How to Succeed as a Clinician Educator

Grand Rounds

April 12, 2007

Neil A Kurtzman, MDGrover Murray ProfessorUniversity Distinguished ProfessorTexas Tech University Medical Center

• What is a clinician educator?What is a clinician educator?• Any clinician who teaches medicineAny clinician who teaches medicine• A clinician teacher who doesn’t earn his A clinician teacher who doesn’t earn his

keep from grants or practicekeep from grants or practice• This is a problem we’ll come back toThis is a problem we’ll come back to

• A clinician whose main focus is teachingA clinician whose main focus is teaching• UndergraduatesUndergraduates• ResidentsResidents• FellowsFellows• Other physiciansOther physicians• Is a clinician educator a new track?Is a clinician educator a new track?

• Just as music student studies Bach, Just as music student studies Bach, Mozart, and Beethoven without expecting Mozart, and Beethoven without expecting to equal them, it’s useful to study the great to equal them, it’s useful to study the great clinician educators of the pastclinician educators of the past

• I’ll pick twoI’ll pick two• One from the 19One from the 19thth century century• One from the 20th One from the 20th

• William Osler 1848-1919William Osler 1848-1919• Donald Seldin 1920-Donald Seldin 1920-• ? 21? 21stst century century

The Four DoctorsThe Four Doctors

Sargent 1905Sargent 1905

William Osler

• Born Ontario, CanadaBorn Ontario, Canada• Originally planned to enter the ministryOriginally planned to enter the ministry• MD McGill University 1872MD McGill University 1872• Started first journal club ever as a studentStarted first journal club ever as a student• Chair of Clinical Medicine U of P 1884Chair of Clinical Medicine U of P 1884• Chief of Staff Johns Hopkins Hospital 1889Chief of Staff Johns Hopkins Hospital 1889• First Professor of Medicine 1893First Professor of Medicine 1893• Regius Professor of Medicine, Oxford 1905-Regius Professor of Medicine, Oxford 1905-

19191919

• Started the first medical residencyStarted the first medical residency• Wrote the first modern textbook of Wrote the first modern textbook of

medicinemedicine• Brought third year students to the bedsideBrought third year students to the bedside• Inveterate pranksterInveterate prankster• Prodigious readerProdigious reader• Embodies the ideal of the humanistic Embodies the ideal of the humanistic

physicianphysician

“ “He who studies medicine without books He who studies medicine without books sails an uncharted sea, but he who studies sails an uncharted sea, but he who studies medicine without patients does not go to medicine without patients does not go to sea at all.”sea at all.”

Donald SeldinDonald Seldin19951995

• Born Brooklyn, NY 1920Born Brooklyn, NY 1920• BA NYU 1940BA NYU 1940• MD Yale 1943 (first in his class)MD Yale 1943 (first in his class)• PG training under John Peters (his most PG training under John Peters (his most

important influence) at Yaleimportant influence) at Yale• Instructor at Yale 1948 following two years Instructor at Yale 1948 following two years

in the Armyin the Army

John Peters – Seldin’s mentor

• Testified against the Nazi doctors at Testified against the Nazi doctors at Nuremberg – 1946Nuremberg – 1946

• Associate Professor Southwestern Associate Professor Southwestern Medical School – 1951Medical School – 1951

• Chairman 1952 – 1987Chairman 1952 – 1987• Still Professor of MedicineStill Professor of Medicine

• Both rose to important positions at an Both rose to important positions at an early ageearly age

• Both extremely well educatedBoth extremely well educated• Neither did cutting edge research, though Neither did cutting edge research, though

many of their students didmany of their students did• Both built departments from scratchBoth built departments from scratch• Both seem to have mastered virtually all of Both seem to have mastered virtually all of

medicinemedicine

Similarities and Differences

• Both placed great value on the importance Both placed great value on the importance of research at the medical universityof research at the medical university

• Both had enormous impact on their Both had enormous impact on their schoolsschools

• Both inspired generations of studentsBoth inspired generations of students• Their students became leaders of Their students became leaders of

American Medicine at all levelsAmerican Medicine at all levels

• Both were legendary teachersBoth were legendary teachers• Osler a bedside teacherOsler a bedside teacher• Seldin best in the conference roomSeldin best in the conference room• Seldin spent his entire career at one Seldin spent his entire career at one

institutioninstitution• Osler friendly and avuncularOsler friendly and avuncular• Seldin sharp, intolerant of ignoranceSeldin sharp, intolerant of ignorance

• Osler warmOsler warm• Seldin outwardly cool, but actually Seldin outwardly cool, but actually

encouraging and supportive once you got encouraging and supportive once you got his attentionhis attention

• Seldin a ruthlessly accurate judge of talent Seldin a ruthlessly accurate judge of talent which he separated from personalitywhich he separated from personality

• Both attracted the brightest students, but Both attracted the brightest students, but for different reasonsfor different reasons

• Osler a prolific writerOsler a prolific writer• Seldin preferred speaking to writingSeldin preferred speaking to writing• He talked in paragraphsHe talked in paragraphs• Terrified students while attracting the best Terrified students while attracting the best

of them of them

• His lasting achievement is his studentsHis lasting achievement is his students• Though he repeatedly insisted they were Though he repeatedly insisted they were

no better than any othersno better than any others• And they weren’tAnd they weren’t• Thus he must have had a special impact Thus he must have had a special impact

on themon them• Hence the importance of a great clinician Hence the importance of a great clinician

educatoreducator

• Enrico Fermi 1901 – 1954Enrico Fermi 1901 – 1954• Professor of Physics at 24Professor of Physics at 24• Nobel Prize for Physics at 37Nobel Prize for Physics at 37• Built the first atomic reactorBuilt the first atomic reactor• Known for the brilliant simplicity with which Known for the brilliant simplicity with which

he solved problemshe solved problems• Fermi reasoningFermi reasoning

• Both Osler and Seldin were great educators Both Osler and Seldin were great educators though very differentthough very different

• An educator succeeds when he inspires An educator succeeds when he inspires students to learn on their ownstudents to learn on their own

• Which is the only way you really learn anythingWhich is the only way you really learn anything• This is especially important in medicine since This is especially important in medicine since

most of what you learn as a student is outdated most of what you learn as a student is outdated when you complete graduate trainingwhen you complete graduate training

• While you can’t make a silk purse out of a While you can’t make a silk purse out of a sow’s ear it takes skill to make one out of sow’s ear it takes skill to make one out of silksilk

• So how does one become a clinician So how does one become a clinician educator?educator?

• Often happens by accidentOften happens by accident• No one pathNo one path

• There’s no standard widely accepted There’s no standard widely accepted definition of what a clinician educator isdefinition of what a clinician educator is

• There’s no obvious way to pay for themThere’s no obvious way to pay for them• They don’t get grants and generate They don’t get grants and generate

indirect costsindirect costs• When they’re educating they’re not When they’re educating they’re not

generating clinical revenuegenerating clinical revenue

• Thus, it’s easy for them to be seen as an Thus, it’s easy for them to be seen as an economic drag on the departmenteconomic drag on the department

• That’s because the medical school is That’s because the medical school is unlike any other component of the unlike any other component of the universityuniversity

• Clinical faculty are not paid to teachClinical faculty are not paid to teach• They’re expected to generate income They’re expected to generate income

while working for less money than they while working for less money than they could make in practicecould make in practice

• There’s a word for thisThere’s a word for this• CrazyCrazy• There has to be a non-economic reward There has to be a non-economic reward

for thisfor this• RecognitionRecognition• Making a differenceMaking a difference

• Each department of medicine will have to Each department of medicine will have to decide what defines a clinician educatordecide what defines a clinician educator

• How will he be paid?How will he be paid?• How many does the department need?How many does the department need?• How many can it afford?How many can it afford?• How much of a subsidy will the other How much of a subsidy will the other

faculty be willing to provide?faculty be willing to provide?

• How will we know if he’s doing a good job?How will we know if he’s doing a good job?• What’s expected of him?What’s expected of him?• The purpose of a university is the The purpose of a university is the

acquisition and transmittal of knowledgeacquisition and transmittal of knowledge• We seem to have concentrated on the We seem to have concentrated on the

former at the expense of the latterformer at the expense of the latter

2006

• ““Clinician educators are poised to do Clinician educators are poised to do collaborative clinical and translational collaborative clinical and translational research but are still under pressure for research but are still under pressure for clinical productivity.”clinical productivity.”

• As of 2000 at least half of all medical As of 2000 at least half of all medical schools affirmed the values of their schools affirmed the values of their faculty’s educational activity, with many faculty’s educational activity, with many schools providing detailed advice to faculty schools providing detailed advice to faculty members as they assembled their best members as they assembled their best educational materials for promotion educational materials for promotion packets (AAMC website)packets (AAMC website)

• No mention of moneyNo mention of money

• Everybody wants clinician educatorsEverybody wants clinician educators• No one really know how to define themNo one really know how to define them• No way to pay for themNo way to pay for them

• I can only suggest how this business I can only suggest how this business should be organizedshould be organized

• But until there’s a national consensus on But until there’s a national consensus on what a clinician educator is nothing will what a clinician educator is nothing will happenhappen

• Until there’s money there’ll be no Until there’s money there’ll be no consensusconsensus

• Medicine is being suffocated by paperwork Medicine is being suffocated by paperwork and over-administrationand over-administration

• Medical education is setting the paper on Medical education is setting the paper on firefire

• A lecture at our school by a noted medical A lecture at our school by a noted medical historian failed to gain CME credit historian failed to gain CME credit because the paper work was because the paper work was unsatisfactoryunsatisfactory

• Today a clinician teacher is apt to spend Today a clinician teacher is apt to spend more time preparing objectives and more time preparing objectives and questions than teachingquestions than teaching

• Not only is the perfect the enemy of the Not only is the perfect the enemy of the goodgood

• But the good has become the enemy of But the good has become the enemy of the goodthe good

• How much making things better can we How much making things better can we stand?stand?

• We never ask before we regulateWe never ask before we regulate

• A cadre of clinician educators would find A cadre of clinician educators would find more support for a subsidy if they more support for a subsidy if they assumed this administrative burdenassumed this administrative burden

• CME should be run by clinician educatorsCME should be run by clinician educators• Perhaps the IRB as wellPerhaps the IRB as well• These would lessen the amount salary These would lessen the amount salary

required from clinical workrequired from clinical work• Should make both operations more Should make both operations more

palatable to all facultypalatable to all faculty

• Clinician educators, in the main, should be Clinician educators, in the main, should be generalistsgeneralists

• But they should pursue scholarshipBut they should pursue scholarship• Which I will define as excluding studying Which I will define as excluding studying

educationeducation

• He who can, does; he who cannot, He who can, does; he who cannot, teaches - teaches - GB Shaw GB Shaw

• He who can’t do either teaches teachers – He who can’t do either teaches teachers – anonymousanonymous

• He who can’t do either, teaches Gym – He who can’t do either, teaches Gym – Woody AllenWoody Allen

• I give no credit for studying studyingI give no credit for studying studying

• Thus a clinician educator should study Thus a clinician educator should study something peculiar to medicinesomething peculiar to medicine

• Clinical trialsClinical trials• Scholarly reviewsScholarly reviews• Collaborative research with laboratory Collaborative research with laboratory

based colleaguesbased colleagues• Meta-analysesMeta-analyses• Outcomes researchOutcomes research

• Medical economicsMedical economics• EthicsEthics• PoliticsPolitics• Clinical vignettes for basic science Clinical vignettes for basic science

textbookstextbooks• Test questions and evaluationsTest questions and evaluations• Anything but educationAnything but education

• CurriculumCurriculum• We have to have one We have to have one • Except when we don’tExcept when we don’t• James Scholar Program at the University James Scholar Program at the University

of Illinoisof Illinois

Harry Jacobson ’72Harry Jacobson ’72Vice Chancellor for Medical AffairsVice Chancellor for Medical Affairs

Vanderbilt UniversityVanderbilt University

Melvin Laski’76Professor of MedicineTTUHSC

• Write the best one you can and then resist Write the best one you can and then resist the urge to scrub it for a new onethe urge to scrub it for a new one

• Why do medical schools constantly rewrite Why do medical schools constantly rewrite their curricula?their curricula?

• I would advise that a curriculum can be I would advise that a curriculum can be rewritten only after the dean’s been on the rewritten only after the dean’s been on the job for 10 yearsjob for 10 years

• No Department of EducationNo Department of Education• No heavy administrative structureNo heavy administrative structure• No certifying processesNo certifying processes

What not do

    Dear FASEB Society Member Colleagues:Dear FASEB Society Member Colleagues: A final decision concerning NIH’s budget in FY2007 will be made in the next 24 to 48 A final decision concerning NIH’s budget in FY2007 will be made in the next 24 to 48

hours. Congress is hearing from you, but we need you to make one last plea to your hours. Congress is hearing from you, but we need you to make one last plea to your Members of Congress. Please take a moment to read below for a summary of the issue, Members of Congress. Please take a moment to read below for a summary of the issue, as well as the specific action that you can take to make a difference. as well as the specific action that you can take to make a difference.

Background Information – NIH is in Danger of being Flat Funded in FY2007: Background Information – NIH is in Danger of being Flat Funded in FY2007:

Congressional leaders have indicated that they plan to fund most agencies at their Congressional leaders have indicated that they plan to fund most agencies at their FY2006 funding levels. This action would result in NIH being flat-funded in FY2007. Flat FY2006 funding levels. This action would result in NIH being flat-funded in FY2007. Flat funding NIH in FY2007 would actually amount to a three percent reduction (in inflation-funding NIH in FY2007 would actually amount to a three percent reduction (in inflation-adjusted terms) for the agency. adjusted terms) for the agency.

The Opportunity – A Small Amount of $$ is Available to Redistribute: The Opportunity – A Small Amount of $$ is Available to Redistribute:

Senators Tom Harkin (D-IA) and Arlen Specter (R-PA) are making a final case to identify Senators Tom Harkin (D-IA) and Arlen Specter (R-PA) are making a final case to identify NIH as a priority program. Congressional leaders are planning to increase funding levels NIH as a priority program. Congressional leaders are planning to increase funding levels for the programs and agencies they regard as priorities. The elimination of congressional for the programs and agencies they regard as priorities. The elimination of congressional earmarks is allowing for this redistribution of funds. At one time, it appeared that the earmarks is allowing for this redistribution of funds. At one time, it appeared that the odds of NIH receiving a significant increase in FY2007 were not high, but it is becoming odds of NIH receiving a significant increase in FY2007 were not high, but it is becoming increasingly evident that the research community’s message is being heard on Capitol increasingly evident that the research community’s message is being heard on Capitol Hill. Hill.

REQUIRED ACTION: CONTACT YOUR SENATORS AND REPRESENTATIVE REQUIRED ACTION: CONTACT YOUR SENATORS AND REPRESENTATIVE

The fact that Congress plans to redistribute dollars to our nation’s most important The fact that Congress plans to redistribute dollars to our nation’s most important priorities provides us with one last opportunity to push for an increase in NIH’s budget priorities provides us with one last opportunity to push for an increase in NIH’s budget for FY2007. Please take a moment to contact your Senators and Representative in the for FY2007. Please take a moment to contact your Senators and Representative in the next 24 to 48 hours. We must apply pressure to our legislators, and let them know that next 24 to 48 hours. We must apply pressure to our legislators, and let them know that there is a vital need to increase NIH’s budget in FY2007. Therefore, it’s important that there is a vital need to increase NIH’s budget in FY2007. Therefore, it’s important that you urge your Senators and Representatives to tell their Congressional leaders that NIH you urge your Senators and Representatives to tell their Congressional leaders that NIH is an important priority for our country, and that supporting NIH results in scientific is an important priority for our country, and that supporting NIH results in scientific breakthroughs and discoveries that promise to improve the health and the quality of life breakthroughs and discoveries that promise to improve the health and the quality of life for millions of people. for millions of people.

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• Background Information – NIH is in Background Information – NIH is in Danger of being Flat Funded in FY2007Danger of being Flat Funded in FY2007

• From FY 98 to 06 the NIH Budget has From FY 98 to 06 the NIH Budget has increased 110%increased 110%

• Now $28.7 billionNow $28.7 billion• How much should the NIH budget be?How much should the NIH budget be?• Apparently 100% of GDPApparently 100% of GDP

• What’s the real mission of the NIH?What’s the real mission of the NIH?• Eternal youth and immortalityEternal youth and immortality• Which is why everybody loves itWhich is why everybody loves it• What would happen is all research What would happen is all research

stoppedstopped• In the developed world – very littleIn the developed world – very little

• But what if education stopped?But what if education stopped?• Nothing would workNothing would work• Compare the budget for medical education Compare the budget for medical education

with that of the NIH if you want to see what with that of the NIH if you want to see what people really valuepeople really value

[T]he clinical scholar, the academic core of [T]he clinical scholar, the academic core of the department, is an individual who the department, is an individual who advances first-rate clinical science and at advances first-rate clinical science and at the same time is competent in clinical the same time is competent in clinical medicine and in teaching.medicine and in teaching.

Donald Seldin 2003Donald Seldin 2003

The ideal college is Mark Hopkins on one The ideal college is Mark Hopkins on one end of a log with a student on the other.end of a log with a student on the other.

James A Garfield (Later US President) James A Garfield (Later US President) 18711871

“ “Every man who is educated at all, is, and Every man who is educated at all, is, and must be self-educated….It is for the want must be self-educated….It is for the want of understanding this properly, that of understanding this properly, that expectations are entertained of expectations are entertained of instructors….Young men will not set instructors….Young men will not set themselves efficiently at work until they themselves efficiently at work until they feel that there is an all important part feel that there is an all important part which they must perform for themselves, which they must perform for themselves, and which no one can do for them…. It is and which no one can do for them…. It is his (an instructor’s) power to give an his (an instructor’s) power to give an impulse to the minds of his pupils and impulse to the minds of his pupils and induce them to labor.”induce them to labor.”

Mark Hopkins 1836Mark Hopkins 1836

• The medical school must establish a culture of The medical school must establish a culture of excitement in biomedical scienceexcitement in biomedical science

• There are many healers in society, but the There are many healers in society, but the only healer who brings medical science to the only healer who brings medical science to the patient is the physicianpatient is the physician

• The clinical educator must demonstrate the The clinical educator must demonstrate the meaningful application of medical science to meaningful application of medical science to medical studentsmedical students

• When you care for the sick there are When you care for the sick there are ethical and humane constraintsethical and humane constraints

• Only the clinician educator can Only the clinician educator can demonstrate the artful interaction between demonstrate the artful interaction between ethics and medicine and between ethics and medicine and between compassion and technologycompassion and technology

Borrowed from Seldin 2003Borrowed from Seldin 2003

• Institutional loyaltyInstitutional loyalty• The alumni often have itThe alumni often have it• But the faculty and the school seem to But the faculty and the school seem to

have lost ithave lost it• If we’re going to have a culture of If we’re going to have a culture of

excitement about biomedical science we’ll excitement about biomedical science we’ll have to find it (loyalty)have to find it (loyalty)

• Thus there is no one right way to be a Thus there is no one right way to be a successful clinician educatorsuccessful clinician educator

• Each physician who succeeds in this path Each physician who succeeds in this path will have to find his own waywill have to find his own way

• Perhaps the old model of a clinician who Perhaps the old model of a clinician who does research and teaches is still the best.does research and teaches is still the best.

Thank you SandraThank you Sandra