Identifying Value Factors in Institutional Leaders' Perspectives on Investing in Health Professions Educators.

Importance: Investing in educators, educational innovation, and scholarship is essential for excellence in health professions education and health care. Funds for education innovations and educator development remain at significant risk because they virtually never generate offsetting revenue. A broader shared framework is needed to determine the value of such investments. Objective: To explore the value factors using the value measurement methodology domains (individual, financial, operational, social or societal, strategic or political) that health professions leaders placed on educator investment programs, including intramural grants and endowed chairs. Design, Setting, and Participants: This qualitative study used semi-structured interviews with participants from an urban academic health professions institution and its affiliated systems that were conducted between June and September 2019 and were audio recorded and transcribed. Thematic analysis was used to identify themes with a constructivist orientation. Participants included 31 leaders at multiple levels of the organization (eg, deans, department chairs, and health system leaders) and with a range of experience. Individuals who did not respond initially were followed up with until a sufficient representation of leader roles was achieved. Main Outcomes and Measures: Outcomes include value factors defined by the leaders for educator investment programs across the 5 value measurement methodology domains: individual, financial, operational, social or societal, and strategic or political. Results: This study included 29 leaders (5 [17%] campus or university leaders; 3 [10%] health systems leaders; 6 [21%] health professions school leaders; 15 [52%] department leaders). They identified value factors across the 5 value measurement methods domains. Individual factors emphasized the impact on faculty career, stature, and personal and professional development. Financial factors included tangible support, the ability to attract additional resources, and the importance of these investments as a monetary input rather than output. Operational factors identified educational programs and faculty recruitment or retention. Social and societal factors showcased scholarship and dissemination benefits to the external community beyond the organization and to the internal community of faculty, learners, and patients. Strategic and political factors highlighted impact on culture and symbolism, innovation, and organizational success. Conclusions and Relevance: These findings suggest that health sciences and health system leaders find value in funding educator investment programs in multiple domains beyond direct financial return on investment. These value factors can inform program design and evaluation, effective feedback to leaders, and advocacy for future investments. This approach can be used by other institutions to identify context-specific value factors.

Impact of an Innovative Endowed Chair Program on Medical Educator Recipients.

PURPOSE: Rarely do faculty members receive endowed chairs as recognition for their work as educators. In addition to the title, endowed chairholders have traditionally received discretionary income to pursue value-added work. This study assessed the impact on recipients of receiving an endowed chair for education. METHOD: The authors conducted a qualitative thematic analysis between 2018 and 2020, interviewing University of California, San Francisco, School of Medicine chairholders who had completed at least one 5-year term. Authors double-coded all transcripts, reconciled codes, applied social cognitive career theory during analysis, and identified themes through an iterative consensus-building approach. RESULTS: Twenty-three of 24 (96%) eligible faculty members from 16 departments participated. Themes identified were symbolism, resources, education and educator credibility, development, and impact. The chair was a symbol that brought recognition, indicated quality, and amplified visibility and status within the institution and externally. Receiving an endowed chair conferred credibility on recipients and empowered them in the educational domain. The resources allowed chairholders the flexibility to undertake activities that were of value to them, to mentees, and to the organization. Holding the chair facilitated professional development for self and others. Chair recipients reported impact that persisted long after their term(s) concluded. A model of impact emerged, suggesting that simply possessing the chair title led to visibility and gravitas, which, combined with resources, allowed the holder to leverage opportunities in education. CONCLUSIONS: The endowed chair is an important strategy for career development in education for the chairholder and enhances the position of education institutionally. Having a plan sharpens the focus on activities, results, and impact.

Impact of an in-person versus web-based practice standardized patient examination on student performance on a subsequent high-stakes standardized patient examination.

BACKGROUND: Optimal methods of preparing students for high-stakes standardized patient (SP) examinations are unknown. PURPOSES: The purpose is to compare the impact of two formats of a formative SP examination (Web-based vs. in-person) on scores on a subsequent high-stakes SP examination and to compare students' satisfaction with each formative examination format. METHODS: Clustered randomized trial comparing a Web-based module versus in-person formative SP examination. We compared scores on a subsequent high-stakes SP examination and satisfaction. RESULTS: Scores on the subsequent high-stakes SP examination did not differ between the two formative formats but were higher after the formative assessment than without (p < .001). Satisfaction was higher with the in-person than Web-based formative assessment format (4.00 vs. 3.62 on a 5-point scale, p = .01). CONCLUSIONS: Two formats of a formative SP examination led to equivalent improvement in scores on a subsequent high-stakes examination. Students preferred an in-person formative examination to online but were satisfied with both.

Lessons learned about integrating a medical school curriculum: perceptions of students, faculty and curriculum leaders.

OBJECTIVE: Recent educational reform in US medical schools has created integrated curricular structures. This study investigated how stakeholders in a newly integrated curriculum - students, course directors and curriculum leaders - define integration and perceive its successes and challenges during its first year. METHODS: We conducted interviews with curriculum reform leaders, course directors and first year medical students. Interview transcripts were analysed for themes, which were compared within and across stakeholder groups. RESULTS: Three curriculum leaders, four Year 1 course directors and six Year 1 medical students were interviewed. Fifteen students participated in a group interview. Four major themes emerged: interdisciplinary teaching; interdisciplinary faculty collaboration; building curricular links, and sequencing and framing curricular content. Cross-group analysis revealed participant agreement that an integrated curriculum required interdisciplinary teaching, clinical application and careful oversight. Differences among groups were also identified. Faculty (course directors and curriculum leaders) discussed faculty collaboration and the challenges of faculty buy-in and course implementation. Students highlighted the impact of integration on their learning and the challenges of sequencing and scaffolding content. Both students and course directors focused on course monitoring and conceptual links for student learning. CONCLUSIONS: Integrating a curriculum is a complex process. It is differentially understood and experienced by students and faculty, and can refer to instructional method, content, faculty work or synthesis of knowledge in the minds of learners. It can occur at different rates and some subjects are integrated more easily than others. We point to some specific considerations as medical schools embark on curriculum reform.

Applying innovative educational principles when classes grow and resources are limited: Biochemistry experiences at Muhimbili University of Allied Health Sciences.

Teaching to large classes is often challenging particularly when the faculty and teaching resources are limited. Innovative, less staff intensive ways need to be explored to enhance teaching and to engage students. We describe our experience teaching biochemistry to 350 students at Muhimbili University of Health and Allied Sciences (MUHAS) under severe resource limitations and highlight our efforts to enhance the teaching effectiveness. We focus on peer assisted learning and present three pilot initiatives that we developed to supplement teaching and facilitate student interaction within the classroom. These included; instructor-facilitated small group activities within large group settings, peer-led tutorials to provide supplemental teaching and peer-assisted instruction in IT skills to enable access to online biochemistry learning resources. All our efforts were practical, low cost and well received by our learners. They may be applied in many different settings where faculties face similar challenges.

Rethinking the Educator Portfolio: An Innovative Criteria-Based Model.

PROBLEM: Academic medical centers struggle to achieve parity in advancement and promotions between educators and discovery-oriented researchers in part because of narrow definitions of scholarship, lack of clear criteria for measuring excellence, and barriers to making educational contributions available for peer review. Despite recent progress in expanding scholarship definitions and identifying excellence criteria, these advances are not integrated into educator portfolio (EP) templates or curriculum vitae platforms. APPROACH: From 2013 to 2015, a working group from the Academy of Medical Educators (AME) at the University of California, San Francisco (UCSF) designed a streamlined, criteria-based EP (EP 2.0) template highlighting faculty members' recent activities in education and setting rigorous evaluation methods to enable educational scholarship to be objectively evaluated for academic advancement, AME membership, and professional development. OUTCOMES: The EP 2.0 template was integrated into the AME application, resulting in high overall satisfaction among candidates and the selection committee and positive feedback on the template's transparency, ease of use, and streamlined format. In 2016, the EP 2.0 template was integrated into the campus-wide curriculum vitae platform and academic advancement system. NEXT STEPS: The authors plan to increase awareness of the EP 2.0 template by educating promotions committees and faculty at UCSF and partnering with other institutions to disseminate it for use. They also plan to study the impact of the template on supporting educators by making their important scholarly contributions available for peer review, providing guidance for professional development, and decreasing disparities in promotions.

Leadership lessons from curricular change at the University of California, San Francisco, School of Medicine.

After successive Liaison Committee on Medical Education accreditation reports that criticized the University of California, San Francisco, School of Medicine for lack of instructional innovation and curriculum oversight, the dean issued a mandate for curriculum reform in 1997. Could a medical school that prided itself on innovation in research and health care do the same in education? The authors describe their five-phase curriculum change process and correlate this to an eight-step leadership model. The first phase of curricular change is to establish a compelling need for change; it requires leaders to create a sense of urgency and build a guiding coalition to achieve action. The second phase of curriculum reform is to envision a bold new curriculum; leaders must develop such a vision and communicate it broadly. The third phase is to design curriculum and obtain the necessary approvals; this requires leaders to empower broad-based action and generate short-term wins. In the fourth phase, specific courses are developed for the new curriculum, and leaders continue to empower broad-based action, generate short-term wins, consolidate gains, and produce more change. During the fifth phase of implementation and evaluation, leaders need to further consolidate gains, produce more change, and anchor new approaches in the institution. Arising from this experience and the correlation of curricular change phases with leadership steps, the authors identify 27 specific leadership strategies they employed in their curricular reform process.

The impact of intramural grants on educators' careers and on medical education innovation.

PURPOSE: The University of California, San Francisco (UCSF), Haile T. Debas Academy of Medical Educators Innovations Funding program awards competitive grants to create novel curricula and faculty development programs, compare pedagogical approaches, and design learner assessment methods. The authors examined the principal investigators' (PIs') perceptions of the impact of these intramural grants on their careers and on medical education innovation. METHOD: At 12 months (project completion) and 24 months (follow-up), PIs submit a progress report describing the impact of their grant on their careers, work with collaborators, subsequent funding, project dissemination, and the UCSF curriculum. The authors analyzed these reports using qualitative thematic analysis and achieved consensus in coding and interpretation through discussion. RESULTS: From 2001 to 2012, the program funded 77 PIs to lead 103 projects, awarding over $2.2 million. The authors analyzed reports from 88 grants (85.4%) awarded to 68 PIs (88.3%). PIs noted that the funding led to accelerated promotion, expanded networking opportunities, enhanced knowledge and skills, more scholarly publications and presentations, extramural funding, and local and national recognition. They also reported that the funding improved their status in their departments, enhanced their careers as medical educators, laid the foundation for subsequent projects, and engaged an array of stakeholders, including trainees and junior faculty. CONCLUSIONS: These modest intramural education grants not only created innovative, enduring programs but also promoted educators' professional identity formation, fostered collaborations, supported junior faculty in finding their desired career paths, provided advancement opportunities, and raised the local and national profiles of recipients.

An anticipatory quality improvement process for curricular reform.

OBJECTIVE: Over half of American medical schools are currently engaged in significant curricular reform. Traditionally, evaluation of the efficacy of educational changes has occurred well after the implementation of curricular reform, resulting in significant time elapsed before modification of goals and content can be accomplished. We were interested in establishing a process by which a new curriculum could be reviewed and refined before its actual introduction. DESCRIPTION: The University of California, San Francisco (UCSF) School of Medicine embarked upon a new curriculum for the class entering in September 2001. Two separate committees coordinated plans for curricular change. The Essential Core Steering Committee was responsible for the first two years of training, and the Integrated Clinical Steering Committee guided the development of the third-and fourth-year curriculum. Both groups operated under guidelines of curricular reform, established by the School's Committee on Curriculum and Educational Policy, that emphasized integration of basic, clinical, and social sciences; longitudinal inclusion of themes such as behavior, culture, and ethics; use of clinical cases in teaching; and inclusion of small-group and problem-based learning. In early 2001, the deans of education and curricular affairs appointed an ad hoc committee to examine the status of the first-year curriculum, which had been entirely reformulated into a series of new multidisciplinary block courses. This ad hoc committee was composed of students and clinical faculty members who had not been substantially involved in the detailed planning of the blocks. The charge to the committee was to critique the progress of individual courses, and the first year as a whole, in meeting the goals outlined above, and to make recommendations for improving the preparation of students for the clinical years. To accomplish these goals, the committee reviewed background planning documents; interviewed each course director using a standardized set of questions; and examined course schedules, cases, and detailed learning objectives for particular sessions. In July 2001, the committee reported back to the deans with specific recommendations for coordinating the block courses, and about the success in creating integration and the overall balance of topics students would learn. Specific recommendations included increasing the use of pediatric and geriatric cases across courses, creating a case database, developing explicit plans to relocate uncovered material in the four-year curriculum, and bolstering participation of clinical faculty during the first-year blocks. These recommendations were then presented to and endorsed by the Essential Core Steering Committee, which implemented an action plan prior to the September 2001 start date. DISCUSSION: This proactive approach to quality improvement added an evaluation point before the new curriculum was actually unveiled. The anticipatory planning process substantially aided the interdisciplinary developmental process, increased input into the first-year curriculum by clerkship directors, and identified problems that would have otherwise become apparent after implementation. We believe this model adds value to the curriculum planning process.

Intersessions: covering the bases in the clinical year.

OBJECTIVE: At most medical schools students spend the core clerkship year entirely in clinical settings, geographically dispersed, and assigned to separate teams. Because of the immediacy of experiential learning in the clinical environment, this year is often the highlight of medical school. However, the intensity of the experience and the dispersion of students poses serious challenges to student well being and professional development, and to meeting important educational objectives best taught in the clinical year but difficult to implement in competition with direct patient care. To address these challenges in a way that does not interfere with the clinical experiences, we developed and are implementing three one-week intersessions. These are designated weeks between clerkship rotations when all third-year students are "off rotations" and studying together in an integrative, collaborative and reflective manner. DESCRIPTION: We identified themes for the intersession course from several sources. In response to strong documentation by past students of isolation and insufficient opportunity to reflect on their experiences during the core clerkships we placed a high priority on students gathering together as a class and on professional development. Additionally, based on knowledge gaps identified in the AAMC Graduation Questionnaire and our commitment to integrating basic science teaching into the clinical year, we developed the following five themes: evidence-based medicine, ethics, health systems (quality; resource allocation), advances in science (recent advances that fundamentally shift clinical practice), and professional development. Each intersession week consists of 20 hours of structured contact time; 75% is devoted to small-group learning. The weeks rely heavily on student directed and collaborative learning to complete required readings and assignments. All sessions build on the clinical experiences students have had during clerkships and enhance the students' skills for upcoming rotations. DISCUSSION: In 1999-2000, we restructured the clinical core year into eight-week modules allowing us to gather the entire class, in between clerkships, for intersessions. We phased in two intersession weeks in 2000-2001 and are implementing three intersession weeks in 2001-2002 (October, February, and June). In the evaluations of the first year's intersessions students valued the opportunity to gather together, to process their clinical experience, and to utilize their clinical experience to drive learning in important, clinically relevant areas that are not consistently taught in the clerkships. Evaluations from the first intersession of the second cycle further underscore the preference for learning experiences that are highly relevant to the clinical year (e.g., practicing efficient search strategies to quickly answer clinical questions, utilizing systematic reviews, discussing ethics cases from the students' experiences) and the benefits of faculty facilitated small-group discussions over lecture time. The advances in science sessions are most effective when they focus on advances in diseases that students are likely to have encountered. In our next phase, we will use Web-based interfaces to collect cases from students on clerkships and to promote discussion of topics in anticipation of the next intersession. As we continue to refine intersessions, our experience so far provides good evidence to support intersessions as a successful curricular innovation.

Residency is not a race: our ten-year experience with a flexible schedule residency training option.

PURPOSE: To evaluate the Flexible Option (FO), a residency training schedule offered by the University of California, San Francisco, Pediatric Residency Program. METHOD: In 2002, structured telephone interviews were conducted with residents who participated in the FO between 1992 and 2002. Twenty-four of the 284 pediatrics residents during this time participated in the FO. Descriptive interview data were analyzed. A Web-based questionnaire was sent to 72 regularly scheduled (RS) residents at the end of 2001-02. FO and RS residents' specialty board performances were compared. RESULTS: Twenty-one FO residents participated in the telephone interviews. The majority reported that the FO was critical to their success as residents. Most requested the FO for personal and family reasons; over 40% would otherwise have requested leaves from the residency. The most common perceived disadvantages were delay in graduation and financial concerns. Forty-two RS residents completed the online questionnaire. Seventeen percent considered the FO an important factor in program selection; 43% had considered participating in the FO. Seventy-nine percent felt that the FO had a positive effect on the general morale of the program. RS residents perceived that the FO increased workload (43%) and created scheduling problems (52%). However, 88% of RS residents encouraged the program to continue offering the FO. Specialty board scores were similar across FO and RS residents. CONCLUSIONS: Participants perceived that the FO's advantages outweighed the disadvantages. There were no concerning academic disadvantages identified in FO participants. Wide-spread support was found throughout the residency program to sustain the FO. More residency programs should consider creating and offering flexible scheduling options.

Outcomes of different clerkship models: longitudinal integrated, hybrid, and block.

PURPOSE: To examine student perceptions and learning outcomes of three different third-year clerkship models: a yearlong, longitudinal, integrated clerkship (LIC); six-month clerkships with continuity (hybrid); and traditional, discipline-specific block clerkships (BCs). METHOD: The authors compared the perceptions regarding the clerkship year and the hidden curriculum, as well as the pre- and postclerkship academic performance, of third-year medical students participating in LIC, hybrid, and BC models between 2006 and 2010. RESULTS: Generally, LIC students rated the following clerkship experiences higher than did the hybrid and BC students: faculty teaching, faculty observation of clinical skills, feedback, and the clerkship overall. Students in the LIC observed more positive role-modeling behaviors and had more patient-centered experiences than BC students. All students preferred to see patients more than once, work within a consistent site or system, and work with a stable group of peers and faculty mentors over time. Whereas students in both the LIC and the hybrid models outperformed their BC counterparts in clinical skills, student performance on the U.S. Medical Licensing Exam Step 2 (clinical knowledge) was equivalent across models. CONCLUSIONS: Key differences in student experiences and outcomes between the continuity clerkship models (LIC and hybrid) and BCs reinforce the literature and the educational framework for continuity in clinical learning. The benefits to student outcomes seem to increase with greater opportunities for continuity.

Partnering on education for health: Muhimbili University of Health and Allied Sciences and the University of California San Francisco.

In 2005, Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania and the University of California San Francisco (UCSF) in the United States joined to form a partnership across all the schools in our institutions. Although our goal is to address the health workforce crisis in Tanzania, we have gained much as institutions. We review the work undertaken and point out how this education partnership differs from many research collaborations. Important characteristics include: (i) activities grew out of MUHAS's institutional needs, but also benefit UCSF; (ii) working across professions changed the discourse from 'medical education' to 'health professions education'; (iii) challenged by gaps in our respective health-care systems, both institutions chose a new focus, interprofessional team work; (iv) despite being so differently resourced, MUHAS and UCSF seek strategies to address growing class sizes; and (v) we involved a wider range of people - faculty, administrators, students, and residents - at both institutions than is usually the case with research. This partnership has convinced us to exhort other academic leaders in the health arena to seek opportunities together to enlighten and enliven our educational enterprises.

Curricular transformation of health professions education in Tanzania: the process at Muhimbili University of Health and Allied Sciences (2008-2011).

Tanzania requires more health professionals equipped to tackle its serious health challenges. When it became an independent university in 2007, Muhimbili University of Health and Allied Sciences (MUHAS) decided to transform its educational offerings to ensure its students practice competently and contribute to improving population health. In 2008, in collaboration with the University of California San Francisco (UCSF), all MUHAS's schools (dentistry, medicine, nursing, pharmacy, and public health and social sciences) and institutes (traditional medicine and allied health sciences) began a university-wide process to revise curricula. Adopting university-wide committee structures, procedures, and a common schedule, MUHAS faculty set out to: (i) identify specific competencies for students to achieve by graduation (in eight domains, six that are inter-professional, hence consistent across schools); (ii) engage stakeholders to understand adequacies and inadequacies of current curricula; and (iii) restructure and revise curricula introducing competencies. The Tanzania Commission for Universities accredited the curricula in September 2011, and faculty started implementation with first-year students in October 2011. We learned that curricular revision of this magnitude requires: a compelling directive for change, designated leadership, resource mobilization inclusion of all stakeholders, clear guiding principles, an iterative plan linking flexible timetables to phases for curriculum development, engagement in skills training for the cultivation of future leaders, and extensive communication.

Predicting failing performance on a standardized patient clinical performance examination: the importance of communication and professionalism skills deficits.

BACKGROUND: The purpose is to determine which assessment measures identify medical students at risk of failing a clinical performance examination (CPX). METHOD: Retrospective case-control, multiyear design, contingency table analysis, n = 149. RESULTS: We identified two predictors of CPX failure in patient-physician interaction skills: low clerkship ratings (odds ratio 1.79, P = .008) and student progress review for communication or professionalism concerns (odds ratio 2.64, P = .002). No assessments predicted CPX failure in clinical skills. CONCLUSIONS: Performance concerns in communication and professionalism identify students at risk of failing the patient-physician interaction portion of a CPX. This correlation suggests that both faculty and standardized patients can detect noncognitive traits predictive of failing performance. Early identification of these students may allow for development of a structured supplemental curriculum with increased opportunities for practice and feedback. The lack of predictors in the clinical skills portion suggests limited faculty observation or feedback.

What training is needed in the fourth year of medical school? Views of residency program directors.

PURPOSE: To identify common struggles of interns, determine residency program directors' (PDs') views of the competencies to be gained in the fourth year of medical school, and apply this information to formulate goals of curricular reform and student advising. METHOD: In 2007, semistructured interviews were conducted with 30 PDs in the 10 most common specialty choices of students at the University of California, San Francisco, School of Medicine to assess the PDs' priorities for knowledge, skills, and attitudes to be acquired in the fourth year. Interviews were coded to identify major themes. RESULTS: Common struggles of interns were lack of self-reflection and improvement, poor organizational skills, underdeveloped professionalism, and lack of medical knowledge. The Accreditation Council for Graduate Medical Education competencies of patient care, practice-based learning and improvement, interpersonal and communication skills, and professionalism were deemed fundamental to fourth-year students' development. Rotations recommended across specialties were a subinternship in a student's future field and in internal medicine (IM), rotations in an IM subspecialty, critical care, and emergency and ambulatory medicine. PDs encouraged minimizing additional time spent in the student's future field. Suggested coursework included an intensively coached transitional subinternship and courses to improve students' medical knowledge. CONCLUSIONS: PDs deemed the fourth year to have a critical role in the curriculum. There was consensus about expected fourth-year competencies and the common clinical experiences that best prepare students for residency training. These findings support using the fourth year to transition students to graduate medical training and highlight areas for curricular innovation.

Transitional clerkship: an experiential course based on workplace learning theory.

Starting clerkships is anxiety provoking for medical students. To ease the transition from preclerkship to clerkship curricula, schools offer classroom-based courses which may not be the best model for preparing learners. Drawing from workplace learning theory, the authors developed a seven-day transitional clerkship (TC) in 2007 at the University of California, San Francisco School of Medicine in which students spent half of the course in the hospital, learning routines and logistics of the wards along with their roles and responsibilities as members of ward teams. Twice, they admitted and followed a patient into the next day as part of a shadow team that had no patient-care responsibilities. Dedicated preceptors gave feedback on oral presentations and patient write-ups. Satisfaction with the TC was higher than with the previous year's classroom-based course. TC students felt clearer about their roles and more confident in their abilities as third-year students compared with previous students. TC students continued to rate the transitional course highly after their first clinical rotation. Preceptors were enthusiastic about the course and expressed willingness to commit to future TC preceptorships. The transitional course models an approach to translating workplace learning theory into practice and demonstrates improved satisfaction, better understanding of roles, and increased confidence among new third-year students.