the

Emergency Medicine Core Content Task Force and the Scope of Training Task Force. Directors also

serve on ABMS committees and as representatives to the AMA.

Senior Director

Current directors become senior directors following their terms of appointment on the board. Senior

directors may participate in the PTP program, may be selected by the board for appointment to the

Emergency Medicine Residency Review Committee, and may be supported by the board in ongoing

involvement within the ABMS.

A Final Thought

ABEM’s Longitudinal Study shows that the major factors that promote career satisfaction in emergency

medicine are 1) emergency medicine residency training, 2) perceived low levels of stress and fatigue

(largely related to the particular job that one chooses), and 3) the perception that emergency medicine is

exciting and challenging (largely related to "keeping up" medically and "getting involved" in emergency

medicine outside of one’s clinical practice). Involvement with ABEM or other emergency medicine

organizations not only benefits those organizations in their efforts to develop and advance our specialty,

but also benefits the individual by creating a sense of accomplishment within an environment that

promotes the development of strong personal and professional relationships that are often lifelong and

sustaining.

American College of Emergency Physicians

Author: Robert Schafermeyer

The American College of Emergency Physicians (ACEP) believes that the support of academic

emergency medicine is essential to the success of the residency programs, of the faculty and,

ultimately, to the success of the specialty. ACEP currently provides the following programs or activities

for faculty development.

Teaching Fellowship

For over 10 years ACEP has implemented the teaching fellowship program. The program is a 12-day

course covered in two separate sessions (August and March). Session topics include instructional

system design, curriculum development, effective teaching methods, evaluation methods, the RRC-EM

process, funding and grantmanship, mentoring and research, scientific writing and publishing, and life

management skills. The program is designed for faculty in residency programs who want to improve

their skills, for residents interested in an academic career, and other physicians who have responsibility

for teaching emergency medicine. This program is updated regularly based on evaluations and needs

assessment.

Research Training

The Emergency Medicine Basic Research Skills (EMBRS) workshop is a 4 year-old program that was

developed for junior faculty with limited research experience. Also, it was developed for physicians in

academic and community medical centers who are interested in research but have little training in

research basics, for physicians involved in mentoring young researchers, and for fellows in non-

research fellowships. The workshop is a 12-day course covered in two separate sessions (November

and April). Edward A. Panacek, MD, MPH, FACEP, is the course director. Topics include design basics

for clinical research, research methods, statistics, IRB and informed consent, presenting research, grant

writing, and finding funding sources. This program is updated on a regular basis, similar to the one

utilized for the teaching fellowship.

Research Forum

This annual program, held in conjunction with ACEP's Scientific Assembly, provides a forum for

researchers to discuss original emergency medicine research. The program includes oral and poster

presentations as well as a moderated session on the best and most interesting scientific presentation.

The Emergency Medicine Foundation (EMF) presents awards for the best paper and for the young

investigator. The awards support emergency medicine faculty and residents in their academic

achievement efforts.

National Case Presentation Competition (CPC)

The finals competition is sponsored by CORD, SAEM, EMRA and ACEP. Cases are presented by

emergency medicine residents and then discussed by residency program attending physicians.

National Faculty Teaching Award

This annual award honors up to 10 outstanding emergency medicine faculty. This award is designed to

support emergency medicine faculty in their academic efforts, particularly for emergency medicine

faculty in tenure track positions. The award is based on significant contributions in the traditional

academic areas of clinical teaching, lecture presentations at their institution and at a state and regional

level, research, specialty society and community service.

Emergency Medicine Foundation (EMF) Grants

EMF provides several $50,000 career development grants, a $50,000 established investigator award,

and several $35,000 research fellowship grants each year. The career development awards are

intended for emergency medicine faculty at the instructor or assistant professor level who need seed

money or release time to begin a promising research project. They are designed to be career launching.

The $50,000 established investigator award is intended to fund projects by established researchers who

may wish to try a pilot project or undertake research in a new area.

The $35,000 research fellowships are designed for emergency medicine residency graduates who will

spend another year acquiring specific basic or clinical research skills and further didactic training in

research methodology.

Advocacy Policies

Through its collaborative efforts with other emergency medicine organizations and through its Academic

Affairs Committee activities, ACEP develops policies that support residency programs and faculty.

Examples of current activity include collaboration with CORD on development of a residency closure

process, and in conjunction with SAEM development of a policy on faculty sabbaticals. ACEP has

wellness policies on family leave, physician impairment, and shift work.

ACEP supports legislative and regulatory efforts through activities in the Washington, DC office. The

office monitors graduate medical education legislation to identify key issues, to introduce legislative

efforts, to amend pending legislation and to coordinate efforts with the AAMC and SAEM. The office

regularly responds to the Health Care Finance Administration (HCFA) through public comment letters

and through meeting with officials at HCFA.

All of these programs and advocacy efforts are provided to enhance the academic faculty's ability to

enhance their career and to provide quality emergency medical residency training.

Society for Academic Emergency Medicine

Author: Brian J. Zink

Overview of SAEM

The Society for Academic Emergency Medicine (SAEM) is the largest academic organization in

emergency medicine (EM). SAEM was formed by the 1989 merger of the University Association of

Emergency Medicine and the Society for Teachers of Emergency Medicine. Approximately 2,100 of the

5,000 members of SAEM are active members who hold faculty positions at the nation's academic

emergency medicine programs. About 2,000 are resident members, and the remainder are medical

student and associate members. SAEM's Executive Headquarters in Lansing, Michigan, are staffed by

an Executive Director and a staff of about 5-6 people. The Society sponsors Academic Emergency

Medicine, a journal of peer-reviewed EM literature.

The SAEM Board of Directors, consisting of 11 elected members, is responsible for developing policies

and meeting the Society's mission of "improving patient care by advancing research and education in

emergency medicine". The work and activities of SAEM primarily take place through the Board of

Directors and the committees, task forces, and interest groups of the organization. Currently, there are

16 committees and task forces, and 27 interest groups. Interest groups vary from a minimum of 20

members up to over 100 members. The SAEM committees and task forces are responsible for carrying

out the yearly objectives that are developed in conjunction with the Board of Directors. Each of the

objectives involves a process or activity that relates to advancing research or education in the specialty.

The interest groups have a looser structure and develop their own objectives. Interest group projects

may range, for example, from attempting to influence federal policy in their area, to developing

educational products, to conducting multi-center research investigations. Interest groups serve as

breeding grounds and think tanks for innovative academic ideas.

The Annual Meeting

Each year SAEM sponsors an Annual Meeting that is the world's largest forum for the presentation of

original research in emergency medicine. The meeting also highlights educational presentations,

programs and projects. A variety of sessions each year are targeted toward the developing faculty

member; this might include a grant-writing workshop, a luncheon with senior researchers, a didactic

session on statistics, a teaching skills session, or a panel discussion on how to become involved in

health policy. The Meeting is an excellent time for networking with academic emergency physicians from

other programs, and for receiving advice and counsel from more experienced academicians. A large

amount of Society work also takes place at the Annual Meeting. Committees, tack forces, and interest

groups meet, organize, and initiate their work for the year.

Faculty Development Opportunities in SAEM

SAEM can play a key role in an individual's faculty development. The spectrum of SAEM involvement

can extend from simply reading the Society's journal, Academic Emergency Medicine and attending

didactic sessions at the Annual Meeting, to being elected to serve on the Board of Directors. As an

emergency medicine faculty member develops and seeks promotion, one common requirement for

advancement to the Associate Professor level is documentation of scholarly activity on a national level.

While this can occur through a faculty member's specific research and educational activities, it can also

occur through serving an important role in a national academic organization like SAEM.

A Stepwise Guide for SAEM Involvement

For those faculty who may be interested in career development that includes active SAEM involvement,

I would propose the following steps. This process does not happen overnight - it may take 5-10 years to

complete the steps listed below.

1. Become a member, subscribe to and read Academic Emergency Medicine, and the SAEM

Newsletter, and visit the SAEM website, www.saem.org. A great deal of information on the organization

and opportunities for academicians is found in these sources.

2. Attend and participate in the Annual Meeting. Ideally this will start as a resident physician. The Annual

Meeting is a great opportunity to get to know national figures in EM, and to network and interact with

peers and colleagues and mentors in the areas of research and education. Presentation of an abstract

or educational project at the Annual Meeting will increase a faculty member's standing in academic EM,

and will often result in that person being brought into a sphere of like-minded academicians.

3. Interest group involvement - Most young faculty members will define an area of research or

educational interests. En route to developing expertise in this area, the faculty member will have to get

to know the leaders in the focus area, and become familiar with their work. One good way to do this

within SAEM is to become involved in an interest group in the focus area. SAEM has 27 interest groups,

which cover a wide spectrum of topics and areas. Most junior faculty can find one or more interest

groups that deal with their academic interests. If an interest group does not exist for the faculty

member's area of interest, it is possible for a faculty member to start an interest group by finding 20

other members who are willing to pay the interest groups dues and initiate a new interest group. The

SAEM Executive Office can help with this process. There is no selection process for interest group

members, and the only requirement is the payment of a modest dues fee. It is possible for a junior

faculty member to rise to a leadership role in most interest groups within a few years by being an active

and eager participant. Some interest groups have committees and sub-committees, and heading up one

of these can be a good administrative experience. SAEM interest group involvement often provides a

young faculty member the opportunity to establish a mentor relationship with someone who is at a

different institution, and may have unique insights and experiences.

4. Committee and Task Force involvement - The next step to becoming more involved in the workings of

SAEM is to become a committee or task force member. Each year a committee and task force interest

form is sent out to SAEM members. Members submit their name for consideration to the President-Elect

who selects committee and task force rosters. The potential committee member is asked to describe

why he or she is interested in the particular committee, and what they could bring to the committee. The

President-Elect will attempt to have broad and diverse representation on committees and task forces.

Each year about 1/3 of the committee and task force rosters are turned over to allow participation of

new members. Surprisingly, fewer than 10% of active SAEM members submit a committee or task force

interest form. Therefore, the chances of being named as a committee or task force member are fairly

good. Table 1 lists the current SAEM committees and task forces. Since committee and task force

members normally do not serve more than 3 years, it is important to be an active, involved committee

member. The work that is done by members of the SAEM committees and task forces is voluntary, and

must be begged, borrowed, or stolen from other academic time. This makes it a challenge for even the

most well-meaning members to actively participate and results in relatively few people doing much of

the work of the Society. A high level of interest and hard work by a committee member counts as much

as experience, and it is possible for the committee member, even at a relatively junior level, to be able

to become a sub-committee chair, or even to be recommended as the next chair of the committee.

Therefore, those members who are able to work harder and put in more time than the average member

are usually "rewarded" with more responsibility.

5. Chairing a Committee or Task Force - After a period of distinguished service as a committee or task

force member, the next step is to chair a committee or task force. Usually a direct discussion with the

President-Elect is needed to determine if this position would be possible or appropriate as the faculty

member is moving up within the Society. As chair of a committee or task force, the faculty member

assumes greater responsibility for meeting the objectives that are laid out each year. This normally

involves the completion of projects, such as an educational product, position paper, or development of a

policy statement. By serving as chair, the faculty member develops administrative skills in managing a

fairly large and diverse group of committee or task force members. The Chair must also work with a

Board of Directors liaison and the Executive Office. Excellent communication skills are obviously an

important prerequisite to holding this position. It is difficult to estimate the number of hours that are

spent carrying out the duties of a SAEM committee chair, but it probably falls in the range of 5 to 20

hours per month.

6. Holding an Elected Position in SAEM: The elected positions in SAEM are as follows:

President

President-Elect

Board of Directors Members

Secretary/Treasurer

Nominating Committee Members

Constitution and By-laws Committee Members

Those who wish to be considered for elected positions must be nominated or nominate themselves to

the Chair of the Nominating Committee, who is the President-Elect. All nominations are considered by

the Nominating Committee, and the nominees are notified if they have been selected as candidates.

Most members who are nominated for these positions have made a progression in the Society from

committee or task force members to leadership positions on committees or task forces, to this next step.

Most members who are nominated for the Board of Directors will have chaired committees or task

forces, and have an excellent working knowledge of the organization. The duties of elected positions

vary considerably. Members of the Nominating Committee and Constitution and By-laws Committee will

have periods of relatively heavy work during the year, but the amount of work involved is not nearly as

much as for the President, President-Elect, Board of Directors, and Secretary/Treasurer. The Board of

Directors and Officers commit significant amount of time to SAEM activities. The reward for this time

commitment is the acquisition of a national understanding of the workings of academic emergency

medicine, and the establishment of contacts and acquaintances that can be valuable assets throughout

ones career.

Summary

The developing EM faculty member can utilize SAEM in a number of ways to promote his or her career.

This can range from scholarly activities in research and education at the Annual Meeting or Regional

Meetings to participation in scientific and educational projects in interest groups, to administrative work

within the SAEM. It is a simple process to become involved in SAEM, and once a member becomes

acquainted with the organization, it is not difficult to progress within the Society to play a larger role. By

following the above steps, with a little extra work and a positive, collaborative approach, it is possible for

almost anyone to become a significant contributor to the organization. This type of work gives the

member a national perspective that help in research and education activities, and will also be valuable

when the promotion and tenure are considered.

Career Longevity & Strategies for Continued Growth & Success

The Rank of Associate Professor. . . How to Get There

Author: Brooks F. Bock & Gloria J. Kuhn

The rank of Associate Professor is a laudable goal and worthy of the necessary efforts required to

achieve it. Physicians working within an academic environment will find that promotion brings not only

prestige but is also public acknowledgement of substantial contribution to the knowledge, education and

service within one's discipline. This recognition adds to the respect of the department and specialty in

which one works. The academic community understands well the concept of promotion. It is the "coin of

the realm" in which academicians have chosen to reside.

In practical terms, promotion makes a faculty member more mobile if he or she chooses to pursue an

academic position in another institution. It helps with negotiating protected time because it suggests

productivity. It is particularly useful when working with faculty members from other departments.

Assistant Professors are "junior faculty" while those with the rank of Associate Professor or Professor

are "senior faculty." This seniority carries weight in collaborative efforts with faculty members from other

departments.

Unfortunately, those who have spent a lifetime in academic practice and never achieved promotion are

viewed with suspicion simply because their accomplishments have not been recognized and rewarded.

This suspicion is best exemplified by the fact that inability to attain promotion results in dismissal from

some, but not all, universities after a certain period of time.

Those who are productive and capable, which most of us are, can achieve promotion by continuing to

do the things we do and adding some planning and forethought to our activities. Ideally, this plan should

be a first step in faculty development.

Faculty often experience promotion to the rank of Associate Professor within an LCME accredited

Medical School as the most difficult academic step on the promotion and tenure continuum. The

purpose of this chapter is to aid faculty members in planning their careers with the goal of successful

attainment of the rank of Associate Professor.

The Promotion and Tenure Process

Almost all Medical Schools initially appoint accredited residency program graduates at the Instructor or

Assistant Professor level. After this, the promotion/tenure (P/T) process is unique to each individual

institution.1 This variability should encourage each faculty member to read their institution's by-laws,

learn about the promotion process, and understand what constitutes scholarly activity within their

academic environment.

Medical School faculty are generally evaluated, and therefore promoted, on the basis of three major

activities; teaching, other academic activity, and service (which, in many institutions includes clinical

expertise). The P/T committee is made up of faculty members who have already achieved promotion

and may be tenured. These individuals are charged by the institution with the task of insuring that all

faculty who are promoted have achieved expertise in an academic area, are excellent teachers, have

fulfilled service requirements, and have contributed in a meaningful way to the mission of the institution.

In the past, this meant that a faculty member had to become a successful researcher as demonstrated

by grants funded from external, preferably national, sources and authored a number of peer-reviewed

original contributions. Overwhelming weight was given to original research compared to teaching and

service.

A revolution is taking place in the academic community. Today many institutions are recognizing and

accepting the concept of "expanded scholarship" as articulated by Ernest Boyer.2 As Boyer noted, while

the scholarship of discovery (original research) is vital to the academic community it needs to be

expanded by the scholarships of integration, application, and teaching. It is often in these three latter

types of scholarship that clinical faculty members excel. This expanded view has opened the way for

clinical faculty to achieve deserved recognition and reward for their work and contribution to their

institutions.

The P/T committee has always required documentation of productivity and demonstration of expertise,

but the value awarded to teaching and service has increased and the type of activity recognized as

scholarly has broadened. What has not changed is the need for excellence and expertise. There is

recognition that clinical and teaching excellence are not scholarship until shared with the academic

community outside of one's own institution.3,4 This sharing usually takes the form of published

materials. The University of Allegheny has stated, "…teaching excellence and innovation are not

scholarship until they are made public in some form where other educators have access to them…"

Many institutions now recognize published curricula, videotape, and software, in addition to peer

reviewed articles, as suitable evidence of scholarship. The degree to which these materials may be

used in support of the promotion/tenure process remains institution-specific.

To accommodate this change in philosophy, many institutions have formed "tracks" for faculty. Each

track has different requirements and guidelines for promotion. The exact titles of the tracks may vary by

institution and there may be divisions within tracks to accommodate unique roles. Still, there are

generally two or three broad tracks that are universally recognized.

One, identified as a Research-Educator track is intended for individuals of doctoral rank in both basic

science and clinical departments with a major career commitment to basic science or clinical research

that is likely to result in funding by peer-review granting agencies. Such individuals are provided with

protected time to pursue their research interest and to participate in teaching and service activities.

The second track, identified as the Clinician-Educator track is intended primarily for clinical faculty and

represents a scholarly academic track of equal stature/status as the Research-Educator track. Research

and service activities are expected. This track emphasizes and recognizes the unique role of the

clinician-educator at the forefront of faculty within the School/College of Medicine.

The third track, identified as the Research track is designed for individuals of doctoral rank with a career

dedicated to research. These faculty members are provided with time and space to carry out their

research objectives and are generally funded by national peer-review agencies. Teaching and service

activities may not be required but some contribution to the intellectual ambience of the academic

community is expected. The promotion process varies by university. Many institutions combine these

three options into two tracks: The so-called traditional track, with an emphasis on research, either

clinical or basic science, and the clinical track, which may include both the clinician-educator and

clinician-researcher career paths.

Some general guidelines for success are useful. The press of clinical responsibility combined with the

significant expectation of a university P/T committee mitigates against advancement of clinically oriented

faculty like those in Emergency Medicine. It is therefore vital that faculty members carefully plan their

careers and manage their time appropriately. Being a "jack of all trades" is interesting but not particularly

useful when your portfolio is placed before a peer-review committee. This committee looks for evidence

of excellence and focus in an area of academic endeavor.

Appropriate scholarship has traditionally been evidenced by publications of original research in peer

reviewed journals. Research focus in a particular area is highly desirable and increases the potential for

external grant support and promotion. Many institutions will only award tenure to those who can

demonstrate ability to obtain funding through outside grants. The expanded view of scholarship now

enables articles that are not based solely on the discovery of new scientific knowledge to be used when

attempting to demonstrate productivity and excellence in scholarship. Examples include published

curricula, syllabi, and multimedia materials that have been used for teaching.

Excellence in teaching is demonstrated through the acceptance of major teaching responsibilities that

are completed successfully. Student and resident evaluations play a major role in this area. Frequently,

institutions judge teaching excellence through peer evaluation. Teaching awards, both internal and

external to the home institution, carry great weight as proof of excellence.

Anticipated service activity includes evidence of peer recognition as an academic professional at the

regional and/or national level as well as willingness to accept and effectively assume administrative and

committee responsibilities. Faculty members may demonstrate clinical excellence by documenting the

application or integration of innovations in medical practice and describing these in teaching or printed

material. In all instances, objective evidence of excellence in the performance of professional activities,

specialty board certification, and membership in appropriate selective professional organizations is

expected but is not, in and of itself, sufficient to obtain promotion.

It is crucial that physicians read their institutional by-laws. Ideally this should be done during the initial

interview process when applying for a faculty position. The by-laws determine how faculty are promoted

and rewarded within the academic community. It is also important to find out if the institution has an

active faculty development program.

Academically oriented emergency physicians should understand the consequence of accepting a tenure

track appointment. This environment generally requires the physician to achieve promotion within a

finite period of time or seek employment elsewhere. The advantage of this system is that pressure is

placed on the department to ensure promotion and the department chair not only becomes expert in

helping faculty accomplish the tasks that are necessary, but also is closely involved in monitoring

progress. Conversely, the faculty member may feel a great deal of pressure to engage in research,

obtain grants, and publish in peer-reviewed journals.

Non-tenure track positions don't usually involve specific time frames for promotion. Thus, the chair may

not monitor faculty performance leading to promotion as carefully as s/he would monitor tenure track

faculty. Additionally, the faculty member may not feel the same amount of pressure to be promoted and

so may not work as hard in the scholarly arena.

The following questions are useful in assessing the potential of promotion within a specific department.

1. How many faculty members have been promoted in the department?

2. Does the Chair help faculty manage time so that scholarly activities can be accomplished?

3. Has a mentoring program been created within the school and/or department to support faculty

development?

4. Is adequate secretarial support available?

5. Will financial support to attend educational meetings be available?

A mentoring program is crucial as research has shown that faculty members who have mentors achieve

a higher rate of promotion within the academic community. However, the most important variable is

time. If the clinical commitment is very heavy and the clinical schedule onerous it takes an extremely

dedicated, committed, and organized individual to succeed in meeting the scholarly requirements

necessary for promotion.

A job description and duties should be part of one's contract. The amount of clinical service required

should be clearly stated. Additionally, evaluations conducted by the chair should state clearly whether

the faculty member has fulfilled all obligations so that s/he remains on track for promotion.

Planning for Promotion

The aspiring faculty member needs to develop a plan, generally formulated in conjunction with his/her

Chair, to determine what will be expected prior to being recommended for promotion to the Associate

Professor level. As mentioned, this plan may involve a time clock. This is especially true in institutions

whose by-laws demand that all faculty members be tenured. This clock is usually set for between seven

to nine years. This means that the faculty member must complete all of the requirements for promotion

within that time period or leave the faculty. Many faculty members, with the support of their chair,

choose the non-tenure track position to avoid this concern.

Documentation for Promotion

P/T committees sometimes lack the documentation necessary to demonstrate expertise as an educator,

scholar and clinician.5 The deficits are usually found in the teaching and clinical area. Research

experience, if present, is easily assessed through grant listings and publications.

Because of this difficulty with lack of documentation, many universities have turned to the

teaching/educator portfolio as a way to document productivity.6 It is analogous to the portfolio used by

artists and architects to demonstrate the scope and caliber of their work. Some institutions now require

that their faculty members maintain a portfolio. There are a number of articles/books which detail how a

teaching portfolio can be constructed and used for purposes of evaluation and promotion.7-9

When the portfolio is used for evaluation it should contain documentation of all that has been

accomplished. When used for promotion purposes it should contain a statement of how the faculty

member has contributed to the scholarly community and added to the value of the institution. It should

provide examples of the faculty member's best works supporting the premise that the faculty member

has academic expertise in one of the four major domains of scholarship: Discovery, application,

integration, or teaching.

Universities place great weight on evaluations by students and residents and these should be included

in documentation supplied to the P/T committee. Any evaluations of teaching by peers are of value.

Teaching awards or awards granted for service to professional organizations help to demonstrate

excellence either in the educational or clinical arena.

An up to date curriculum vitae (CV) is essential. Suggestions for how to construct one are included in

Chapter 2.1 in this Handbook (see Table of Contents). It is vital that the submitted CV conform to the

format specified by the individual institution. A complete bibliography of authored work should be

prepared.

Conclusion

Attaining promotion to the level of Associate Professor requires planning that should ideally begin at the

start of an academic career. Engaging in activity that allows a faculty member to gain teaching expertise

and a focus of research is essential. Clinical excellence is a requirement unless one is engaged solely in

the Research Track. Documentation of accomplishments that demonstrate the value of the individual to

the institution and show how that individual has contributed to the scholarly environment are mandatory.

The rewards of achievement are well worth the effort for they attest to recognition by the academic

community that a faculty member has been successful in adding to the value of that community and

helping fulfill its mission of teaching, research, and service.

Bibliography

1. Levinson, W, Branch W, Kroenke K. Clinician-educators in academic medical centers: A two-part

challenge. Ann Internal Med, 1998;129:59-64.

2. Boyer E., Scholarship Reconsidered: Priorities of the Professoriate, 1990, Princeton, NY: Carnegie

Foundation for the Advancement of Teaching.

3. Barchi R, Lowery B. Scholarship in the medical faculty from the university perspective: Retaining

academic values. Acad Med, 2000;75:899-905.

4. Nieman, L., et al. Implementing a comprehensive approach to managing faculty roles, rewards, and

development in an era of change. Acad Med 1997;72:496-504.

5. Jones R, Froom J. Faculty and administration views of problems in faculty evaluation. Acad Med,

1994;69:476-483.

6. Beasley B, Wright S, Confrancesco J. Promotion criteria for clinician-educators in the United States

and Canada. JAMA 1998;278:723-728.

7. Seldin, P., The Teaching Portfolio. A practical guide to improved performance and promotion/tenure

decisions. 2nd ed. 1997, Bolton, MA: Anker Publishing Company Inc.

8. Shulman, L., "The Educator's Portfolio." 1990: Presentation at Conference on Assessment in Higher

Education.

9. Simpson, D., A. Beecher, and J. Lindemann, The Educator's Portfolio. 4th ed. 1998, Milwaukee, WI:

Medical College of Wisconsin.

Mentoring Faculty Members to the Next Level

Authors: David W. Wright and Jerris R. Hedges

Other sections of this faculty development guide will address aspects of seeking a mentor and

interacting with that individual. This section will focus upon the faculty member serving as a mentor.

Because Emergency Medicine is a relatively young specialty, many faculty members, even those at the

Instructor and Assistant Professor level, have taken on leadership and mentoring roles. This can result

in only a few years of experience separating the mentor from the mentee.

Two problems exist with this model. First, one of the most important benefits of a mentor is guidance

provided through past experience. Young mentors rarely have had the opportunity to gain the wisdom

and experience, or develop the world view, needed to be a good mentor. Ignorance, or lack of insight,

can have a disastrous result for someone’s career. Also, the inexperience of the mentoring relationship

can lead to an unstructured mentoring program and poor guidance for the mentee.

Despite these problems, mentoring of junior faculty, even by junior faculty, can be rewarding and

educational for both parties. Most problems can be avoided by following two key principles. First, even

the junior mentor should have a good senior mentor. The experience of a senior mentor can be

transmitted through the junior mentor to his/her mentee, and provide a great learning experience for the

mentor "in-training." Second, the development of a well-organized mentoring plan will provide structure

and stability to a mentoring relationship between faculty members of all levels.

As the junior faculty member looks to achieve promotion to Associate Professor and subsequently to

Full Professor, she/he should expect to have mentorship serve an important role in the promotion. This

chapter will focus on the following 1) why be a mentor?; 2) the mentoring relationship; 3) key steps on

how to be a great mentor; 4) mentoring in specific areas; 5) what are the pitfalls of a mentor/mentee

relationship?; and 6) how does one take credit for serving as a mentor?

Why be a mentor?

Mentorship is a special form of educational service. The relationship is highly personal and individual.

As such, it can be immensely rewarding. Mentoring may help create a career-long relationship between

individuals with overlapping academic interests. Such a relationship is most likely to impart a certain

degree of permanence or immortality to the academic efforts of the mentor – producing "academic

progeny".

On a more practical basis, the relationship provides mentors with junior faculty members who will

collaborate on shared scholarship, clinical service, and educational goals. A team approach will

generally be more productive than solo efforts. Further, when applying for promotion, an important

aspect of the application process is demonstration that one's academic efforts have influenced the

academic efforts of other faculty members. Mentoring relationships are important examples of one's

influence on the careers of others. To this end, it is wise to provide mentorship not only in one's own

department or institution, but to provide that service on a national level.

From a personal perspective, mentees in a mentoring relationship become extensions of the mentor.

Mentees recognize and share new academic opportunities with the mentor. The relationship opens the

mentor to new academic perspectives. Therefore, the relationship is intellectually stimulating, gratifying

on a personal level, and academically symbiotic.

The mentoring relationship

In Greek mythology, Ulysses entrusted his son's development to his old and trusted friend Mentor, when

he departed for the Trojan War. (1) Mentor served as a surrogate father for Telemechus. Just as

parental relationships can be complex, so can academic mentoring. Generally the rules of life and

academic practice have a limited instruction manual. The rules are often flexible and situationally

dependent.

Key steps on how to be a great mentor

To help guide the mentee through their academic career, gather up the tenure and promotion guidelines

for the University and the academic Department. Determine the goals and objectives of the University

and the Department and review how success is measured. Then, meet with the mentee and develop

short-term and long-term goals based on the goals of the mentee, along with the expectations of the

University and Department. These short-term and long-term goals will allow you and your mentee to

develop a comprehensive career plan that maps out a successful career path for the mentee. Create a

timeline for specific achievements based on the short-term and long-term goals, and keep to the

schedule. Set regular mentoring sessions, initially 1 –2 hours a week, to assess the success of the

short-term objectives. Keep a file and a checklist of the goals and objectives of the mentee. Also,

require the mentee to keep a checklist of their goals and objectives that includes the timeline, the tenure

and promotions guidelines, and a teaching portfolio. Review the mentee's folder on a regular basis.

When questions arise that you can’t answer, ask your senior mentor.

Mentoring in specific areas

The Research Mentor

The ultimate objective for a research mentor is for their mentee to become an independent researcher

as defined by a continuous record of publications and extramural funding ( preferably NIH). As an

independent researcher, the mentee has learned critical thinking skills, idea development, hypothesis

generation, project design, grant writing and funding skills, proper ethics in research, and manuscript

writing. This does not mean that the mentor has to teach all of these skills, but rather identifies

resources and opportunities for the mentee to obtain them. Also, the mentor can help pull a

multidisciplinary research team together to support the mentee. The mentor can identify colleagues with

similar interests at other institutions and propose a broader policy role that can broaden the impact of

the mentee's research findings. The mentor can help the mentee in acquisition of a study section

membership to further the mentee's influence and learning. The development of a research career for

junior faculty is a long and arduous process, and the wisdom of an experienced mentor can mean the

difference between rapid success and a slow painful failure. The mentor should create a plan for the

mentee's research development that includes learning the skills necessary for independent research.

The Education Mentor

Education has many facets and many styles. The mentor can expose the mentee to a variety of styles

and help determine the best fit for the mentee. The mentor can demonstrate organizational skills and

the effective incorporation of multimedia into didactic lectures. The mentor can share lecture skills and

review the role of lectures outside the department on a regional and national level in career

development. The mentor can assist with curriculum development, methods of evaluating learner

knowledge and skill acquisition and retention, and publishing educational scholarship. The mentor can

help in the development of the teaching portfolio and use it as a guide for the continuing development of

the mentee-educator ( 2) The portfolio should contain the essential elements of the mentee's teaching

philosophy and how he or she is going to accomplish their goals. The education mentor can teach the

mentee skills for interacting with students, residents, and colleagues and how to use these skills to the

best educational advantage.

The Administrative Mentor

Mentoring an individual who has aspirations for administration requires an open honest assessment of

the mentee's personnel management skills. Some individuals may require extensive leadership training.

The training can involve personality assessment and development, faculty and staff interaction skills,

delegation skills, management skills, and strategic planning. The mentor can demonstrate the balance

between support of an assigned administrative responsibility and retaining clinical skills and producing

scholarship. The mentor can introduce the mentee to key clinicians and administrators in other areas of

the medical center and within national organizations focusing on this administrative role. Developing a

meaningful working relationship with these individuals, and understanding their background,

contributions to the administrative field, and related priorities can be of immense value to the mentee.

The mentor can help the mentee apply management tools and better understand interpersonal and

group dynamics in theory and practice that influence group thought and action. People skills and day-to-

day interactions are the most difficult and important skills for the mentee to master.

The Clinical Mentor

The clinical mentor demonstrates the essential skills for critical thinking and problem solving. The

mentor can share methods for retention of clinical knowledge and acquisition of new clinical skills and

understandings. The mentor can demonstrate the advantages and disadvantages of technical

innovations (e.g., ultrasound techniques, procedural skills, parenteral sedation methods), which will

facilitate clinical practice. The mentor can develop systems of care and standardized approaches to the

evaluation of common or difficult clinical presentations to share with the mentee. The clinical mentor can

teach the mentee skills entailed in interacting with patients, nurses, support staff and colleagues , along

with time management skills. The key to all mentoring is an open sharing of one's experience and

knowledge. It need not be structured, but it must be frequent enough to sustain enthusiasm, information

acquisition, and to positively influence progress.

What are the pitfalls of mentoring?

The relationship

Certainly, impediments which block the information sharing must be avoided. Poor communication is as

bad as a personality conflict between the mentee and mentor. Both individuals must find value in the

relationship and make the effort to sustain the exchange. Like any relationship, there will be moments of

doubt. One party may question the sincerity or motivation of the other. While it is important to have

priorities, clear goals, and mutual commitments, plans must be flexible. Mentors must adjust to the

mentee's life changes. The mentoring relationship may even be placed on hold during extended periods

of time. However, the mentor and mentee should look for opportunities to advance their mutual plans

rather than excuses to set them aside.

Expectations

Another concern is that a mentor may believe that she/he must meet all of a mentee's needs. While the

mentor can address many needs, the mentee should seek a variety of mentors who can provide support

for different needs. (3) Mentors also must understand their limits. They can facilitate, but they cannot

accomplish goals on behalf of the mentees. Publications and grants cannot be guaranteed.

Experimental outcomes cannot be predicted with accuracy. Indeed, perhaps some of the best lessons

are provided by these "teachable moments" when things do not go right. The mentor can provide much

wisdom and guidance when the mentee has reached an impasse .

Planning

A sure plan for failure is not developing a plan with, and for, the mentee. The importance of short-term

goals, long-term goals, and measurable benchmarks cannot be overemphasized. These goals chart the

course for the mentoring relationship.

How does one take credit?

Arguments over ownership of an idea or priority of discovery have killed many a scholarly mentoring

relationship. The mentor must recognize that the mentee will often feel less empowered and may

hesitate to discuss these issues openly. Hence, it is critical that the mentor take the initiative and

discuss options with the mentee before deeply pursing a project that will consume much time and

energy on the part of both individuals. The result of such discussions should be written down wherever

possible.

Quite often, the contributions made by the mentor are not of a creative nature. Often the recognition

should be limited to an acknowledgment on a paper, thesis, or presentation. Again, the mentor should

be realistic and seek to promote the mentee and not her/himself in such circumstances where the

contribution is more a service than a creative venture.

It is wise for the mid career- or senior-level faculty member to keep a list of junior faculty members for

whom she/he has served as a mentor, whether in the same or another department. Demonstrating the

mentorship of these individuals with a listing of the mentee's accomplishments makes a powerful

argument that the faculty member has added educational or service value to the institution. These

contributions should be shared with and acknowledged by the faculty mentor's departmental chair on a

yearly basis. They should be highlighted in the promotional dossier created at the time the mentor

applies for promotion.

Final thoughts

While it is up to the mentee to seek mentors, the faculty member who highlight's the efforts of her/his

mentees will be sought after. Such a faculty member must balance the commitment to mentoring in the

same manner that she/he balances the many other academic commitments. It is a rewarding activity

and should be a part of everyone's academic role. (4)

References

1. Clutterbuck D. Everyone needs a mentor; fostering talent at work. 2nd Ed. Institute of Personnel

Management, 1992.

2 Seldin P. The Teaching Portfolio : A Practical Guide to Improved Performance and Promotion/Tenure

Decisions. Anker Publishing Co; 2nd edition, 1997

3. Morahan P. How to find and be your own best mentor. Acad Physician & Scientist

(November/December 2000); 8.

4. National Academy of Sciences, National Academy of Engineering and the Institute of Medicine:

Advisor, teacher, role model, friend. National Academy Press, Washington, D.C. 1997

Mentoring Faculty Members to the Next Level

Authors: David W. Wright and Jerris R. Hedges

Other sections of this faculty development guide will address aspects of seeking a mentor and

interacting with that individual. This section will focus upon the faculty member serving as a mentor.

Because Emergency Medicine is a relatively young specialty, many faculty members, even those at the

Instructor and Assistant Professor level, have taken on leadership and mentoring roles. This can result

in only a few years of experience separating the mentor from the mentee.

Two problems exist with this model. First, one of the most important benefits of a mentor is guidance

provided through past experience. Young mentors rarely have had the opportunity to gain the wisdom

and experience, or develop the world view, needed to be a good mentor. Ignorance, or lack of insight,

can have a disastrous result for someone’s career. Also, the inexperience of the mentoring relationship

can lead to an unstructured mentoring program and poor guidance for the mentee.

Despite these problems, mentoring of junior faculty, even by junior faculty, can be rewarding and

educational for both parties. Most problems can be avoided by following two key principles. First, even

the junior mentor should have a good senior mentor. The experience of a senior mentor can be

transmitted through the junior mentor to his/her mentee, and provide a great learning experience for the

mentor "in-training." Second, the development of a well-organized mentoring plan will provide structure

and stability to a mentoring relationship between faculty members of all levels.

As the junior faculty member looks to achieve promotion to Associate Professor and subsequently to

Full Professor, she/he should expect to have mentorship serve an important role in the promotion. This

chapter will focus on the following 1) why be a mentor?; 2) the mentoring relationship; 3) key steps on

how to be a great mentor; 4) mentoring in specific areas; 5) what are the pitfalls of a mentor/mentee

relationship?; and 6) how does one take credit for serving as a mentor?

Why be a mentor?

Mentorship is a special form of educational service. The relationship is highly personal and individual.

As such, it can be immensely rewarding. Mentoring may help create a career-long relationship between

individuals with overlapping academic interests. Such a relationship is most likely to impart a certain

degree of permanence or immortality to the academic efforts of the mentor – producing "academic

progeny".

On a more practical basis, the relationship provides mentors with junior faculty members who will

collaborate on shared scholarship, clinical service, and educational goals. A team approach will

generally be more productive than solo efforts. Further, when applying for promotion, an important

aspect of the application process is demonstration that one's academic efforts have influenced the

academic efforts of other faculty members. Mentoring relationships are important examples of one's

influence on the careers of others. To this end, it is wise to provide mentorship not only in one's own

department or institution, but to provide that service on a national level.

From a personal perspective, mentees in a mentoring relationship become extensions of the mentor.

Mentees recognize and share new academic opportunities with the mentor. The relationship opens the

mentor to new academic perspectives. Therefore, the relationship is intellectually stimulating, gratifying

on a personal level, and academically symbiotic.

The mentoring relationship

In Greek mythology, Ulysses entrusted his son's development to his old and trusted friend Mentor, when

he departed for the Trojan War. (1) Mentor served as a surrogate father for Telemechus. Just as

parental relationships can be complex, so can academic mentoring. Generally the rules of life and

academic practice have a limited instruction manual. The rules are often flexible and situationally

dependent.

Key steps on how to be a great mentor

To help guide the mentee through their academic career, gather up the tenure and promotion guidelines

for the University and the academic Department. Determine the goals and objectives of the University

and the Department and review how success is measured. Then, meet with the mentee and develop

short-term and long-term goals based on the goals of the mentee, along with the expectations of the

University and Department. These short-term and long-term goals will allow you and your mentee to

develop a comprehensive career plan that maps out a successful career path for the mentee. Create a

timeline for specific achievements based on the short-term and long-term goals, and keep to the

schedule. Set regular mentoring sessions, initially 1 –2 hours a week, to assess the success of the

short-term objectives. Keep a file and a checklist of the goals and objectives of the mentee. Also,

require the mentee to keep a checklist of their goals and objectives that includes the timeline, the tenure

and promotions guidelines, and a teaching portfolio. Review the mentee's folder on a regular basis.

When questions arise that you can’t answer, ask your senior mentor.

Mentoring in specific areas

The Research Mentor

The ultimate objective for a research mentor is for their mentee to become an independent researcher

as defined by a continuous record of publications and extramural funding ( preferably NIH). As an

independent researcher, the mentee has learned critical thinking skills, idea development, hypothesis

generation, project design, grant writing and funding skills, proper ethics in research, and manuscript

writing. This does not mean that the mentor has to teach all of these skills, but rather identifies

resources and opportunities for the mentee to obtain them. Also, the mentor can help pull a

multidisciplinary research team together to support the mentee. The mentor can identify colleagues with

similar interests at other institutions and propose a broader policy role that can broaden the impact of

the mentee's research findings. The mentor can help the mentee in acquisition of a study section

membership to further the mentee's influence and learning. The development of a research career for

junior faculty is a long and arduous process, and the wisdom of an experienced mentor can mean the

difference between rapid success and a slow painful failure. The mentor should create a plan for the

mentee's research development that includes learning the skills necessary for independent research.

The Education Mentor

Education has many facets and many styles. The mentor can expose the mentee to a variety of styles

and help determine the best fit for the mentee. The mentor can demonstrate organizational skills and

the effective incorporation of multimedia into didactic lectures. The mentor can share lecture skills and

review the role of lectures outside the department on a regional and national level in career

development. The mentor can assist with curriculum development, methods of evaluating learner

knowledge and skill acquisition and retention, and publishing educational scholarship. The mentor can

help in the development of the teaching portfolio and use it as a guide for the continuing development of

the mentee-educator ( 2) The portfolio should contain the essential elements of the mentee's teaching

philosophy and how he or she is going to accomplish their goals. The education mentor can teach the

mentee skills for interacting with students, residents, and colleagues and how to use these skills to the

best educational advantage.

The Administrative Mentor

Mentoring an individual who has aspirations for administration requires an open honest assessment of

the mentee's personnel management skills. Some individuals may require extensive leadership training.

The training can involve personality assessment and development, faculty and staff interaction skills,

delegation skills, management skills, and strategic planning. The mentor can demonstrate the balance

between support of an assigned administrative responsibility and retaining clinical skills and producing

scholarship. The mentor can introduce the mentee to key clinicians and administrators in other areas of

the medical center and within national organizations focusing on this administrative role. Developing a

meaningful working relationship with these individuals, and understanding their background,

contributions to the administrative field, and related priorities can be of immense value to the mentee.

The mentor can help the mentee apply management tools and better understand interpersonal and

group dynamics in theory and practice that influence group thought and action. People skills and day-to-

day interactions are the most difficult and important skills for the mentee to master.

The Clinical Mentor

The clinical mentor demonstrates the essential skills for critical thinking and problem solving. The

mentor can share methods for retention of clinical knowledge and acquisition of new clinical skills and

understandings. The mentor can demonstrate the advantages and disadvantages of technical

innovations (e.g., ultrasound techniques, procedural skills, parenteral sedation methods), which will

facilitate clinical practice. The mentor can develop systems of care and standardized approaches to the

evaluation of common or difficult clinical presentations to share with the mentee. The clinical mentor can

teach the mentee skills entailed in interacting with patients, nurses, support staff and colleagues , along

with time management skills. The key to all mentoring is an open sharing of one's experience and

knowledge. It need not be structured, but it must be frequent enough to sustain enthusiasm, information

acquisition, and to positively influence progress.

What are the pitfalls of mentoring?

The relationship

Certainly, impediments which block the information sharing must be avoided. Poor communication is as

bad as a personality conflict between the mentee and mentor. Both individuals must find value in the

relationship and make the effort to sustain the exchange. Like any relationship, there will be moments of

doubt. One party may question the sincerity or motivation of the other. While it is important to have

priorities, clear goals, and mutual commitments, plans must be flexible. Mentors must adjust to the

mentee's life changes. The mentoring relationship may even be placed on hold during extended periods

of time. However, the mentor and mentee should look for opportunities to advance their mutual plans

rather than excuses to set them aside.

Expectations

Another concern is that a mentor may believe that she/he must meet all of a mentee's needs. While the

mentor can address many needs, the mentee should seek a variety of mentors who can provide support

for different needs. (3) Mentors also must understand their limits. They can facilitate, but they cannot

accomplish goals on behalf of the mentees. Publications and grants cannot be guaranteed.

Experimental outcomes cannot be predicted with accuracy. Indeed, perhaps some of the best lessons

are provided by these "teachable moments" when things do not go right. The mentor can provide much

wisdom and guidance when the mentee has reached an impasse .

Planning

A sure plan for failure is not developing a plan with, and for, the mentee. The importance of short-term

goals, long-term goals, and measurable benchmarks cannot be overemphasized. These goals chart the

course for the mentoring relationship.

How does one take credit?

Arguments over ownership of an idea or priority of discovery have killed many a scholarly mentoring

relationship. The mentor must recognize that the mentee will often feel less empowered and may

hesitate to discuss these issues openly. Hence, it is critical that the mentor take the initiative and

discuss options with the mentee before deeply pursing a project that will consume much time and

energy on the part of both individuals. The result of such discussions should be written down wherever

possible.

Quite often, the contributions made by the mentor are not of a creative nature. Often the recognition

should be limited to an acknowledgment on a paper, thesis, or presentation. Again, the mentor should

be realistic and seek to promote the mentee and not her/himself in such circumstances where the

contribution is more a service than a creative venture.

It is wise for the mid career- or senior-level faculty member to keep a list of junior faculty members for

whom she/he has served as a mentor, whether in the same or another department. Demonstrating the

mentorship of these individuals with a listing of the mentee's accomplishments makes a powerful

argument that the faculty member has added educational or service value to the institution. These

contributions should be shared with and acknowledged by the faculty mentor's departmental chair on a

yearly basis. They should be highlighted in the promotional dossier created at the time the mentor

applies for promotion.

Final thoughts

While it is up to the mentee to seek mentors, the faculty member who highlight's the efforts of her/his

mentees will be sought after. Such a faculty member must balance the commitment to mentoring in the

same manner that she/he balances the many other academic commitments. It is a rewarding activity

and should be a part of everyone's academic role. (4)

References

1. Clutterbuck D. Everyone needs a mentor; fostering talent at work. 2nd Ed. Institute of Personnel

Management, 1992.

2 Seldin P. The Teaching Portfolio : A Practical Guide to Improved Performance and Promotion/Tenure

Decisions. Anker Publishing Co; 2nd edition, 1997

3. Morahan P. How to find and be your own best mentor. Acad Physician & Scientist

(November/December 2000); 8.

4. National Academy of Sciences, National Academy of Engineering and the Institute of Medicine:

Advisor, teacher, role model, friend. National Academy Press, Washington, D.C. 1997

Assuming a Leadership Position: a checklist for success

Author: Sandra M. Schneider

To be chosen among your peers to lead is indeed a great honor. Whether it is leadership at the local,

regional, or national level; whether in a professional or community venue, leadership carries significant

responsibilities and rewards. In many ways your life will be different. Your actions and words now will

carry greater weight, reflecting the entire enterprise. Casual suggestions can become law; off-handed

comments become official declarations. Time commitments, particularly those that take away from

family, can be costly. The feeling of honor, duty and ego satisfaction may lead you to accept the

leadership position, but then find yourself ill prepared and even frustrated when the real work of

leadership begins.

Preparation:

Have you mastered the basics? The first step is to master the basic skills of your profession. There is no

shortcut around this. You should take every opportunity to learn. If asked to go to some ‘boring’ meeting,

go and listen and learn. If you hear jargon you are unfamiliar with, write it down and ask about it. Take

advantage of every opportunity to see how the system works. Woody Allen said, "90% of life is showing

up". Although humorous at first glance, it is profoundly true. Finally take every opportunity to meet

people and get to know them.

Do you have a good reputation? Learn to network at organizational functions. Be friendly. Never utter a

negative word about anyone. Learn to be professional in your interactions. Be wary of becoming a

single issue person. Though it is easier to build a reputation by taking a stand on a volatile issue, a true

leader must represent the entire constituency.

Do you have the management and leadership skills necessary? Learn about leadership. Read, attend

seminars, listen and learn. Learn how to use your personality and talents as a leader. Leaders are not

born, but are made.

Finding a mentor or mentors can be very important. Although many may find the right path by

themselves, having a mentor to open doors and give directions at the right times can make the best use

of your time. There are a few essentials to every leadership position – time management, conflict

negotiation, constructive feedback, basic finance. These are the tools of the trade. No leader can be

successful without competency in each of these. There is a myriad of courses, self-help books, and

videos available in each of the areas.

Are you enjoying the work required to get to a leadership position? Have fun learning and working your

way up. Leadership is most rewarding when it is not initially sought. If you are not having fun getting to

the top, you will not have fun once you are there. And if you are not having fun in the leadership role, not

only should you question why you have bothered, but also it is likely that you will fail as a leader.

The right (?) opportunity:

Are your motives for wanting this position genuine? First and foremost you should examine motivation.

Why are you interested in a position that offers more work and more accountability? Is it the opportunity

to effect change, the self-satisfaction that comes from being selected, or the money and power that

come with the title? Especially in the military, is it the chance to lead or to command? An honest

examination of these questions will help to guide your leadership style. Guarding against a tendency to

command or rule may require constant diligence. The lure of money may prolong a leadership term

beyond what is good for either party. The quest for personal power can be devastating to the

organization.

Are you aware of the organization’s motives? Is there expectation of major change or maintenance of

the status quo? What are the priorities for the organization at this time?

Are you passionate about the organization? A leader must first and foremost have a passion. Passion

cannot be taught; it must come naturally from within. One must believe in the organization. That belief

may include needed change to organizational process, but you must believe in the basic values of the

organization. For example, you may assume the position of department chief primarily to effect a major

overhaul in services. Your passion is the organization as a whole and your vision is to create the

changes that will bring your department in line with the organization

Do you know what you want to accomplish as a leader? Although some claim to identify a natural

leader, what they are generally identifying is a person with creativity, passion and vision; a person

unafraid to go along a different path and the communication skills and vision to get others to follow. The

key is simply identifying the area that excites the individual. Vision can be molded if not taught. Passion

is the key. From there vision is derived from creative thinking, strategic analysis, experience and

mentoring. Vision is creativity tempered with knowledge gained from experience.

The leader must articulate a vision. Every organization needs something to strive for (we will be number

1, we will increase our membership, etc). The vision should be clear to all. Slogans, laminated cards

with mission and vision statements, reciting of mottoes, etc are tools to ingrain the vision into the group.

The vision should hold something for everyone. It must make all the work and energy worthwhile to the

individual. While the vision should appear to be attainable, be careful not to reach it too quickly. Once

the vision becomes reality, either a new vision or new leader will be needed. Nevertheless, the leader

must show the vision and the path to get there.

Does your skill set match the organization’s? Mastery of the skills leading to the position of leadership is

essential. If the organization is a clinical department or educational organization then the leader must

have proven skills in that area. He should be a master teacher, an exceptional clinician. His skills in

these areas should be above reproach. If he is to be the leader of an organization, then he should be

recognized as a master of the qualities the organization exemplifies. For example, if it is a research

organization he should be a respected researcher, first. If it is a political organization, he should have

proven political skills.

Day to day operations

Are you comfortable with your (new) peer group? Once you have assumed a position of leadership, you

are the organization. Your actions and words reflect on the organization. Candid conversations casting

doubt on decisions made will at best condemn them and may confuse the listener. Disagree in private,

support in public. Whatever the body (i.e. board of directors) decides can be discussed vigorously in

private deliberations but must be strongly supported outside the boardroom. You may and will take the

blame for something you have violently opposed.

Do you have the necessary support away from the organization? Leadership is very lonely. Your former

peers may now be you subordinates. Relationships change. Some want favor; some want access and

influence. You need support from outside the organization to survive.

Do you have the necessary support of your superiors? Do you know what they expect of you? Often the

true agendas are hidden. ‘We want a good clinical department’ may actually mean ‘We want you to fix

the finances’. Understanding their priorities is essential. Be cautious of using your superiors to fight your

battles. YOU need to be viewed as the problem solver, not the problem maker or problem identifier.

Do you have the support of your subordinates? Do they respect you? The leader of a clinical

department that cannot work clinically can be problematic. The leader of an academic department that

cannot teach or perform research gives fuel to disgruntled constituents.

Do you have the support of the support staff? A great personal assistant is invaluable. They will offer

helpful hints, keep track of the rumor mill, and make acceptable excuses for your failures. A disgruntled

support staff can easily sabotage you. Simply consider how many ways a personal assistant can break

an appointment.

Do you know the culture of the organization? Do your homework. You must know your job and

demonstrate your competency. Analyze the organization and its work habits. Are communications oral

or written? Are meetings cordial or caustic? Each organization has a unique culture. Cultural errors are

tolerated for only a brief period. After this ‘honeymoon’ cultural errors will be interpreted as social

clumsiness and detract from your leadership.

Do you have a thick skin? Just as your words and actions reflect the organizations, people will treat you

as if you are the organization. Frustration about the global state of the organization (or world) will be

directed to you personally. At times it may feel that you are responsible for all that is bad and nothing

that is good. People will hold you accountable for financial and economic swings. It is hard not to take

these comments personally. However they are really not addressed to you, but rather to the position you

temporarily hold. Remember that you must in time surrender the leadership position you hold. When

that day comes, it will no longer be you, but now your successor who holds that responsibility.

Are you a good communicator? Most of your job is communication. You must communicate your vision.

You must listen to your constituency. You must communicate your organization’s view to outside

agencies and individuals. You must listen to your constituency. You must interpret interactions with

outside agencies to your organization..

Are you a people person? You must know your constituency on a human basis. Find out what is

important. Remember special dates, events, and issues in their lives. Celebrate successes and

empathize with losses. Many leaders find tickle files and prompting cards valuable to remember

spouse/children’s names, special events, etc. Don’t be surprised if your relationship with your

colleagues abruptly changes. Those who were your dearest friends may become less open, those who

were previously distant may suddenly want to be close. You will find yourself not welcome at certain

occasions designed to let off steam.

Are you approachable? Your constituents will need to communicate with you freely and openly. You in

turn must answer back as the organization. In each conversation there is need to assess the who, what,

when, and why. Who does this individual represent, himself or a group? What does he want, change, a

chance to vent, reassurance? When do you need to act on his comments, today, after further

discussion, perhaps never? Why has he chosen today, was there a sentinel event, a growing

insurrection? Each conversation leads to an action. Again these can be analyzed in the who, what,

when, and why sequence. Who needs to act on this, you, a higher or lower power? Be careful what you

‘kick upstairs’. You have been appointed a problem solver. If you must rely on a higher authority for an

action, go prepared with a solution and a reason. There is much to be said for using a lower authority to

negotiate in your place. What needs to be done? You can simply note the complaint or act to correct it.

Consensus may need to be built first. When should the action be taken? Why does it need to be done?

Do you need to make a change to keep a valuable employee or because it is the right thing to do? What

are the implications for others if this change is made? Will another group suffer because of concessions

made? What is the precedent that is being set? Finally every action carries its own implementation. Who

will make and articulate the change? What change will need to occur and what impact will that have on

others? When is the best time to make a change?

Are you decisive? Learn to make decisions quickly and fairly. Do not agonize over small items.

Whenever possible, concede early minor issues that ‘cost’ nothing. Let the group decide issues that are

not crucial to your vision or the running of the organization.

Can you make change? Making change is a part of leadership. Change is difficult and uncomfortable,

even if the change is universally acknowledged for the good. There must be a reason to endure the

uncomfortable change. A crisis unites a group against an ‘enemy’ and gives the power to endure

change. History shows the value of an enemy and crisis such as the race to the moon or the attack on

Pearl Harbor. If there is no crisis or enemy, there is both value and danger in creating a crisis. A crisis is

necessary for change but a contrived crisis (such as some of the famine at the start of the Soviet Union)

will lead to anger and distrust if detected. An outside party vilified to unite your forces may someday

need to be your friend or collaborator. Often leaders are judged by their ability to inspire their

constituency as well as to cooperate with peer leaders. Vilifying other organizations/organizational

leaders will provide short-term gains, but negative long-term consequences. The best enemies are

vague. Managed care is a better enemy than the Surgery Department.

Change requires buy-in from the constituency. People will not readily make change. In any change there

are 3 groups of people. The core believers understand and readily adopt the change. The core

disbelievers will never understand or adapt to the change. If change is adopted these people will likely

leave the organization. The last group is the most crucial. These are the swing voters, the group for

which change has less impact. The size of this group and its final inclination will determine whether

change is enacted. Mandated change will nearly always fail.

Perhaps the most common mistake made in creating change is failing to plan the implementation. Once

a course of action is decided, communication of the change and implementation must be carefully

planned. In fact, this phase of the change process should receive the greatest emphasis and

consideration. For every proposed change there is a correct time, person and crisis. All three must be

correct or the change will not occur. For example a change in trauma care may need to wait until there

is a change of leadership in Surgery.

Do you know the history of the organization? Beware of the power of history. Within every organization

is at least one person who will hold steadfastly to history. While we clearly must learn from history, we

must be wary of dominating all future interactions. Organizations grow and change (especially when

leadership changes). Rivalries and emotions precipitated by past events may preclude future beneficial

alliances.

Are you being asked to give special consideration/privileges? Be wary of change to accommodate an

individual. A strange or unusual organizational pattern generally grows out of the need to accommodate

an individual rather than for the betterment of the organization. Convoluted reporting structures,

redundancies in responsibilities, and layers of bureaucracy often surround a powerful but inept

individual. Awareness should not lead to immediate replacement of that individual; after all they got

there because of their political power. However, for every change there is a right time, person, and

crisis.

Closure

Is your ego tied to the position? All leadership positions must come to an end. Recognizing the need to

step down or step aside is difficult. Even when there is a defined term limit it is difficult to completely

sever the ties to leadership. Past presidents struggle with letting go of power, watching another step in

and (even worse) improve on your successes. As a leader you must constantly reassess your political

strength. Do you remain a visionary? Are your political skills still sharp? Can you maintain the energy

and enthusiasm to continue the battle for success? Long before the day comes when these questions

lead to a decision to step down, you must begin to groom your replacement. A truly successful leader

has already identified potential leaders and mentored them. Although one of these may at some time

replace you, the best leader is not threatened by the growth of a subordinate. Instead a truly great

leader anticipates the end of their term and rejoices in the successes they have spawned.

A word of caution:

"There was, as Squealer was never tired of explaining, endless work in the supervision and organization

of the farm. Much of this work was of a kind that the other animals were too ignorant to understand. For

example, Squealer told them the pigs had to expend enormous labors every day upon mysterious things

called "files," "reports," minutes," and "memoranda." These were large sheets of paper which had to be

closely covered with writing, and as soon as they were so covered, they were burnt in the furnace. This

was of the highest importance for the welfare of the farm, Squealer said. But still, neither pigs nor dogs

produced any food by their own labor; and there were very many of them, and their appetites were

always good… All animals are equal, but some animals are more equal than others." Animal Farm, by

George Orwell.

How to Evaluate a Potential New Opportunity

Author: John Marx

Opportunities in academic emergency medicine can be assiduously sought or just rise out of the

proverbial blue. These may occur at any point in one's career and at any age and stage of one's life.

DISCOVER THE OPPORTUNITY

Active Approach: There are three basic search methods.

Letters of Approach: One tactic is to send out a letter of introduction containing your curriculum vitae.

This is not an unusual tactic for the senior resident. The letter can be sent out as a mass mailing, that is

to every program in the United States, or in a manner targeted toward a specific geography or types of

programs. Success of this method relies heavily upon timing. These letters can be delivered at any time

but will likely be read with greater interest in the late winter and early spring when chairs are sizing up

their needs for the coming academic year. While the subject has not been studied, empiricism suggests

that a large proportion of these letters prompt generic and empty responses or wind up in the

bottomless circular file.

Human Resources: People who know people are the luckiest people. The fact is that individuals within

programs are the first to know about good positions soon to become available. It's a smart idea to check

in with colleagues in those programs and parts of the country you desire. Putting out feelers like this

requires a bit of moxie but can be very productive.

Advertising: A simple way of getting a sense for what's out there is to "review the literature". Peer-review

journals in emergency medicine, newsletters, web sites and the like enumerate scores of opportunities.

These tend to surface one to several months after the host department has publicly stated the need.

Certain programs prefer to subscribe to the informal advertising approach of sending a letter to the

chairs of programs across the country stating that a certain type of position is available and would those

chairs please forward the names of any members of their faculties as potential candidates.

Passive Approach

In this scenario, you wait to be asked to the prom. This is likely to occur in two circumstances. In the

first, you've been an outstanding resident and the chair of your department would like to have you on the

faculty. In the second, you've been around a while, have established a reputation, and are being sought

for a higher level position, for example, chair, program director, or research director. If you're a senior

resident or young faculty, then passive approach is risky, at best.

Timing

For the senior resident, it's appropriate to begin the search in the late summer or early fall. A second hot

spot is in the spring when individuals who have promised to take certain positions on certain faculties

have opted out at the last minute. At that point, chairs are a bit more on the desperate side.

For the individual already on a faculty, these same kinetic principles apply. But, positions can open at

any time of the year, and it's a matter of being fortunate enough to hear about the openings or

constantly being on the hunt for them.

RESEARCH THE OPPORTUNITY

Preliminary Fact-finding

It makes no sense to rush off to an interview without having done considerable groundwork in advance.

Interviews are no walk in the park for either side. These take time, effort and money and should never

be taken lightly. There is no reason to proceed to that stage until you have a reasonable sense that a

legitimate opportunity exists. Likewise, the chair wants to size you up as much as possible and avoid the

rigor of interviewing a candidate who's a bad fit or never had interest in the first place.

Telephone Interview: You and the chair should spend a good measure of time sorting out the basics of

the position, the faculty, and the training program. Useful data can also be acquired from other members

of the faculty, particularly those in an area of your interest. Newer faculty will have a good sense of what

you should be asking about and what surprises might be in store. A bit harder to find but even more

valuable are those faculty who have recently departed.

Disclosure: Some applicants want to keep secret the fact that they are looking at another job. This is

only partly reasonable. If you're happy where you are, it's understandable that you don't want to be an

unsettling influence. Sometimes you wind up making your fellow faculty and chair nervous or cause

them to believe that you don't like them or your role there any longer. If you wind up staying where you

are or until you leave, this can make for a discomfiting situation. At this preliminary stage, you might be

able to get away with closed conversations with the department where you're interested in finding a

spot. However, at some point or another, and usually much earlier than you like (or realize), the outside

chair will make contact with your department in order to acquire a reference, thereby spilling the beans.

In this case, you're far better off having alerted the key individuals of your current faculty to this prospect

and hopefully ensuring their willingness to provide you a fair evaluation. Other candidates are

deliberately outspoken around their own institution about their prospects elsewhere. Those in this latter

category may be looking to improve their existing situation by insinuating their disappointment with

what's in hand and emoting the need to improve their lot in life by going elsewhere.

Miscellaneous: It's reasonable to spend a bit of effort researching the program. The RRC accreditation,

program history, faculty profile, and departmental accomplishments can be found through various

sources, including the program's own website.

Onsite Evaluation

This constitutes the interview process. The program will set up your itinerary as far as being toured

through the facility and meeting with various individuals. It's reasonable to provide input into this,

particularly if there are key figures with whom you wish to spend time. The number of visits that will be

sponsored by the host department may be zero, is usually one and can be more, particularly if you are

searching for a higher level position, notably the chair. You are certainly welcome to visit the program as

many times as you wish or need at your own expense. In this case, you should simply let the chair know

that you're coming and that you're interested in visiting with certain members of their or other faculties or

administrators.

Interviews: You'll want to spend time with the chair especially, various faculty (particularly those with

whom you would interrelate position-wise), the departmental administrator, and the head nurse.

Clinical Site: It is very worth your while to spend at least a shift working side by side with one or more

faculty attendings. This can be a real eye opener into how the department operates, the role of

emergency medicine residents in the department and the perception toward emergency medicine within

the institution. This is also a wonderful opportunity to speak with nurses and paramedics. It is also a

chance to appraise ancillary services.

WHAT'S IMPORTANT TO YOU

Know Yourself

This may not be the sole lame aphorism in this chapter, but it may well be the most important. Try to

take the time to understand what you want professionally and personally, how many hours you wish to

commit to your profession and where you'd like to be in the next 5, 10, or 25 years. Some of us are

incredibly compulsive in planning every little detail in our lives. Others of us are much more the day-to-

day existentialist and have trouble scripting these plans. Where- ever you lie on the spectrum, this is a

helpful self-appraisal technique. In fact, it should be repeated on an annual basis as if you were

preparing resolutions for the new academic year.

Certainly, the author of these plans is not just you but rather, you and the key members of your life. In

addition, taking the time to "interview" others in the field, particularly those with considerable experience,

can be very rewarding and enlightening.

The Role

Many factors deserve your careful consideration.

Clinical: How many hours will you work, which hours will these be (especially vs. others on the faculty),

and how will these change over time are all of considerable interest. As importantly, what is your role as

the clinical attending? What is expected of you as far as direct care provision, care supervision, problem

solving, documentation and teaching? You should get the specifics of this from the chair, the working

knowledge from the faculty, and the general sense of the playing field from your observations during

your interview.

Academics: The academic horn of plenty includes didactic teaching, writing, clinical research, bench

research, program development, and roles in academic societies. It's critical to understand which and

when these opportunities will be available to you. Certain roles beg specific conversations. For example,

if your wish is to have a predominant part of your nonclinical time spent in bench research, you would

want to know what facilities, equipment, personnel, and protected time are being proffered. For this and

most other roles, the chair will be the go-to individual. In addition, the chair should be able to speak to

the amount of commitment the department is willing to give to various endeavors. This commitment

includes adjustments in clinical hours, changes in administrative responsibility, and hard dollar support.

Administration: You may wish and you most certainly will be expected to take on administrative

responsibility within the department and the hospital. Specific needs will likely exist, and the existing

faculty may attempt to scramble their administrative load, leaving something less desirable for you to

scoop up. However, likes and dislikes vary widely within a faculty. You will want to express your

preferred administrative role, be willing to accept what is available and negotiate to be next in line or a

role player in that area to which you aspire.

The Players

For most, there is nothing more important than the people with whom you will work over the next few to

many years. Integrity, honesty, commitment, and selflessness are among attributes to hope for and

emulate in your fellow faculty.

Your Department: You clearly want to have a good sense for the chair as to manner of leadership and

departmental goals. You can derive a sense for this from your interviews with the chair, the

conversations held with other members of the department and perhaps sitting in on a faculty meeting if

able. The chair should be able to espouse clearly the mission of the department and the fellow faculty

can corroborate or refute whether the chair, faculty and hospital have resolve toward this mission.

Administration: Is the departmental administrator responsive to the needs of the department and

sufficiently empowered to see to their solution?

Other Departments: The chairs, program directors, and research directors of other departments can be

extremely influential in regard to emergency medicine generally and your role on the faculty, specifically.

The Place

The medical center is a key building block.

Financial Status: There is little that is more crucial these days in medical education across America.

This information can be difficult to derive. A good sense can be gotten from review of 5 years of overall

and operating budgets for the hospital, the division of medical education, and emergency medicine

specifically. Likewise, have positions been cut through the hospital or in emergency medicine? Valued

positions that can be cut include physicians, of course, but also key support personnel, for example, in

research.

Support of Medical Education: Hopefully, emergency medicine carries the same stature as other

departments in the eyes of the dean or senior administrator in medical education. Roles on committees,

access to financial and personnel support, and budgetary allocations are measures to be considered.

Benefits

Compensation: This includes base salary, merit increase, and performance incentives. Comparative

standards are available through the AAMC and the SAEM Salary Survey.

Perquisites: This is a complex area that includes health and dental benefits, disability, liability, vacation,

and retirement plans.

Support Services: These include Information Services, secretarial support, office space, research

equipment, the grants and contracts office, biostatistical support, and medical arts. Never to be

forgotten, of course, is parking.

Advancement

This can be considered in various forms.

Promotion and Tenure: It's worth spending an hour studying the "bylaws" of the P&T Committee. In

addition, the chair and members of the department should be able to provide a sense for what's needed

to get to the next level as well as the department's success in doing so.

Intra-departmental: It's tough to discover at the front end whether and when you'll be able to move up

the ladder within the department. This depends in large part on your own efforts but also on whether

certain positions will become available. At some point, you may feel compelled to move elsewhere

because you're stuck in a particular spot.

Special Opportunities: Check the track record of the members of the faculty as to positions held in

medical societies and academic societies. Will these be open to you and will the chair be supportive of

your taking on these additional roles?

Niche: The typical academic emergency physician begins to develop a special interest early on. Over

time, you as a faculty member should be able to acquire expertise and academic opportunities within

your niche such that you will become recognized for this, and therefore be sought accordingly for

collaborative efforts, grant writing, speaking opportunities and non-peer-writing projects.

WHAT'S IMPORTANT TO THE DEPARTMENT

Needs

The respective department will seek you for a specific need. You may come on as a utility infielder

where you'll play various positions but not take on a high profile role. Or, you are moving into a newly

vacated position or one that has just been created. It is very important that you understand what they

want, expect, and will accept both in the present and in the future.

Performance Standard

Whether you're a senior resident, young faculty, or senior member, the chair and department you're

interviewing with will want to know as much about you as possible. Your curriculum vitae will provide a

start. More importantly, the chair in particular should certainly check your references carefully as

regards your potential, your personality, and most importantly, whether you'll be a good fit.

NEGOTIATIONS

Dealmaker

You should and will want to work entirely with the chair. The chair, of course, answers to both the faculty

and to administration and will have limitations set by both. However, the chair should understand these

limitations at the front end and be empowered to deliberate with you. The wise chair will, of course,

listen carefully to the faculty and their impressions of the candidates.

Style

It's understandable that candidates want to shine themselves up a bit, but it's only right to be honest and

be yourself. Pretending to be otherwise will result in disappointment, if not disaster, for you the applicant

as well as for the receiving department. Hope for a win-win situation by achieving much of what you

desire but being flexible and accepting certain responsibilities or benefits that aren't your favorites.

As far as deadlines, it's understandable that you may be considering a position on one or more faculties

at the same time. You should not be pressured to make a decision before the match burns out. On the

other hand, asking for extension after extension on the deadline is unfair to a department who will need

to move quickly to fill the position that you turn down.

Contractuals

You will sign a contract, and you will certainly want to study that contract carefully and seek the

assistance of one more expert than you in this arena. You can take the legal beagle approach and ask

for every single detail and subdetail to be written into the contract. Or, you can rely mostly on a

handshake. The smartest strategy depends on what you're comfortable with but lies somewhere in

between these two. Neither the handshake nor the 100 page contract is fail-safe, particularly given the

dynamic situation of health care and medical education.

WRAPUP

Try to find out who you are and what you would like to do and be in your life. Certainly, this is easier

said than done. Then, it's a matter of finding the role and making the most of it. In this game, your talent

and most especially, your effort, make up 90% of the equation and is far more important than the actual

position or place where that position resides. There is luck of course, or if you will, fate, but you'll have

no control over that. Finally, understand that academic emergency medicine provides fertile ground for

an extraordinarily wide variety of people who wish to give something back as teachers, care providers,

and role models.

Bibliography

1. Marx JA. Academic emergency medicine in the year 2000. (eds: Hobgood,Cherri MD, Zink Brian,

MD) Emergency Medicine: An Academic Career Guide. Published by SAEM and EMRA. 2000. P 9-12.

2. Iserson KV, Adams J, Cordell WH, Graff L, Halamka J, Ling L, Peacock WF, Sklar D, Stair T.

Academic emergency medicine's future. Acad Emerg Med 1999;6:137-144.

3. Kristal SL, Randall-Kristal KA, Thompson, BM, Marx JA. 1998-1999 SAEM Emergency Medicine

Faculty Salary and Benefits Survey. Acad Emerg Med 1999;12:1261-1271.

4. 4. Ling LJ, Wilkinson J, Holroyd B. New models for emergency and ambulatory care at academic

health centers-Part III: Boston and Alberta, Canada. Acad Emerg Med 1995;2:1001-1006.

5. Lewis LM, Callaham ML, Kellerman AL, Marx JA, White DJ: Collaboration in emergency medicine

research: A consensus statement. Acad Emerg Med 1998;5:152-156.

Becoming a chair of an academic department

Author: W. Brian Gibler

Introduction

An academic emergency physician may be tempted by the opportunity to pursue the position of Chair of

a Department or Chief of a Division of Emergency Medicine. How can the successful

clinician/teacher/researcher decide if such a move makes sense, career-wise? The decision to pursue a

leadership role in an academic Department of Emergency Medicine should be obvious to the individual,

as well as to his/her peers. Hopefully the following information, offered from my perspective, will help

you decide if a Chair position is right for you.

Antecedents

Are leaders born or made? The likely answer is a combination of natural and learned characteristics. In

your life experiences thus far, you probably have been exposed to a number of individuals that people

naturally follow. Sports teams, families, clubs, organizations, and work groups all tend to be led by one

or two members that define the goals, direction, and ultimately the vision of the entire body. A number of

characteristics including athletic skill (Michael Jordan), charisma (John F. Kennedy), strength (Attila the

Hun), drive (Bill Gates), and intelligence (Abraham Lincoln) cause others to follow. Most of us are not

born with the expression of these characteristics at a level that would allow us to become historical

figures or cultural icons. There are many individuals, however, that have a combination of

characteristics, which can be honed and cultivated over time to allow one to lead a group. If you served

as the organizational center for groups in the past, created organizations to serve a need, were elected

team captain, chief resident, or purposefully chose to be the first to have a new experience or job, you

have the basic core of a leader. A mentor interested in developing your leadership skills can often

identify these characteristics and experiences.

Requirements

Chair candidates for Emergency Medicine positions in academic medical centers typically undergo the

same scrutiny as candidates for other academic departments. In high-powered, academic medical

centers, Chair candidates are expected to achieve success nationally as clinicians, teachers, and

researchers. Ideally, these individuals also have administrative experience that includes managing

people as well as developing a budget. In some circumstances, serving as a Residency Director or Vice

Chair provides this valuable exposure to management.

Search committees at research-intensive institutions expect to hire clinician scientists that have been

extremely successful at obtaining peer-reviewed federal and foundation funding. In addition, individuals

interested in becoming the Chair at such centers should have a national and sometimes international

reputation achieved through major peer-reviewed publications. Other less research-intensive academic

medical centers may emphasize clinical teaching experience with previous management training.

Goals Must Change: I to We

While obtaining the credentials as a clinician, teacher, and researcher necessary to be competitive for a

Chair position, you must be focused on your own career. While this self-centered approach to a career

is essential to achieving national prominence, this behavior can be disastrous for a Chair. The

successful Chair must literally become a coach, cheerleader, and mentor for his/her faculty and

residents. While the Chair is expected to continue to pursue interests and expertise that provides

national prominence for a Department, faculty in particular must be mentored and supported. Rather

than receiving satisfaction from one’s own accomplishments as a Chair, the success of the team (the

Department) becomes essential.

Begin With the End in Mind

This phrase is borrowed from Stephen Covey, author of Seven Habits of Highly Effective People. If you

are considering the pursuit of a Chair position, even in the relatively distant future, as a new faculty

member you must carefully build your career to be competitive for this position. Seeking a Chair job,

particularly at a major academic institution, requires career planning which can cover a decade or more.

First, identify a mentor that will work with you to achieve this leadership position. Hopefully, someone

that has successfully performed in this leadership role will be willing to help you climb this ladder.

Developing a focused research career while obtaining external corporate, foundation, and federal

funding provides the national prominence necessary to be competitive in a Chair search process.

Clinical expertise is a given and this should be a natural companion to bedside and didactic teaching.

Most academic emergency physicians enjoy clinical medicine and are enthusiastic teachers of the

specialty.

Obtaining the administrative experience necessary to gain people and budgetary management skills is

the area where your mentor can be most helpful to you. While the research, clinical, and teaching

accomplishments require your long term drive and tenacity, a Chair mentor can provide you with

important leadership positions within a Department that allow you to achieve management success.

Obviously you have a 7-10 year career plan, which allows you to "build" your Curriculum Vitae to

maximize your competitiveness for a Chair job.

Mostly Positives, But Some Negatives

If you enjoy team victory and the success of others, being a Departmental Chair is an ideal position.

There is perhaps no greater career satisfaction than to see your faculty successfully obtain funded

grants, publish important papers, and ultimately receive academic promotion. It truly is a greater thrill

than achieving these milestones in your own career. Developing a synergistic Department where faculty

and residents work together to accomplish goals that coincide with your vision of the future can be an

amazing experience.

While the clinical, teaching, and research efforts can be invigorating, the current financial climate of

medicine in general can make the Chair’s job a difficult one. In the past, financial skills were not as

essential as they are in the current environment. Understanding Departmental budgets, hospital

finances, decreasing reimbursement, and managed care can be difficult for the

clinician/teacher/researcher initially and often are not nearly as exciting as clinical diagnosis or scientific

discovery. If you do not enjoy finances and budgetary issues, I would not advise seeking a Chair

position.

The general financial climate for academic medical centers is also stormy. Reimbursement for resident

education, patient care, and medical student education seems to be in nearly constant flux. Federal and

State funding sources are subject to the vagaries of the current political climate. Clearly this has caused

many academic Emergency Departments to form alliances with community hospital EDs with expected

difficulties bridging these often very different cultures.

For some of these reasons, many outstanding academic emergency physicians decide to remain as

clinician/teacher/researchers without pursuing leadership positions in Departments. Knowing your own

talents, frustration level, and ability to give others credit can help you decide if a Departmental Chair

position is for you. Leadership can be extremely exciting as decisions that you make can have

significant impact on the Department and everyone that works for the Department. This level of

responsibility can take a substantial toll on your personal life, if you allow it to do so.

Conclusion

In this chapter, some of the issues involved in helping you make the decision to pursue an academic

Chair position are discussed. Becoming a Departmental leader can be extraordinarily rewarding for any

academic emergency physician. Faculty and residents working together to achieve a common vision

represents a career accomplishment for a Chair, which exceeds any individual achievements. This job is

not easy, however. Theodore Roosevelt expressed this eloquently:

"It is not the critic who counts, not the man who points out how the strong man stumbles, or where the

doer of deeds could have done better. The credit belongs to the man who is actually in the arena;

whose face is marred by dirt and sweat and blood; who strives valiantly; who errs and comes up short

again and again; who knows the great enthusiasms, the great devotions, and spends himself in a worthy

cause; who at best knows in the end the triumph of high achievements; and who at worst, if he fails, at

least fails while daring greatly so that his place shall never be with those cold timid souls who know

neither victory nor defeat."

My friends, it would be my pleasure to have you join me in the muck of the arena.

Academic Emergency Physicians as Institutional Leaders

Authors: Louis Ling, Gail Anderson Jr., Ann Harwood-Nuss, and Mark Steele

INTRODUCTION

For emergency physicians who develop a special skill for administrative problem-solving there are

many opportunities. Academic emergency physicians are well trained and well prepared to become

part of the hospital and medical school administration. The specialty of emergency medicine enables its

practitioners to develop goal directed behavior, the ability to prioritize, and fully utilize available

resources. The application of these learned skills in the area of administration is invaluable.

A background in emergency medicine also exposes its physicians to the broad scope of other medical

specialties, the challenges they face, and the individuals involved. Residency training includes off-

service rotations and the daily clinical practice of emergency medicine places us in the "fishbowl" where

we interact with almost every other specialty. Emergency medicine faculties rely on other specialties to

develop off-service rotations as well as to train non-emergency medicine resident physicians in the

emergency department. Few other specialties that have the opportunity to know and understand the

majority of other disciplines in quite the manner an emergency physician does. This knowledge is

extremely valuable in the administrative arena and places emergency physicians in a unique position to

serve the medical staff and educational programs on their campus. The emergency physician in a

leadership position can understanding the clinical, educational and administrative challenges faced by

our colleagues, represent their needs and support their goals. This gives emergency physicians the

unique opportunity to develop rapport and understand challenges facing this wide array of other

specialties.

As a hospital based specialty, a hospital will frequently turn to emergency physicians to improve

hospital affairs. Successful emergency physicians have learned to be diplomatic and can communicate

well with other physicians in a collaborative fashion. Frequently, emergency physician develop a

problem solving approach similar to their busy practice, which is direct and efficient, enabling us to

solve problems and help other physicians. After several years of this type of interchange, it is no

wonder that a successful emergency physician may develop a reputation as a problem-solver and a

team player, ideal skills needed for an institutional leader.

Several case studies demonstrate how several academic emergency physicians have evolved during

their career to include increasing institutional responsibilities.

CASE STUDIES

Gail Anderson, Jr., is Medical Director at the Harbor-UCLA Medical Center and Assistant Dean at the

UCLA School of Medicine. In addition, he is currently serving as the acting chief medical officer for the

hospital’s parent organization, the Department of Health Services (DHS) of the County of Los Angeles.

Previously, he had served as the Senior Vice President of Medical Affairs at the Grady Health System

and Associate Dean at the Emory University School of Medicine in Atlanta. Although his interest in

medical administration had origins from residency experiences, his role in directing Grady’s Surgical

Emergency Clinic and completion of a MBA program in the 1980s contributed to his appointment as the

hospital’s Associate Medical Director. His activities at the state and national level in ACEP as well as

participation in the Hospital Medical Staff Sections of the Medical Association of Georgia and the AMA

provided exposure to organized medicine and the broad constituency of medical staff issues.

Appreciation of the frequent diversity of clinical and academic perspectives was important in gaining the

support of the two medical school faculties who ultimately pressed for his appointment as Grady’s chief

medical officer when his predecessor was not re-appointed. When he was recruited to Harbor in 1998,

the need for building consensus among the medical staff was an important issue. His initial focus was

helping the hospital to achieve a successful JCAHO survey before turning to the recruitment of

department chairs and local staff problems prior to a request for him to serve as interim Associate

Director for Los Angeles County’s DHS.

Ann Harwood-Nuss has drawn on past experiences as well, prior to her appointment as Associate

Dean for Educational Affairs at the University of Florida College of Medicine at Jacksonville.

Administrative opportunities during her career in academic emergency medicine included program

director, chair, Director of Graduate Medical Education, and Assistant Dean for Educational Affairs, as

well as national leadership positions with ACEP. These experiences provided a rich opportunity to

master the scope of accreditation issues and graduate medical education. Her clinical experiences

enabled exposure to other medical specialties, thus preparing her for the administrative oversight role

in the Dean's Office of all GME programs. Knowledge gaps were present, however, and the acquisition

of new knowledge about the principles behind federal support for GME was essential for job

performance and support of the residency programs. Dr. Harwood-Nuss believes that preparation for

administrative leadership within a University system might include preliminary or concurrent training,

such as an MBA. Increasing federal and State regulations commonly require understanding of statute

language and federal financing of GME, a knowledge base not inherently intuitive to clinicians. In her

current position, a close collaboration exists with the teaching hospital Reimbursement Office, and an

optimal blend of effort based on a thorough understanding of GME and federal regulations.

Louis Ling is Associate Medical Director for Medical Education at Hennepin County Medical Center in

Minneapolis, MN since 1990. He used his past experience as a resident member on the Residency

Review Committee (RRC) to assist the faculty and eventually became the Associate Residency

Director for Emergency Medicine. Knowledge of the accreditation process was helpful to other

specialties in the hospital and he was frequently called on to give advice on these and soon other

medical education topics. Getting involved in national committees at SAEM and ACEP as well as

continued membership on the RRC gave opportunities to discuss these topics and to learn new

concepts to improve the home institution which in turn gave experience that could be shared nationally.

He was asked to coordinate hospital-wide educational affairs when his predecessor became the

medical director.

Mark Steele, is Chief Medical Officer (CMO) at Truman Medical Center (TMC) and Associate Dean for

TMC Programs at the University of Missouri - Kansas City (UMKC) School of Medicine in Kansas City,

Missouri and has been since 1999. He served as Program Director for the UMKC/TMC Emergency

Medicine Residency Program for seven years and Vice-chairman and then Chair of the Department of

Emergency Medicine for thirteen years. Just prior to becoming the CMO and Associate Dean, he

served as President of the TMC Medical Staff and President of the systems physician practice plan. As

a result of these leadership roles, he was asked to apply for the newly created CMO/Associate Dean

position. This position became necessary when a non-physician was hired as CEO. In his current role,

Dr. Steele oversees all of the medical affairs of the hospital, coordinates the resident and student

rotations, and other residency related activities including the NRMP "match" and resident graduation

ceremony. He is in a position to significantly impact other residency-related needs such as the resident

salaries, resident/student call quarters and conference and meeting space, and he helps to coordinate

the research infrastructure for the institution. Opportunities to impact clinical care at the hospital is

significant. He is involved in physician recruitment for several of the hospital-based specialties and

deals with issues of a multidisciplinary nature such as ED overcrowding and ambulance diversion,

issues of obvious importance to EP’s. He is also heads up the PI and Risk Management activities of the

hospital including the evaluation of sentinel events, as well as matters relating to credentialing and

privileging of the medical staff.

PITFALLS OF INSTITUTIONAL POSITIONS

The dual life as an institutional official and emergency physician presents some challenges. One

difficulty is learning to give up responsibilities in the emergency department to others. It is important not

to speak for the emergency department but to ensure that a separate individual can represent that

perspective. Otherwise, the institutional role is crippled by the constant conflict of interest or perceived

conflict between the institution and the emergency department priorities. Sensitivity to the possibility of

favoritism while conversely avoiding the opposite (over compensation) is challenging. Balancing the

needs of the hospital, university and physician practice group is always an issue.

It is important to have a good understanding of responsibilities with the emergency department chair,

especially if there is clinical salary support. Consider an exit plan if this administrative position does not

work out and whether you think this is a permanent or temporary career change. Increased institutional

and especially financial responsibility makes it more likely that you may fail or need to leave because of

political pressures out of your control when the institutional leadership changes, or with organizational

restructuring or mergers. Consider whether you will be comfortable rejoining the department faculty full-

time or would want to leave the institution to continue an administrative career.

ACADEMIC EXPECTATIONS CHANGE

Academic promotion may or may not progress in the traditional manner. The amount of time available

to pursue teaching/ research activities is usually severely curtailed. The busy medical director may

have to sacrifice some coveted academic recognition and achievements to fulfill duties to the institution.

Frequently, faculty members in such appointments maybe placed in an academic series delineated for

administrative physicians. Ultimately, the joy and satisfaction that comes from the work is making a

broader impact on patient care and helping to craft an environment that will allow fellow physicians to

effectively practice their profession and flourish in their teaching and research endeavors.

Academic productivity will certainly decrease but is not necessarily abolished. It may be possible to

lecture to the EM residents regularly and maintain participation in research such as Mark Steele with

the EMERGENCY ID NET research group. Ann Harwood-Nuss and Louis Ling have both continued to

edit textbooks but it is certainly a challenge for any administrative physician to maintain these activities

given the significant administrative burden.

SUCCEEDING IN THE INSTITUTION

Requirements of the medical director/associate dean position most importantly include good

communication skills, respect of ones colleagues, and common sense. A willingness to do what is right

and in the best interest of patient care is also important.

Prior administrative experience in a leadership role is probably the most important preparation for this

type of position. Mark Steele participated in a three-part medical director course jointly sponsored by

the National Association of Public Hospitals (NAPH) and the Wagner School of Public Health Service.

Similar leadership type courses are available through the Harvard School of Public Health and the

AAMC, which offers an Executive Development Seminar. They cover topics typical of most leadership

courses, including such as negotiation skills, media training, effective communication, budgeting, etc.

The opportunity to network with others in similar positions may be the most helpful part of these

courses. While taking at least one such course is recommended, it alone will obviously not turn one into

an effective administrator/leader overnight.

According to Gail Anderson, The foundation of a successful medical director is built on trust. The

support of the department chairs/chiefs is fundamental to making any significant progress. As a group,

these individuals must believe that the chief medical officer will deal with each of them in a fair and

forthright manner. Likewise, the other administrative colleagues must believe that the medical director

will honestly represent the needs of the institution and its patients. Perception that certain interests are

favored at the expense of others can be destructive to institutional morale. Thus, an emergency

physician needs to very careful to avoid being seen as using the role to advance the goals of the ED

over those of other departments. As long as the best interests of the patients are in the forefront, the

medical director’s support can remain firm.

The dynamic tensions that exist between various groups in academic medical centers provide an

opportunity for the chief medical officer to impact clinical care, education of house staff and students,

and research programs. If you happen to be an expert in these issues, the contribution can be more

obvious than when the matter is outside your specialty area. After considering input from reliable faculty

sources, and sometimes external individuals, the medical director often has to make decisions that may

or may not be pleasing to all parties. Usually, however, if appropriate inclusion, consideration and

discussion has taken place, the personality and influence of the office can be effective in guiding the

parties to reach a satisfactory solution. This is the real gratification of the job – creating the right mix to

catalyze very talented individuals to a point where they can achieve a previously elusive resolution.

NETWORKING

After joining the hospital or medical school administration, it is critical to develop a network of others

with the same interests. To keep this network it is critical to be active in different organizations such as

the American Association of Medical Colleges (AAMC) or Association for Hospital Medical Education

(AHME) or the medical school section of the American Medical Association (AMA) and to volunteer for

others such as the ACGME. The actual organization matters less than the exchange and interaction.

Some of these organizations are outside the usual emergency medicine realm but in time, as more

emergency physicians evolve into these roles, they have also become more visible in these

organizations.

TO SEE OR NOT TO SEE PATIENTS

Mark Steele believes- it is very important to remain clinically active to maintain credibility with the

medical staff. He is 75% administrative, 25% clinical (20% time clinical or one eight hour shift/week and

5% reserved for educational/research activity within the ED). This is not dramatically different from his

breakdown as chair (65% administrative, 35% clinical) but the administrative piece has certainly

changed. The ED staff allows him the flexibility to choose his shifts and as a result, he does not work

weekends for the most part but though they have offered to allow him to not work nights but he has

chosen to do so. He sensed a change in the way he was treated by fellow physicians almost overnight

after assuming his new role. One day soon after his appointment, one of the staff neurologists saw him

and said "there’s the administrator." She later saw him in scrubs when he was working in the ED and

she seemed surprised but pleased to learn that he still did clinical work.

According to Louis Ling, it is a constant challenge to stay competent clinically with less clinical time and

less time to spend on current reading. To remain up to date, the academic setting is advantageous for

the high number of state-of-the-art conferences, especially case conferences. Case conferences allow

discussion and thinking about challenging cases to which administrative physicians have less

exposure. The setting and the amount of clinical practice will vary but should probably involve exposure

to patients every week, but since he is half time paid by emergency medicine, his clinical shifts are

distributed through the weekends and nights proportionately.

The nature of faculty "shifts" in the Emergency Department make active clinical practice somewhat

difficult. The administrator’s normal duties occur during the traditional workweek, whereas an

emergency physician’s duties occur around the clock, seven days a week. Active clinical participation in

evening, night and weekend shifts may result in excess absence at a variety of administrative

gatherings. Ann Harwood-Nuss restricts her clinical activities to weekend ED shifts to avoid this conflict.

Gail Anderson notes that the ability to remain clinically active will vary with the demands of the

particular position and institution. At the associate medical director level, it may be possible and even

desirable to have some direct patient care activity. It is difficult to imagine that anyone can be credible

in the chief medical officer role without having demonstrated competence as a clinician. However, in

today’s highly complex health care environment a considerable amount of time, attention, and energy is

required to meet the myriad external regulatory requirements as well as the internal clinical operational

issues. "Protected" clinical time may be a luxury, at least in large public teaching institutions where

there is an expectation of immediate access to the top medical administrative officer when pressing

issues frequently arise. One should not be caught in a tug of war between a direct patient care

obligation and a duty to simultaneously attend to a critical institutional problem.

CONCLUSION:

When emergency medicine was young, it was at a disadvantage because the establishment was

unable to understand the emergency medicine perspective. That could only change as emergency

physicians matured and became the establishment. Emergency physicians are well trained and well

positioned take on leadership roles. The opportunities exist and emergency physicians should take

advantage of them. It is good for the individual, good for the specialty and good for the institution

On Becoming the Dean

On Becoming the Dean

Author: Vincent P Verdile, MD

Any emergency physician who has entertained the travails of a lifelong commitment to academic

medicine understands clearly the pathway to a successful career. A demonstrated mastery in the

endeavors of research, clinical practice and teaching are all essential. Medical schools have well

established academic promotion and tenure guidelines that articulate the pre-requisites for advancing

from Instructor to tenured Professor. To succeed in academia, one must focus on the long-term

objective of promotion. While success is measured in many ways, understandably, for those dedicated

to academia, becoming a tenured professor in emergency medicine is a recognizable milestone.

Perhaps the most coveted title in a medical school however, is that of the Dean. The Dean of a medical

school represents the highest authority in the academic medicine hierarchy. The scope of responsiblities

for the contemporary Dean crosses the entire spectrum of an academic health science center (AHCS)

including but not limited to patient care, education, research, and the business of medicine.

Unfortunately, since emergency medicine is such a ralatively new discipline in the house of Medicine,

there are few mentors and generally there are no established guidelines for emergency physicians to

follow to become a Dean. If an emergency physician wishes to obtain a deanship, where does the

process begin? While each medical school can have it's own unique system; this chapter will outline the

issues for emergency physicians to better comprehend to process.

Selection of the Dean

The nature of the selection process varies depending on the institution and the scope of responsibilities

for the Dean. Larger universities with multiple health care related educational programs might require a

different Dean than a small, single mission medical school. Whether or not a physician practice is part of

the medical school and the extent to which research and the research enterprise is focal to the

university's profile are all relevant and will determine the type of Dean that is sought after.

Traditionally a decanal search, commissioned by the Board of Directors/Trustees (BOD) of the

university or medical school, would be initiated as soon as they are made aware that an incumbent

Dean is stepping down. These searches can be resource intensive for an institution and can take a

considerable amount of time to complete (6 –18 months). Search firms can be retained to the do the

screening and queuing of candidates for an internal search committee. While search firms can expedite

the process, they will usually make it more expensive.

At anyone point in time there may be a fair number of the 125 Dean positions open and with active

searches underway. Currently, according to the Association of American Medical College's directory,

there are 13 acting or interim Deans in place with many active searches in progress. This can prompt a

BOD to test internal candidates in the role as "interim" or "acting". This can work both ways for the

candidate serving as interim in that great success may mean the permanent job is offered, and anything

less than great success, by whatever metric, can mean the search for the permanent will not result in

the interim getting the job. Internal candidates have an advantage in knowing the institution, the politics

and the scope of the position. The disadvantage is that there would be no honeymoon if selected and

the managerial style will be well known to the other leaders in the institution.

For external candidates, the challenge is to learn as much as possible about the medical school or

university during the interview process. This should include, but not be limited to the extent of the

endowment, the National Institutes of Health (NIH) ranking of the institution, the scope of the

responsibilities and the general hierarchical structure of the dean within the framework of the entire

AHSC. Depending on the by-laws of the university or medical school, the BOD usually retains the

responsibility to install a Dean once the selection process produces a candidate. For internal

candidates, deanships are frequently thrust upon them, first as interim to stabilize an organizational

crisis, and then depending on the decanal search process, becoming permanent. Whether internal or

external, the appointment of a Dean of a medical school is a chance to serve in an AHSC at a level

where strategic directions can be set and legacies can be established.

The AAMC estimates that between 1980 and 1992, Deans held the position for an average of 31/2 years.

While the high rate of turnover is clearly multifactorial, it begs the question of the validity of the

traditional deacanal search process. Clearly, given the dynamic forces affecting AHSC's in this country,

the qualities of a successful medical school leader must be identified.

Qualities of the Dean

In my opinion, the qualities that make for a successful emergency physician lend themselves very well

to the Dean's position. The Dean must be able to multi-task, move from topic to topic in rapid

succession, and not be perturbed by the emotional roller coaster that comes with the position. There are

many different constituents that must be satisfied, and any successes achieved by the medical school

faculty must not be shared while any failures rest entirely with the Dean. The analogies to caring for

patients in the emergency department is remarkable.

The Dean must have impressive interpersonal skills. Communication is paramount to success, as is a

sense of fairness, consensus building and empowering faculty and staff. While the responsibility for

delivering successful education, research and patient care missions rests with the Dean, the ability to

delegate is essential to getting the job done.

The Dean must have credible credentials, be dedicated to all the constituents…. faculty, students,

patients and staff and be honest. A key factor in producing the missions is having the trust and loyalty of

the faculty and promoting faculty empowerment. Because of the current health care and health

education environment, the Dean must also have balance and the ability to adapt to change. Knowledge

and analytic skills are essential to understand the ever-changing landscape of the medical education

and research environment. Familiarity with state and federal policies that impact medical schools and

their missions is paramount.

The final quality that must be emphasized for a successful dean is that of being able to make decisions

and sometimes with not all of the necessary data. Indecisiveness will paralyze the medical school, and

weaken the Dean's position of power in the AHSC. Being decisive, may lead to an erroneous decision,

but this can always be corrected at a later time. A Dean who is unable to make decisions and see them

through to fruition will never be successful.

Responsibilities of the Dean

The Dean will be expected to have a mastery over the business of the physician practice. Many medical

colleges are highly dependent on the revenue from the clinical practice to fuel the less than optimal

revenue generating missions. This financial reality ties the success of the education and research

mission to the clinical enterprise. Therefore the Dean must be an astute clinician, financially savvy and a

born entrepreneur.

Next the Dean must be the guardian of the educational mission. Many AHSC are under siege because

of financial exigencies. The education mission, while revenue generating, often can not sustain itself

given the true costs of educating physicians and scientists. The Dean must be willing to advocate for the

educational imperatives and negotiate tenaciously for every dollar needed to deliver the mission. While

expertise in adult education methodology is helpful, more importantly the Dean must be able to develop

an educational strategic plan, critically evaluate the educational process, determine the desired

outcomes, and hold the faculty and academic administration accountable for the mission. As clinical

faculties are pushed harder and harder to generate clinical revenue, the time spent in medical education

is infringed upon. The Dean must be able to demonstrate the compensation for medical education as

well as articulate the deliverables for the clinical faculty.

As long as the NIH continues to increase the amount of federal dollars available for research, medical

schools will intensely compete for those dollars. The benefits to the research program and the medical

school are enormous because of the indirect revenues from NIH grants. Furthermore, to the extent that

it is valued, the NIH ranking of medical schools based on the funding can be an important metric for

students interested in medical education or basic science training.

The Dean must be sure that the science of the medical school is pointed towards the areas that the NIH

is funding and plan accordingly. Analogous to the clinical faculty, the basic scientists have limited time

for the education mission as they are forever pressured to generate grants. It is incumbent upon the

Dean to be sure the scientists have a clear understanding of the expected role they play in both the

graduate studies and medical education programs.

Another quality to mention, also pertaining to research is that of research compliance. In many medical

schools the Dean serves as the Research Compliance Officer for all human and animal research

programs. While being a champion of the research mission it is imperative that the compliance with

federal assurances for safe research practices is maintained in order to stay in the research business

for the long term. It is encumbent upon the Dean to be sure the medical school fosters an intellectual

milieu that is ever curious about science but ever sensitive to the needs of patients.

The resources available to any Dean are finite. Given an unlimited budget, most Dean's would over

spend! Therefore, it is important for Dean's to spend considerable time raising money for the medical

school's missions. Fund raising takes on increasing importance for Deans at medical schools with small

endowments or in the face of new demands (i.e. new buildings) on fixed resources. Alumni are the

natural first choice to solicit support, but foundations, corporations, grateful patients and the general

public are also potential benefactors. Fund raising can and perhaps should consume a fair amount of a

Dean's time to help secure the future financial viability of the medical school.

Perhaps the least exciting and yet undeniably important responsibility of the Dean is to be an effective

administrator. Any medical school, large or small, has at its core a business, facilities, employees,

contracts, and strategic planning. Furthermore an essential responsibility of the Dean is to select

department chairs and medical school administrators (Associate and Assistant Deans), which will

directly impact on the effectiveness administration. Appointments will reflect on the Dean's ability to

manage the medical school. Administratively, the Dean must possess all of the skills of an accountant,

an organizer, a social worker and a visionary.

The Dean will be in a position of power and have all of the responsibilities of the position in any

institution that places value on the tripartite mission…. education, research and patient care.

Conclusion

The attainment of a deanship at one of one hundred twenty five medical schools in this country is clearly

one of the most recognized and coveted positions in academic medicine today. While the pathway to a

deanship is infrequently through academic emergency medicine, it is likely that given the training,

decision making ability, and ever growing stature in academic medicine that emergency physicians will

be recruited to participate in the searches for leadership in medical schools.

This chapter has outlined some of the issues that will confront emergency physicians interested in

becoming the Dean. The dynamics that are shaping the future of AHCS's will require a non-traditional

Dean. Emergency physicians as our history has shown, have been non-traditionalists in the House of

Medicine and in this author's opinion make superb candidates for deanships.

SUGGESTED READINGS

1. Hellman S. Tales of the unnatural: Return from the dean (d). JAMA 1998;280:1657-1658.

2. Davis BC. Ten questions every dean should ask. Currents 1998;28-32.

3. Cullinan M. But what does a dean do? The Chronicle of Higher Education March 9, 2001, B5.

4. O'Connell GE, Grosch WN. Using quality management to balance the economic and humane

imperatives in behavioral healthcare. J Qual Improv 2001;27:107-116.

5. Pardes H. The perilous state of academic medicine. JAMA 2000;283:2427-2429.

6. Griner PF, Danoff D. Sustaining change in medical education. JAMA; 2000:283:2429-2431.

7. Aaron HJ. The plight of academic medical centers. Brookings Policy Brief. 2000;59:1-8.

8. Bonner TL. Crushing the commercial spirit in academic medicine: A crusade that failed. Acad

Med 1999;74:1067-1071.

9. Bentsen T. Getting personal could be key to deans' durability. AAMC Reporter 1998;7:1-3.

10. Clawson DK, Wilson EA. The medical school dean, reflections and directions. McClanahan

Publishing House, Lexington, KY 1999. www.aamc.org/about/cod/opendeanship/start.htm

11.

Prophylaxis Against Academic Burnout

Author: Carey D Chisholm

Introduction

The academic career has many unique challenges and sources of stress. Over time the risk of

"academic burn-out" will confront many if not most emergency physicians engaged in academics.

Fortunately, many of the very sources of burn-out may in fact serve as resources for career longevity

and fulfillment.

Potential sources of stress in academic emergency medicine revolve around the lack of set limits within

one’s job setting. The job is simply never "finished". In fact, there are frequently simultaneous and

possibly conflicting tasks that may pull one in multiple directions. The grant deadline, manuscript

revision, textbook chapter deadline, national committee task, hospital and departmental committees,

medical student letter of recommendation and resident counseling are simply layers added onto one’s

clinical responsibilities. Without proper planning and the correct frame of mind, these constant deadlines

and tasks can create a sense of personal chaos and job dissatisfaction. Furthermore, one’s ethical

responsibilities to mentor and teach medical students and residents creates the need to approach tasks

with a perfectionistic inclination.

Fortunately, there are many components of an academic career that can counterbalance these

stressors and perhaps assist in preventing job dissatisfaction and burn-out. While multiple jobs may be

taxing, they also prevent one from becoming numbed by repetition and the rut of routine. Intellectually,

the myriad of challenges poised by our patient population, inquisitive medical students and assertive,

intelligent EM residents serve as daily challenges for us to remain a student for life. Intellectual curiosity

is valued and cherished in the academic setting. As one progresses in their career, areas of true

expertise are developed, and are highly valued by medical students, residents and colleagues at a

national or international level. Opportunities abound to learn new skill sets, accept new administrative or

teaching challenges, and engage in professional growth opportunities.

Have a mission statement or a personal vision. Ideally this integrates your personal and professional

life with both the home and work environment. Failure to do so will result in conflicts, often

subconscious, that result in long term insidious stressors. Without this personal mission statement, it

becomes impossible to prioritize tasks and budget how one should allocate their time. The personal

mission statement is your rudder, and those who fail to have one will risk drifting aimlessly through their

career.

Develop Time Management skills. This is the most important stress management and productivity tool

that one can have. If you have not had formal training in time management, it is almost certain that you

are working twice as hard and accomplishing only two-thirds of what you are capable of doing. Learn

and develop this skill set for your professional future and family sanity. You must have a personal

mission statement, a prioritized task list and a planning device that is comfortable for you to carry and

use. Time management experts estimate that for every hour spent "planning" you "save" an additional 3

hours. Perhaps most important is the sense of personal control that comes with time management.

Personal Planner (Organizer)

This device must be portable and kept with you at all times. Computer based models are popular, but

the bottom line is that no device is effective if not used, and there’s nothing "wrong" with a paper based

system if preferred. A month at a glance scheduling calendar is the minimum, although most academic

physicians will need a week or even a day at a glance. Recurring dates such as monthly committee

meetings must be entered (include social events such as birthdays too). "Retrograde planning" of

preparatory steps can then be entered into the task planner. This critical skill begins with a final product

deadline (e.g. presentation at a national meeting) and breaks it into component parts. Each component

part is then assigned a deadline in your planner, allowing a stepwise progression towards the final goal.

The more specific each component part, the better. Building in a buffer for each component completion

deadline allows unexpected crises (or opportunities) to be addressed. Tasks are prioritized each day to

channel your activities towards obtaining your most important goals and meeting upcoming deadlines.

This is not simply a "to do" list, as it isn’t the number, but rather the quality, of the tasks accomplished

that is important. Such a device should also contain contacts (never look up a phone number more than

once) and serve as a repository for "brainstorms" that fleetingly emerge from our subconscious. At least

weekly you need to sit down and plan your upcoming week in some detail, while looking ahead over the

next month. At least once a month, look ahead for the next 6 months to refresh your memory about

upcoming projects and deadlines.

Learn to say "NO". This is a common skill among almost all successful academic faculty members. At

some point, usually about the 5-10th year of our career, we realize that we cannot continue to add new

responsibilities and fulfill existing obligations and tasks well. As more and more tasks are added,

projects become rushed and deadlines are missed. Frustration mounts as it becomes evident that we

are no longer producing high quality work. Before taking on a new task or responsibility, examine it

critically to see if it meets your professional (and personal) mission statement. If it does, develop an

accurate assessment of the time commitment. Where will those hours come from? Select another

current activity of equal time commitment and off-load it before accepting the new challenge. And be

careful to maintain a "crisis buffer" of time as invariably family illnesses, or other unexpected events will

develop. Failure to do so assures that the "crisis management" comes out of personal (family) time or

means missed deadlines.

Delegation: Many of us do not delegate tasks well. This is often rationalized by thinking that only you

are capable of performing the task (correctly), or concern that your value to the organization may be

diminished (and you therefore may become expendable) if others are taught to do tasks for which you

are responsible. Remember however that you can delegate authority to do a task, but you cannot

delegate responsibility for assuring the product is completed. Learn what items can be assigned to

others to accomplish for you. The time invested in training an assistant will pay off many times over in

the time you save by effective delegation. This is also key in developing our future leaders and an

invaluable component of the mentoring process. Develop priorities and stick to them. Decide the t time

with which projects need to be accomplished, and request weekly updates of the progress made.

Work smarter, not longer. Americans work longer hours than any other industrialized nation. Our

ability to work hard serves as a source of pride and has been integral to our productivity. However, the

candle can be burned at both ends for only a finite period of time. By focusing 80% of our efforts on the

critical 20% of high priority tasks, we can increase productivity without increasing our work week.

Indeed, as one progresses in their career, prolonged work hours may serve more as a red flag of

personal disorganization rather than a badge of honor. It’s not how many hours you work that

matters…it’s how productive you are with your hours worked. Almost everyone can easily learn to work

more efficiently through the application of basic time management skills. Workaholics develop

dysfunctional coping strategies and ultimately lose their creativity and productivity. The Starling curve

analogy applies here.

Block out "protected time" every week. This should include both personal as well as professional

time. During such times, accept no phones calls or office visits. This is your private, focused time.

Whenever possible, arrange this during periods of intellectual and physiologic peaks in terms of your

circadian rhythm. Your office door must remain closed in order to discourage passersby from

interrupting you. Use this time also to protect yourself physiologically from the stress of shift work. For

instance, if you are between 2 night shifts, do not allow yourself to be scheduled for a committee

meeting in the mid-afternoon. How many of those attending would be willing to meet with you at 0200

hours in the morning? Use e-mail or a telephone call to convey critical information that may impact

decisions at the meeting. A well run meeting will have both an agenda as well as good minutes, allowing

two opportunities for your input if you choose to miss the meeting. Time for aerobic exercise (minimum

of 20 minutes 3 times a week) should also be guarded from intrusion.

Guard your schedule carefully

Once you create a daily schedule, try to stick to it. This will be extremely difficult as there are many

interruptions that will rob you of time. Phone calls, impromptu meetings, non-scheduled visitors, and

email are all "time robbers". Being available and flexible is important up to a point, but a complete "open

door" policy will likely cause you so many interruptions that you will be left with little quality time to

perform your daily tasks. Unless expecting a phone call, try letting voice mail take messages, batch

them, and return them when taking a break from other tasks. If appropriate, answer by email, which

takes considerably less time. Speaking of email, try to do this only once a day. Many individuals find that

reading and answering email takes less mental concentration than writing publications, reviewing

articles, or designing projects. Consider saving email for the end of the day thereby protecting the more

mentally alert morning hours for important (higher priority) other tasks. If possible, spend some portion

of your office time during off-hours. Many successful academicians will tell you that their most

productive office time is before 9am or after 5pm as this minimizes interruptions and impromptu

meetings by others who "just notice you" in the office.

Other Time Management Tricks

Use your commute time wisely: This can be a source for CME (educational tapes), the major venue to

keep up with current events, an opportunity to plan your next week, or even accomplish work. The use

of a small hand-held Dictaphone is particularly useful for generating letters or organizing your "to do" list.

For drivers, be wary about the use of the phone while operating a vehicle. Books on tape can also

create a recreational outlet.

Record TV programs: This allows you to watch them on your schedule, not theirs, and best of all

allows you to fast forward through all of those mind-numbing commercials. For instance a 3.5 hour

football game can be watched in 1.5 hours by recording it (while you’re outside enjoying the sunshine at

the park). By purchasing your own exercise equipment, you can multi-task even more by watching the

tape while working out. DVD, with subtitles, offers a way to watch movies while exercising.

Take advantage of small chunks of time: Five or six minutes waiting in a line may seem only a minor

annoyance. Ten such episodes in a day quickly add up (over 2 weeks a year!). EM physicians are

masters of multi-tasking, and of turning attention from one thing to another. Capture these otherwise

wasted minutes by keeping your personal planner at hand (or your cell phone, perhaps even that

magazine, journal or novel).

Avoid procrastination: All of us are procrastinators up to a point. This is perhaps the greatest time sink

of all. Deferring activities that we dislike, appear overwhelming, or make us uncomfortable is human

nature. Divide such activities into small "bite-size" pieces, and work slowly (yet progressively) towards

their completion. Build in a series of rewards for those particularly undesirable tasks ("I’ll register the car

today, but go to that movie afterwards"). Finally, a good rule of thumb is to try not to pick up a piece of

paper more than twice without taking some sort of action on it. If you have let it lay for a week without

taking action on it, then likely it isn’t that important anyway. You should strongly consider throwing it

away, or delegating it to someone else to save yourself time better spent in more productive pursuits.

Other Concepts About Burn-Out

EM is a clinical specialty. Accept this, and the clinical work in the ED that accompanies this. Clinical

teaching remains a key activity for EM faculty, and should never be denigrated as a chore. Value your

clinical time and protect it from incursions from other areas of your job. For instance, I do not accept any

non-patient care telephone calls during ED shift time. Trying to solve a difficult administrative problem or

plan a teaching event or committee meeting will result in two inadequate performances, and raise rather

than lower one’s stress levels. Your patients and your students/residents need your focused attention

during these times, and your professional obligation lies with them. Caveat: one cannot maintain the

same clinical work schedule as one’s community colleagues and expect to be academically productive.

Academicians often work unrealistically high clinical workloads.

Institutional alignment. Academicians who remain in their positions for extended periods of time have

developed a sense of "alignment" with the values of their academic center. If the values diverge, conflict

results and longevity is unlikely. New chairmen, Deans, or hospital CEO/CFO’s all may impact an

academic center’s institutional values. Perhaps the best strategy to avoid unpleasant surprises is to

work at centers that have EM departmental representation in search committees for key institutional

personnel.

Play hard. This means that you need to have a personal life and identity that as separate from your role

as an academic EM physician. Your family and close friends require appropriate investment of time and

energy on your part. One of the most frequent themes among business executives is that they wished

they had spent more time with their family than they did. Talk to older mentors and you will be surprised

how pervasive this is. Only strong attention to this and proper planning will allow you to avoid making

this tragic mistake. On a personal level, it is easier to empathize with our patients and our

colleagues/students at work if we are well-rounded and have an active extracurricular life. Family

outings should be part of your regular planning, and never become the victim of meeting a deadline.

"Medicine free" evenings are critical when out with work colleagues at events that include non-medical

spouses and friends. I encourage you to envision how bored you would be if you sat at a dinner table

with a group of accountants and listened to them discuss their "great accounts" all evening. Younger

faculty have more difficulty with this, but with agreement that "medical talk is taboo" (and a few pregnant

pauses the first time you try this), it is surprising how enriching the social event becomes. Non-medical

friends and family are intrigued with the humanistic aspects and stories of our practice, so if you must

revisit the workplace, focus on these (but be careful not to violate patient confidentiality). Vacations

should be exactly that: time away from professional obligations to use for personal relaxation, growth

and family time. Work during a vacation is an oxymoron. Leave it behind and DO NOT feel guilty about

not working. Learn to relax! Your productivity is enhanced by this activity. Set goals for personal

development. For instance, decide to develop a new hobby every other year. This complements your

"student for life" role as a faculty role model, and enriches your life with new knowledge, experiences

and friendships. We read so much material in our professional lives that it is easy to lose track of the joy

of pleasure reading. Again, make a goal to regularly engage in non-medical reading.

Other Wellness Tips

Exercise

This is a critical component of any wellness program. A well designed exercise program not only

increases energy and stamina but also bolsters the immune system. Doing this in combination with

watching TV, pleasure reading, or with a group of friends makes it a social event as well. Exercise not

only provides health benefits for the body, it is also a great stress reliever. Remember going for a walk

to clear your mind when studying for tests? Muscular activity triggers the sympathetic nervous system

and helps keep you mentally alert. Even stretching exercises at your desk may afford a needed mental

break and result in better creativity. As noted above, a minimum of 20 minutes of aerobic exercise or

resistance training three times a week is recommended. Try to schedule some regular time at the gym,

walking, jogging, or other physical activities to maintain peak performance.

Pleasure reading

For reasons discussed earlier, this activity augments one’s humanistic qualities as a physician, adds

social interests, provides an escape from stress and breaks the rut of reading only professional material.

Reading "humanities" books (how other people live and think) allows a broader perspective and

potential for empathy. Setting a goal, such as reading one novel a month, increases the likelihood that

this will be accomplished.

Some of the material in this chapter also appears in the chapter "Physician Wellness in an Academic

Career" co-authored with Debra Perina, MD in the SAEM-EMRA Emergency Medicine: An Academic

Career Guide.

References

Andrew LB, Pollack ML, Wellness for Emergency Physicians, ACEP, Dallas, Texas, 1995.

Gallery ME, Whitley TW, Klovis LK, et al, A study of Occupational Stress and Depression among

Emergency Physicians, Ann Emerg Med, 31, 1992, 58-64.

Hall JN, et al, Factors Associated with Career Longevity in Residency-Trained Emergency Physicians,

Am J Emerg Med, 21, 291, 1992.

Hallery ME, et al, A Study of Occupational Stress and Depression Among Emergency Physicians, Am J

Emerg Med, 21:58, 1992.

Keller KH, Koenig WJ, Management of stress and prevention of burnout in emergency physicians, Ann

Emerg Med, 18, 1989, 79-84.

Meyers MF, Doctors Marriages: A Look at the Problems and their Solutions, Plenum Medical Book Co.,

New York, NY, 1994.

Pfifferling JH, Burnout Self-Appraisal, Center for Professional Well-being, Durham, NC, 1986.

Phifferling JH, Things I Wish They Taught in Medical School, Resident and Staff Physician, 36:85, 1990.

Quill TE, Williamson PR, Health Approaches to Physician Stress, Arch Intern Med, 150, 1990, 1857-

1861.

Sheehy G, New Passages: mapping your life against time, Random House, New York, NY, 1995.

Sotile W, The Medical Marriage: A Couples Survival Guide, Birch Lane Press, 1996.

Whitehead DC, Thomas H, Slapper D, A Rational Approach to Shiftwork in Emergency Medicine, Ann

Emerg Med, 21, 1992, 1250-1258.

Further reading

Alec Mackenzie The Time Trap 3rd

edition, 1997 AMACOM

Alan Lakein How to Get Control of Your Time and Your Life. 1973 Signet

Susan Silver Organized to be the Best. 1995 Adams – Hall Publications

Jane B. Burka & Lenora M. Yuen Procrastination : Why You Do It, What to Do About It 1990 Perseus

Press

Resources for Faculty Development

FACULTY DEVELOPMENT LINKS

The brief annotated bibliography that follows was drawn from the indexed Emergency Medicine

literature using the unmodified search term 'faculty development'. Compared to other specialties,

particularly Family Practice, Emergency Medicine has published relatively little on the subject of faculty

development among academic emergency physicians.

The Champions Project: A Two-tiered Mentoring Approach to Faculty Development

http://www.academicmedicine.org/cgi/content/full/75/5/553

Faculty in Wayne State University's Department of Family Medicine have undertaken the Champions

Project, a systematic, collaborative effort to achieve higher levels of professional performance in the five

domains of patient-centered clinical practice and teaching, evidence-based medicine, practice-based

research, professional academic skills, and leadership and organizational skills. Although facilitated by a

medical educator who coordinates departmental faculty development, each domain is 'championed' by a

core department faculty member who has both skill and interest in the targeted area of faculty

development. In turn, each champion chooses a national-level domain expert for long-term consultation

to design objectives, instruction, and outcome measures for the content area. These faculty create and

deliver, on an ongoing basis, a faculty development curriculum through which department members can

continuously keep their knowledge up to date and improve their skills in each domain. Acad Med

2000;75:553-554.

Faculty Development Site of the Faculty of Medicine of McGill University

http://www.medicine.mcgill.ca/facdev/

This site provides information about faculty-wide workshops at McGill, Medical Education Rounds,

Teaching Scholars Program, and links to medical education sites of interest.

A Faculty Development Workshop on "Developing Successful Workshops"

http://www.academicmedicine.org/cgi/content/full/75/5/554

This workshop was designed to give participants a framework for developing successful workshops and

to take them through each of the planning steps. On the first day, workshop modules consisted of

defining participant needs, setting appropriate objectives, matching content to objectives, and matching

teaching methods to content. On the second day, participants had an opportunity to apply the steps

discussed on the first day to a workshop they were planning to conduct in their own setting, and to

review strategies for evaluating workshops. They worked in pairs to design (or refine) their workshop

content, and then presented their plan to the larger group for feedback and discussion. The last day of

the workshop emphasized facilitation skills for both interactive large-group presentations and small-

group discussions, and each participant was asked to present a part of his or her own workshop to the

group. Each workshop module was introduced by a brief plenary session that summarized the key

issues for discussion and was supplemented by a detailed handout designed to guide workshop

planning. However, most of the activities took place in small groups. Acad Med 2000; 75:554-555.

Faculty Professional Development Workbook

http://www.mcphu.edu/col/wkbkcontents.htm

This website and its links describe the Annual Goals and Objectives process that accompanies the

Faculty Professional Development Conference used at MCP-Hahnemann to assess individual faculty

achievement and offer guidance for professional growth.

A Computer "Boot Camp" for Academic Medicine Faculty

http://www.academicmedicine.org/cgi/content/full/75/5/555-a

The Office of Medical Education Research and Development (OMERAD) at Michigan State University

sponsors an annual faculty development seminar series dedicated to training academic physicians in

essential faculty skills. Computer skills such as word processing, preparing scientific presentations,

information retrieval and management, electronic communication, and bibliographic reference

management are imperative to professional productivity and development. Because most academic

medicine faculty never receive training in computer skills, a series of workshops was developed in 1998

based on Carroll's minimalist design principles. Using Carroll's principles, and the analogy to the military

approach to training, the seminar series was named Computer Boot Camp. Acad Med 2000;75:555-556.

Using the Internet Effectively

http://www.medinfo.ufl.edu/cme/inet/

This program is intended for anyone interested in using the Internet as an effective medical resource. It

includes a complete 25 minute RealAudio lecture with synchronized slides by the Director of Medical

Informatics at the University of Florida.

Medical Informatics for Faculty Development

http://www.omerad.msu.edu/reznich/homepage5.html

The purpose of this site is to introduce physicians and other health professionals and learners 1) to the

many uses of the Internet and 2) to computer skills that will support the academic side of medicine and

medical education. All modules for electronic mail, newsgroups and the web are based upon versions of

the Netscape tool package. Modules that address academic medicine computer skills are based upon

common computer productivity tools such as Microsoft Word.

The Faculty Self-efficacy Scale: A Tool for Evaluating Faculty Development Interventions

http://www.academicmedicine.org/cgi/content/full/75/5/559

The Faculty Self-Efficacy Scale is designed to measure faculty physicians' perceived self-efficacy for

performing tasks within three professional role domains: (1) teaching, including teaching in clinical and

classroom settings; (2) scholarship, including developing and evaluating curricula within an area of

expertise and writing for publication; and (3) professional development, including planning career

strategies and employing key interpersonal skills, such as collaborating and sharing feedback with

colleagues, negotiating professional role boundaries, and managing conflict. The instrument consists of

nine scenarios, each of which describes a common, yet challenging situation pertaining to one of the

three professional role domains. Each scenario is followed by a set of concrete tasks identified by

medical educators as important for effectively addressing the situation described. For example, a

scenario on delivering formal presentations is followed by, "How confident are you that you can: (1)

prepare a presentation focused on a few essential learning points; (2) design slides to enhance your

presentation; (3) use a delivery style that keeps your audience engaged; and (4) incorporate audience

participation methods in your presentation?" Faculty physicians completing the instrument are asked to

rate their perceived capability to carry out each task on an 11-point scale ranging from "cannot do at all"

(0) to "certain can do" (10). Acad Med 2000;75:559-560.

Teaching & Testing:

http://www.academicmedicine.org/cgi/reprint/75/11/1144.pdf

Purpose. Faculty development programs and faculty incentive systems have heightened the need to

validate a connection between the quality of teaching and students’ learning. This study was designed

to determine the association between attending physicians’ and residents’ teacher ratings and their

students’ examination scores. Method. From a database of 362 students, 138 faculty, and 107 residents

in internal medicine, student-faculty (n = 476) and student-resident (n = 474) pairs were identified. All

students were in their third year, rotating on inpatient general medicine and cardiology services, July

1994 through June 1996, at a single institution. The outcome measure for students’ knowledge was the

NBME Subject Examination in internal medicine. To control for students’ baseline knowledge, the

predictors were scores on the USMLE Step 1 and a sequential examination (a clinically-based pre- and

post-clerkship examination). Teaching abilities of faculty and residents were rated by a global item on

the post-clerkship evaluation. Faculty’s ratings used only scores from prior to the study period;

residents’ ratings included those scores students gave during the study period. Results. Multivariate

analyses showed faculty’s teaching ratings were a small but significant predictor of the increase in

students’ knowledge. Residents’ teaching ratings did not predict an increase in students’ knowledge.

Conclusion. Attending faculty’s clinical teaching ability has a positive and significant effect on medical

students’ learning. Acad Med. 2000;75:1144-1146.

Faculty Development in Women's Health

http://www.academicmedicine.org/cgi/reprint/75/11/1095.pdf

The authors present a strategy for residency faculty development in women's health, the reasons that

such a strategy is necessary (e.g., women's health encompasses much more than reproductive and

disease issues, and is cross-disciplinary and intrinsic to all of family practice), and their residency

program's experience with its development and implementation from 1994 to the present. In creating the

program, the residency program's faculty used as a context some lessons learned from family medicine,

since the rapid growth of family medicine provides a historical example of dealing with a critical shortage

of faculty for new residency programs and the need for a new way to train educators. Also, the faculty

reviewed the literature about faculty development in medicine, models of teaching and learning from

women's studies, and group theory, specifically the skills concerning conflict and diversity. They used

the salient elements from each (which the authors outline) in fashioning their new faculty development

program. The resulting program also grew out of focus groups with patients, input from staff, residents,

and faculty, and meetings and workshops, including some intense and highly charged discussions in

which the faculty participants, both men and women, confronted their own views and biases and worked

hard to successfully forge a common and relevant vision of women's health. The program has fostered

faculty who are knowledgeable about the diverse educational skills required to teach women's health.

They use these skills in all curricular content, thus demonstrating a new way to educate residents as

well as faculty. Acad Med. 2000;75:1095-1101.

Council of Emergency Medicine Residency Directors

http://www.cordem.org/facdev/2000prog.htm

The above link is to the Council of Emergency Medicine Residency Directors’ web site. CORD and

AACEM co-sponsors a yearly conference entitled "Navigating the Academic Waters", which touches

upon many topics relating to Faculty Development. Topics available for download include: Common

reasons for manuscript rejection, networking lab, and time management skills.

The Association of American Medical Colleges

http://www.aamc.org/meded/facaffs/biblio/biblio.htm

An extensive bibliography complied by the AAMC containing references to faculty appointment,

promotion, tenure, evaluation of teaching, research, and clinical practice, productivity, and strategies for

further development of teaching and research skills.

Scholarship in Medical Education

AAMC/GEA Project

http://www.medlib.iupui.edu/cgea/geasclrpro.html

Medical schools now recognize that the professional development, reward, and promotion of faculty who

support the core mission of education has been limited by the inability to critically evaluate candidate's

scholarship in this arena. To address this need, the AAMC undertook a project on educational

scholarship in an effort to develop, disseminate, and facilitate implementation of a renewed concept of

scholarship as it relates to medical education. The project steering committee began with a definition of

scholarship and subsequently developed a set of "teacher as scholar" scenarios to explore teaching as

scholarship. These scenarios are provided here as tools to stimulate critical discussion regarding

teaching as scholarship.

Mentors at University of Virginia

http://www.med.virginia.edu/ed-programs/cme/fdp/fdp.html

The University of Virginia medical school provides its junior faculty with a list of mentors at the associate

or full professor level. The goals of the mentor-protégée relationship are: Orienting new faculty,

facilitating introductions, mentoring in research, reviewing grants and manuscripts, evaluating teaching,

supplementing annual career review, preparing professional portfolios, and serving as advocate both

within and beyond the institution. Their faculty development program also includes a year long lecture

series on such topics as teaching with multimedia, searching medical literature, patents, intellectual

property and technology transfer, the new ABCs of Medicine: ICD, CPT, and RVU, a practical workshop

on writing for medical and scientific journals, preparing teaching portfolios for evaluation and promotion,

grant writing workshop, preparing your portfolio for promotion & tenure, keys to effective presentation, &

handouts.

The University of Virginia School of Medicine's website also offers links to other medical schools' web-

based instructional materials for these disciplines:

Anesthesiology / Basic Medical Ethics / Biochemistry / Cardiology / Cell and Tissue Structure /

Dermatology / Doctor-Patient Illness / Endocrinology / Environmental Medicine / Epidemiology / General

Topics / Genetics and Biostatistics / Geriatrics / Gross Anatomy / Introduction to Clinical Medicine /

Microbiology / Nephrology / Neurology / Neuroscience / Obstetrics and Gynecology / Ophthalmology /

Orthopedics / Pathology / Pediatrics / Pharmacology / Physical Diagnosis / Physiology / Primary Care-

AMB Medicine / Psychiatry / Pulmonary / Radiology / Surgery / Toxicology / Trauma

Wright State Faculty Resources

www.med.wright.edu/fca/profdev

The Wright State School of Medicine offers extensive resources for its faculty. These resources are

organized into five categories: (1) Teaching Skills, (2) Clinical Practice, (3) Research, (4) Technical

Skills Development, and (5) Promotion. The school has four main centers that provide these resources:

the Center for Teaching and Learning, the Department of Computing and Telecommunication, the

Center for Professional Development, and University Library Services. Specific skills that can be

acquired include:

Database Network Services

Internet

PowerPoint Presentation

Spreadsheet

Computer Literature Searching

Computer Assisted Learning

Distance Learning

Multimedia Presentation

Teaching Aids (e.g., anatomical models)

Visual Aids (e.g., preparing slides)

Database creation and management

http://www.med.wright.edu/fca/promo/index.html

WSU frequently features articles relevant to faculty development.

"Advice on Preparing Your Dossier"

a) Regarding evaluation documents:

1) Keep evaluations of your teaching and scholarly activities.

2) Summarize evaluations annually to avoid calculating multiple years at the time of promotion review.

When using a Likert scale, you don’t need to calculate percentages of responses; totals are sufficient.

3) Record the number of students (or others) surveyed (i.e., n=3).

4) Include a comments section with the evaluation summary to explain the level of faculty involvement

and type of teaching.

b) Regarding letters of reference

1) Consult with your chair about obtaining letters of reference. The chair, the P&T Committee, or the

Dean’s office, not the candidate, will contact your references about writing a letter.

2) Request their letters early. Frequently, reference letters are the last pieces of the dossier to arrive.

3) Explain in your dossier file why each reference person was chosen (e.g., expert in the field).

c) Regarding publications

Indicate whether the articles are peer reviewed, using "R" for (peer) reviewed, "N" for not peer reviewed,

and "I" for invited.

From: Rx for the Top Ten Mistakes in Promotion Documents

10) Time in rank should not be compressed, even if the faculty member has been perceived as

exceptionally productive.

9) Information must be relevant to faculty member’s productivity at this institution.

8) To be complete, a promotion dossier must address and document all three categories-teaching,

research, and service.

7) Whether teaching 2 or 200, faculty must document each teaching effort and the methods they have

used to evaluate their teaching.

6) When documenting service, faculty are to name each committee, their term of service, and if

appropriate, the leadership role they performed.

5) When describing research in letters of reference, try to avoid using technical language.

4) For articles to have validity in a promotion document, they must be published or in press. Promotion

review committees will not consider articles that are submitted, or in preparation.

3) University guidelines require that teaching be documented and the documentation include student

evaluations and at least two other forms of evaluations.

2) When requesting letters of reference (from internal or external contacts) for a faculty promotion

dossier, chairs should neither state nor imply a bias for or against the candidate up for promotion.

1) Letters of recommendation-from the department’s promotion committee, and the department chair-

should give evidence of the faculty member’s credentials from their perspective rather than referring to

the other letters.

The Chair in Perspective

http://www.med.wright.edu/fca/Articles/ChairPerspect.html

An excellent article on faculty development from one of the leaders in emergency medicine, Dr.Glen

C.Hamilton.

Teaching at OSU

www.osu.edu/education/ftad

The Office of Faculty and Teaching Associate Development (FTAD) at The Ohio State University exists

to help faculty and teaching associates excel in teaching and experience the satisfaction that results

from teaching well. The site contains a listing of readings on teaching, and offers individual

consultations.

2. FACULTY DEVELOPMENT PAPERS:

Jouriles NJ, Kuhn GJ, Moorhead JC, et al: Faculty development in Emergency Medicine. Acad Emerg

Med. 1997;4:1078-1086.

In this excellent article, academic emergency physicians discuss aspects of faculty development,

including: 1) "A chair's method for developing individual faculty" (John Moorhead, MD); 2) "Traditional

promotion and tenure" (Douglas Rund, MD); 3) "Faculty development in a new department" (V. Gail

Ray, MD); and, 4) "Personal development" (Gloria Kuhn, DO). One of the many excellent points in this

article is "beginning with the end in mind". Determine what your long term goal is (long term meaning

>10 years) and "it becomes easier to decide what steps need to be taken to get there. Short term goals

are those steps."

Kuhn GJ, Krome RL: Career planning and development for emergency medicine faculty. J Emerg Med

1997;15:381-385.

The authors propose a methodology to be used by emergency medicine faculty members interested in

career planning and faculty development on an individual basis. The basic competencies needed by

faculty and methods of setting goals are described. Educational courses, workshops, seminars, and

self-study strategies to provide the basic competencies and meet defined goals are described, including

the advantages and disadvantages of each method, the time commitment, and needed resources. The

advantage of this methodology is the ability to customize a program to meet individual needs and fit into

the constraints of available time and monetary resources.

Hamilton GC: A library to assist in the development of academic faculty in emergency medicine. J

Emerg Med 1988;6:551-553.

The author defines faculty development as a training process that strives continually to improve the

creativity, productivity, and longevity of individuals committed to the practice of academic medicine.

From a more than 80-volume personal library, 15 recommended texts in 11 major topics are selected.

This library is designed to assist emergency physicians in obtaining useful sources of information as

part of their continuing education as academic faculty.

Hewson MG: A theory-based faculty development program for clinician-educators. Acad Med

2000;75:498-501.

This essay describes the development, implementation, and evaluation of a theory-based faculty

development program for physician-educators in medicine and pediatrics at The Cleveland Clinic.

Wilkerson L: Strategies for improving teaching practices: a comprehensive approach to faculty

development. Acad Med 1998;73:387-396.

This article details the four components of successful faculty development : (1) professional

development (new faculty members should be oriented to the university and to their various faculty

roles); (2) instructional development (all faculty members should have access to teaching-improvement

workshops, peer coaching, mentoring, and/or consultations); (3) leadership development (academic

programs depend upon effective leaders and well-designed curricula; these leaders should develop the

skills of scholarship to effectively evaluate and advance medical education); (4) organizational

development (empowering faculty members to excel in their roles as educators requires organizational

policies and procedures that encourage and reward teaching and continual learning).

Lemkau JP, and Ahmed SM: Helping junior faculty become published scholars. Acad Med

1999;74:1264-1267.

This article describes how faculty who are novices to publishing can get started, beginning with a

description of the types of scholarship and examples of work that fits into each category. The article also

emphasizes the importance of mentorship from senior faculty.

Rubeck RF: Faculty development: a field of dreams. Acad Med 1998;73(9 Suppl):S32-S37.

This article describes the faculty development efforts of the eight schools that participated in The Robert

Wood Johnson Foundation's "Preparing Physicians for the Future: Program in Medical Education." It

explores the faculty development topics and methods, both shared and unique, among the eight

schools. It then looks at the ways the schools motivated their faculties to participate in their programs.

Finally, it describes some of the outcome measures that were used to gauge the effectiveness of the

faculty development programs. The authors present lessons learned from the successes and failures of

the various programs.

Reid A: Assessment of faculty development program outcomes. Fam Med 1997;29:242-247.

This paper summarizes outcomes reported and methods used in published studies of faculty

development programs in Family Medicine since 1980.

Meurer LN: Published literature on faculty development programs. Fam Med 1997; 29:248-250.

Published faculty development program evaluation articles often leave the program description

incomplete, making it difficult for new program planners to build on previous work. The authors

examined faculty development literature for the inclusion of important program elements. They found

that many important program components, including local needs assessment, leadership and resource

support, stakeholder input, implementation barriers, participant attendance, and cost were each

discussed in fewer than 30% of published articles. The context, input, process, and product framework

is proposed as a guiding model for future program reports.

Ullian JA: Types of faculty development programs. Fam Med. 1997;29:237-241.

This paper offers an overview of faculty development program types, with references to specific

programs described in the recent literature. Faculty development programs have been categorized in a

number of ways. This review uses a variation of those typologies and suggests six types of faculty

development activities: 1) organizational strategies, 2) fellowships, 3) comprehensive local programs, 4)

workshops and seminars, 5) continuing medical education, and 6) individual activities. While these

categories provide a conceptual basis for distinguishing among programs, actual programs in use often

contain elements of more than one type.

Skeff KM: Clinical teaching improvement: past and future for faculty development. Fam Med

1997;29:252-257.

This article discusses 1) the rationale for providing faculty development for clinical teachers, 2) the

competencies needed by clinical teachers, 3) the available programs to assist faculty to master those

competencies, and 4) the evaluation methods that have been used to assess these programs.

Hitchcock MA: Faculty development in the health professions: conclusions and recommendations. Med

Teach 1992;14:295-309.

This report summarizes recent literature reviews and resource books on faculty development. Nine

conclusions about faculty development in the health professions are drawn: (1)the concept of faculty

development is evolving and expanding; (2) research skills are becoming a major focus of faculty

development; (3) teaching skills are still a prominent aspect of faculty development; (4) fellowships are

being used effectively to recruit and train new faculty; (5) the institutional environment has become a

focus of faculty development; (6) faculty evaluation is an effective approach to faculty development; (7)

the efficacy of faculty development needs better research documentation; (8) model curricula have been

developed for different types of faculty; and (9) comprehensive faculty development centers are gaining

in popularity. A set of recommendations based on the conclusions drawn is offered for those planning

faculty development interventions.

Rose EA, Roth LM, Werner PT, Keshwani A, Vallabhaneni V: Using faculty development to solve a

problem of evaluation and management coding: a case study. Acad Med 2000;75:331-336.

The authors used the need to implement CMS (formerly HCFA) regulations as a way to create a faculty

development program. They describe their curriculum, which includes: (1) coding theory; (2) chart

auditing for coding; (3) teams and team building; (4) effective meetings; and (5) structured problem

solving. Following the implementation of their initiative, they found fewer medical coding errors, but also

an improved sense of ability amongst the faculty.

Bennett NL, Davis DA, Easterling WE, et al: Continuing medical education: a new vision of the

professional development of physicians. Acad Med 2001;75:1167-1172.

The authors describe their vision of what continuing medical education (CME) should become in the

changing health care environment. They first discuss six types of literature (e.g., concerning learning

and adult development principles, problem-based/practice-based learning, and other topics) that

contribute to ways of thinking about and understanding CME. They then state their view that the

Association of American Medical Colleges (AAMC) has made a commitment to helping CME be more

effective in the professional development of physicians.

Evans CH: Faculty development in a changing academic environment. Acad Med 1995;70:14-20.

The author outlines a new model of faculty development, explaining that the traditional model of faculty

development is obsolete in the face of shrinking government support, changes in the sophistication,

costs, funding of biomedical research, changes in the reimbursement systems for hospitals and

physicians, a general loss of respect for the medical and scientific professions, and radical changes in

the structure of the health care delivery system.

Bland CJ, Schmitz CC: A guide to the literature on faculty development. In Jack H. Schuster, Daniel W.

Wheller, eds. Enhancing Faculty Careers: Strategies for Development and Renewal. San Francisco:

Jossey-Bass Publisher, 1990 (pp. 298-328).

Bland CJ, Schmitz CC, Stritter FT, et al: Successful Faculty in Academic Medicine: Essential Skills and

How to Acquire Them. New York: Springer Publishing Co., 1990.

Pereira J, Peden J, Campbell K: Instructional technology in medical education: lessons learnt. J

Telemedicine & Telecare 2000;Suppl 2:S56-S58.

New instructional technologies, especially Web-based applications, may play an increasing role in

medical education, particularly for distance and distributed learning. As medical educators turn to this

medium, numerous benefits and opportunities, as well as challenges and pitfalls, will arise. The

successful development and implementation of instructional technologies in medicine require an

appreciation of the medium's heterogeneous nature, its strengths, weaknesses, and limitations. These

in turn rely on partnerships with various experts and the early adoption of evaluation. We have

summarized the lessons learnt from developing Web-based courses on palliative care in a framework

for adopting instructional technologies. This framework incorporates development, implementation, and

evaluation.

Roop SA. Pangaro L: Effect of clinical teaching on student performance during a medicine clerkship. Am

J Med 2001;110:205-209.

PURPOSE: To measure what proportion of student clerkship performance can be attributed to teachers'

educational skills as reported by students. SUBJECTS AND METHODS: From August 1992 to June

1994, we collected critiques of teacher skills from 314 third-year students at the end of a 12-week

medicine clerkship. Interns, residents, attending physicians, and student preceptors were rated (on a 1

to 5 scale) on teaching behaviors from the 7 categories of the Stanford Faculty Development Program

framework. A linear regression model was used to determine the relative contributions of the rated

teaching behaviors in predicting final student performance and improvement across the clerkship

("student growth"), measured using end-of-clerkship variables (clinical grades, National Board of

Medical Examiners medicine shelf examination, practical laboratory examination, and an analytical

essay examination) and preclerkship variables (pre-third-year grade point average [GPA], United States

Medical Licensing Examination, Step I, and clerkship pretest). RESULTS: Data were available for 293

(93%) of 314 students, who completed a total of 2,817 critiques. The students' preclerkship GPA

accounted for the greatest percentage of variance in student performance (28%). Clinical teaching

behaviors accounted for an additional 6% of the variance. For student growth across the clerkship,

teaching accounted for 10% of the variance. Among the 7 Stanford educational categories, teaching

behaviors promoting control of session (r2=5%) and fostering understanding and retention (r2=4%) had

the greatest effect. The resident had the most effect on student growth (r2=6%) when compared with

other teaching levels. Teaching had a greater effect on growth for students with preclerkship GPA above

the mean (16% versus 6%), for older students (24% versus 7%), and for students with a nonscience

undergraduate degree (33% versus 9%). CONCLUSION: The preclerkship GPA, reflecting 2 years of

work, was the most important predictor of student performance. Teaching behavior, as measured by

student assessments, also affected student performance.

Wear D: Asian/Pacific Islander women in medical education: personal and professional challenges.

Teaching & Learning in Medicine 2000;12:156-163.

The purpose of this qualitative study was to identify the complex issues facing Asian/Pacific Islander

(API) women students at one Midwestern medical school as they subjectively experience their medical

training. Of particular interest was how students navigated family influences, career planning, and ethnic

and gender stereotypes. Sixty-five percent of the students reported that their parents exerted various

degrees of encouragement or pressure to enter medicine. The remaining students said that the decision

was entirely theirs (20%) or that the decision had been made for them (15%). Many reported the larger

Asian "community" as a source of influence. A slight majority of students thought they were perceived by

faculty as being "quiet," often too quiet. With only 1 exception, all of the students believed that their

cultural identity influenced their specialty choice. Stressors reported by students centered on

competition, achievement, and formation of intimate relationships (i.e., dating). The authors conclude

that medical educators who provide personal and professional support for API women students should

be keenly aware of the career, gender, and family issues that emerge at the intersection of API and

Euro-American cultures. Faculty development should include an educational component on issues of

concern to API students, men and women. Faculty also need to wrestle with the cultural values of

"modesty, respect for authority, public self-consciousness, and other directness" as they intersect with

assertion as a primary value found in Euro-American culture in general and in medical education in

particular.

Rider EA, Federman DD, Hafler JP: Residents as teachers--a faculty development approach to

programme development. Medical Education 2000;34:955-956.

The authors present a strategy for residency faculty development in women's health, the reasons such a

strategy is necessary (e.g., women's health encompasses much more than reproductive and disease

issues, and is cross-disciplinary and intrinsic to all of family practice), and their residency program's

experience with its development and implementation from 1994 to the present. In creating the program,

the residency program's faculty used as a context some lessons learned from family medicine, since the

rapid growth of family medicine provides a historical example of dealing with a critical shortage of faculty

for new residency programs and the need for a new way to train educators. Also, the faculty reviewed

the literature about faculty development in medicine, models of teaching and learning from women's

studies, and group theory, specifically the skills concerning conflict and diversity. They used the salient

elements from each (which the authors outline) in fashioning their new faculty development program.

The resulting program also grew out of focus groups with patients, input from staff, residents, and

faculty, and meetings and workshops, including some intense and highly charged discussions in which

the faculty participants, both men and women, confronted their own views and biases and worked hard

to successfully forge a common and relevant vision of women's health.

Orlander JD: Co-teaching: a faculty development strategy. Med Educ 2000;34:257-265.

This paper describes a model in which paired physicians focus on developing their teaching skills while

sharing the clinical supervision of residents and medical students. Vignettes, taken from the experiences

of the authors, are used to demonstrate how the model is used to develop effective solutions to

problems and to help in the maturation of one's skill as an educator.

Bazarian JJ, Davis CO, Spillane LL, et al: Teaching emergency medicine residents evidence-based

critical appraisal skills: a controlled trial. Ann Emerg Med 1999;34:148-154.

The objective of this trial was to compare the performance of an evidence-based medicine (EBM)

approach and a traditional approach to teaching critical appraisal skills to emergency medicine

residents. The authors found that compared with a traditional approach, an EBM approach to teaching

critical appraisal did not appear to improve the critical appraisal skills of emergency medicine residents.

However, the trial enrolled only 32 residents.

Johnson CE: Developing residents as teachers: process and content. Pediatrics 1996;97(6 Pt 1):907-

16.

This article is a review of the 3-year experience with the teaching program implemented for the pediatric

residency program at Harvard Medical School--from conceptualization to realization to evaluation-- and

provides one model for others to use in developing a curriculum on teaching.

Hafler JP, Lovejoy FH: Scholarly activities recorded in the portfolios of teacher-clinician faculty. Acad

Med 2000;75:649-652.

The purpose of this article was to explore what contributions to scholarship teacher-clinician faculty list

in the portfolios that they use as evidence for promotion. While the faculty members' portfolios continue

to emphasize original articles as evidence of scholarship (and those mostly in their medical

subspecialties, and less in education), new forms of evidence, such as teaching materials, chapters in

textbooks, syllabi, computer programs, and videotapes, have emerged. Faculty members are also

recording their participation in broad-based teaching activities; their leadership roles for student,

resident, fellow, and continuing medical education levels; and their educational leadership positions

locally, regionally, and nationally on committees that enhance the educational enterprise. This article

nicely compares the number of such achievements reported by assistant, associate and full professors.

Seldin P: The Teaching Portfolio. A practical guide to improved performance and promotion/tenure

decisions. 2nd ed. Bolton, MA: Anker Publishing Company Inc. 1997.

Simpson D, Beecher A, Lindemann J. The Educator's Portfolio. 4th ed. Milwaukee, WI: Medical College

of Wisconsin; 1998.

3. PROMOTION AND TENURE

http://www.dml.georgetown.edu/schmed/faculty/guidelines.html

The appointment, promotion and tenure guidelines for the Georgetown University School of Medicine,

including the non-tenure tracks of Clinician-Educator and Full-time Clinician as well as the tenure tracks

of Research. There are also criteria for Part-time Paid, or Voluntary Faculty.

http://www.aamc.org/about/progemph/access/sum25nod.htm

This link, also referenced above, is to an excellent article entitled "Summary Findings - Changes in

Faculty Promotion Guidelines to Recognize Teaching Effort and Quality". In it, the author discusses the

challenges of academic promotion and the recognition of teaching as a means of attaining promotion.

http://its.hsc.missouri.edu/~medicine/byfapt.shtml

This link to the University of Missouri-Columbia School of medicine’s Faculty Appointment, Promotion

and Tenure Committee covers the requirements for attaining the different professorial ranks. The criteria

are divided into the three categories of teaching, research/creative work/scholarly endeavor, and

service/administration.

http://inside.gwumc.edu/edu/policy/senate/Document/CRITERIA89.htm

Criteria for Promotion and Tenure for the Faculty of the School of Medicine and Health Sciences at the

George Washington University.

http://info.med.yale.edu/faculty/appendixc.htm

Curriculum vitae format for appointment or promotion at the Yale University school of medicine

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Afterword

Triple-threat or Double-fake? The Dilemma of Academic Medicine in the 21st

Century

Author: Latha Stead

The term triple-threat is attributed to an anonymous sportswriter, who used it to describe the gridiron

talents of one Paddy Driscoll, a quarterback for the Chicago Cardinals, the oldest franchise in

professional football. Driscoll, who played both offense and defense, not only passed and ran with equal

facility, but on a particularly memorable fall day in 1924, successfully drop-kicked a field goal from the

50 yard-line. One does not have to be much of a football fan to know that, as the game has evolved and

become increasingly specialized, no single individual would be expected to perform all three tasks of

passing, running, and kicking at a professional level. Hence, with the passage of time, the original

meaning of the term triple-threat has become obsolete.

The analog of the triple-threat in football is baseball's Triple Crown, awarded to the player leading his

league in homers, batting average, and runs batted in (RBI's). No one has won the Triple Crown since

the 60's, and many serious observers of the national pastime believe such a feat to be so deeply

improbable that it effectively rivals the impossibility of achieving triple-threat status in the NFL.

It is tempting to conclude from the foregoing that the athletes of today are somehow made of lesser stuff

than those of earlier generations. However, other data, such as the shattering of Babe Ruth's home run

record - which had stood for more than 70 years - twice in the last half decade, belies such an assertion

as a unifying hypothesis. Indeed, the weight of evidence supports the contention that there may never

again be a Triple Crown winner, not so much because players cannot hit the ball, but rather because

they have become specialists. Thus the great hitters of recent years are either swinging for the fences,

or consistently hitting safely, but not both - and without both, the triple crown cannot be won. Baseball

still contains extraordinary hitters, as good as the Cobbs, Hornsbys, Mantles, Ruths, and Williams of the

past. Similarly in football, the Clarks, Driscolls, Hubbards, Hutsons, and Tarkentons are still out there,

even though it is no longer possible to be a triple-threat. This is because, over time, both sports have

evolved and undergone deep and fundamental changes.

In academic medicine, the game has also changed in equally deep and fundamental ways. Shortly after

the second World War, and continuing for several decades thereafter, those academic medical faculty

held up to students and house officers as role models were commonly described as "triple-threats", i.e.,

independently funded investigators, inspiring teachers, and stellar clinicians. In recent years, such

individuals have become very nearly as extinct as bird's teeth. Although extinction is among the most

natural of biological phenomena, when a highly venerated species becomes endangered because the

cultural ecosystem that once supported it can no longer be sustained in an altered intellectual climate,

there is a natural inclination to try and preserve the dying breed. Nowhere is such behavior more evident

than in academic medicine, where the triple-threat seems to have attained the unique fictional status

ordinarily reserved for myth.

Mythology, Joseph Campbell tells us, builds upon the truths and ideals of an earlier time. Viewed as

metaphor, myth is entertaining and often profoundly revealing. However, taken literally, it provokes a

kind of naive nostalgia that holds the present hostage to a selectively remembered past. This latter

condition approximates the dilemma of academic medicine currently and for the last several decades.

The consequence of any attempt, no matter how earnest, to become a triple-threat in the 21st century

seems more likely than not to result in the hollow grandiosity of a double-fake. Although the etymology

of the term double-fake is more elusive than that of triple-threat, its meaning is clear. When used in

reference to an individual, the term describes one who is not what they purport, or might otherwise

appear, to be.

To maintain even a modicum of clinical expertise in caring for the nearly infinite variety of ED patients

presenting with undifferentiated illness requires constant vigilance and frequent exposure to minimize

skill decay. The challenge of supervising residents and teaching students requires additional levels of

understanding and the ability to reduce mountains of clinical complexity to molehills of clarity. Add to

that, the demands of basic or clinical extramurally funded research, and one is not only committed to a

minimum of roughly 80-100 hours per week - essentially guaranteeing the absence of any semblance of

a sustainable personal life - but is also looking down the barrel of a future that holds a likelihood of

success only marginally better than the probability of winning the Triple Crown in the American League

or becoming a triple-threat in the NFL.

Perhaps the unarticulated expectation that an individual, given sufficient talent, intelligence, and drive

should somehow be able to do it all in 2002 - as was possible 50 years ago, at a time when one might

actually have been a triple threat in academic medicine (or a Triple Crown winner in baseball) - is one of

the reasons why so many of our most talented young physicians leave residency, turn away from

academics, and enter directly into the private sector. Certainly, the enormous debt service medical

students now carry upon graduation - likened by some to the mortgage on a first home, absent the

house - plays a role in driving such a decision. Nevertheless, the dim prospects of job satisfaction,

working under a set of expectations that become increasingly difficult with each passing year, must also

figure somehow in the choice to forego an academic career.

Based on all of the preceding, we would strongly encourage young faculty to choose carefully, to 'play to

their strengths,’ and to focus their interests as narrowly as possible either on teaching and clinical care

or upon research as an area of primary concentration. Because clinical expertise often goes hand in

glove with clinical teaching, combining these two skills in the role of the clinician-educator is quite

common, and not at all unrealistic. Nor is it difficult to imagine an investigator who is also an outstanding

teacher within the circumference of that individual's research interests. However, to expect independent

investigators - who need at least 75% of their time protected from clinical responsibilities if they are to

make meaningful contributions, obtain independent extramural funding, and avoid becoming "hobbyists"

- to perform at the same level of clinical expertise as faculty colleagues who see patients daily, is a

prescription for feelings of inadequacy and burnout.

Coming to terms with the realization that virtually no one can any longer juggle all three academic balls

with equal agility for the duration of a career - is the first step toward moving beyond the myth of the

triple-threat. Then perhaps, academic physicians can establish for themselves more sensible

expectations and standards to which they can reasonably be held.

This is not to suggest that those engaged in the scholarship of teaching should never involve

themselves in the scholarship of application, nor that scholars of discovery should never set foot in the

clinical arena. Rather, each group must recognize the very substantial limits imposed on meaningful

expertise in any area by dint of the way in which the game of academic medicine has been transformed

over the last half century. Clinicians must limit their research activities to goals appropriate to their

knowledge, training, and experience. This means asking early and often for help from their colleagues in

the traditional academic (tenure) track, and taking care not to tackle unreasonably large or complex

questions. There are many forms of academic writing that are appropriate for the clinician-educator;

however, few clinician-educators should harbor expectations of obtaining RO1 funding. Likewise,

successful investigators in the traditional tracks should see patients, but with the requisite humility and

respect for the extraordinary clinical challenges of Emergency Medicine, lest they unwittingly do harm.

They too should seek the frequent consultation of their clinical counterparts within the department who

care for patients regularly - just as the latter ought to seek guidance when circumstances are reversed.

It is the reciprocal relationships among faculty as a group, fueled by mutual self-respect and a realistic,

open appraisal of individual strengths and limitations, that drives the machinery of a successful

academic department. The chair must take the responsibility for the choreography required to balance

such a delicate ecosystem, in order that the department as a single, integrated, interdependent entity -

rather than each of the individual faculty comprising that whole - becomes a triple threat.

Thus, we end the first edition of this Handbook on Faculty Development on a cautionary note. Either we

must soften the unrealistic expectations we have placed upon ourselves in the past, or risk driving some

very talented young people away from academic medicine. It is critically important that junior faculty

focus as single-mindedly as possible on an achievable goal, without regard for the lingering and slightly

pernicious mythology of the triple threat. If this can be accomplished - difficult as it may be to let go of

longstanding, cherished illusions - young faculty will at least be given an opportunity to rediscover the

enormous personal rewards and intellectual satisfaction that a career in academic medicine can

provide.