Emergency Medicine Clerkship Directors - Annals of Emergency ...

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Emergency Medicine Clerkship Directors: Defining the Characteristics of the Workforce Wendy C. Coates, MD Andrew M. Gill, PhD Richard Jordan, MD

From the Department of Emergency Medicine, Harbor–UCLA Medical Center, Torrance, CA (Coates, Jordan); and the Department of Economics, California State University–Fullerton, Fullerton, CA (Gill).

Study objective: Clerkship directors design and implement educational programs for students. Scholarly productivity is necessary for academic advancement. We define characteristics of emergency medicine clerkship directors and evaluate determinants of scholarly productivity and job satisfaction. Methods: This is a cross-sectional survey. Clerkship directors for emergency medicine senior rotations completed a confidential online questionnaire. Demographic data were analyzed with descriptive statistics. Scholarly productivity and job satisfaction indices were created for multivariate analysis. Results: One hundred eleven (82%) of 136 directors responded (age 38.9G7.0 years; men 72.1%; junior academic rank 72.1%; served as clerkship directors for %5 years 77.4%; formal training in education: medical education fellowship 36%, teaching credential 12.7%, emergency medicine subspecialty fellowship 6.3%; support for clerkship director’s activities: clinical hours reduction 2.7G2.3 weekly; minimal training for clerkship director’s role 85.6%; ongoing professional development 40.5%; scholarly productivity: %5 peer-reviewed publications 78.4%, grant 28%, textbook chapter 65%; plan to be clerkship director in 5 years 63%; perceived support from supervisor 88%; perceived value from colleagues 81%; perception that clerkship directors is as important as residency director 47.8%). Multivariate regression shows a significant effect of medical education fellowship (P=.013) and subspecialty training (P=.044). Departmental support enhances the effect of medical education (P=.008) or subspecialty (P=.026) fellowships and improves productivity for senior faculty (P=.047). Multivariate regression explaining job satisfaction shows a positive effect of reduced clinical hours (P=.038) and increased faculty development (P=.033). Conclusion: Most emergency medicine clerkship directors are junior faculty with minimal release time or training for their positions. [Ann Emerg Med. 2005;45:262-268.]

0196-0644/$-see front matter Copyright ª 2005 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2004.09.023

INTRODUCTION Clerkship directors are responsible for designing, implementing, and administering medical student educational programs in emergency medicine. Information about demographic characteristics, formal training in the field of education, faculty development, and support necessary to perform their duties are not known. In the academic structure, scholarly productivity is necessary for promotion and tenure.1,2 Since the modification of the definition of scholarship by Boyer3 in 1990, emergency medicine clerkship directors may also achieve academic success in a clinicianeducator track. 262 Annals of Emergency Medicine

Some specialties have identified characteristics of those who serve as clerkship directors for the primary clerkships of medical school.1,4-7 Formal expectations and support materials have been developed in internal medicine for clerkship directors.8-10 To date, there has been no formal evaluation of clerkship directors in emergency medicine. The objectives of this study are to define the characteristics of emergency medicine clerkship directors in the following areas: demographics, professional responsibilities, scholarly activities, faculty development, and career goals; and to evaluate determinants of scholarly productivity and job satisfaction in a manner similar to that of published reports about clerkship directors in other medical specialties. Volume 45, no. 3 : March 2005

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Editor’s Capsule Summary What is already known on this topic To date, there has been no formal evaluation of the background and responsibilities of clerkship directors in emergency medicine. What question this study addressed This article describes the results of a cross-sectional survey of emergency medicine clerkship directors regarding demographics, formal training, faculty development, and support. What this study adds to our knowledge In 111 surveys received, most individuals serving as clerkship directors in emergency medicine are junior faculty, have been in their role for less than 5 years, and have not received formal training in education. Most hope to remain in their jobs for the foreseeable future. How this might change clinical practice This study will not change clinical practice but may inform how clerkship directors are selected and supported by their institutions.

MATERIALS AND METHODS Study Design, Setting, and Participants The study was approved by our institutional review board. It was a cross-sectional survey of Internet-based data collection completed by clerkship directors at US medical schools. Clerkship directors were identified from a comprehensive list of known available clerkships in emergency medicine that is maintained by the Society for Academic Emergency Medicine. Exclusion criterion was not being a clerkship director. Data Collection and Processing We sent a personal e-mail to each clerkship director, explaining the study, and assigned each a unique, randomly generated personal identification number and a hypertext link to gain access to a secure, Web-based, data collection instrument. Once completed, the answers of each subject were transferred directly to a spreadsheet program maintained on the medical school’s mainframe server for analysis. Subjects were prompted to complete unanswered questions before their responses were submitted. E-mail and telephone follow-up were used to contact nonresponders.

Emergency Medicine Clerkship Directors authors, and the entire survey instrument was validated using a pilot sample of emergency medicine clerkship directors. The survey instrument took approximately 10 minutes to complete and is available for review at http://apps.medsch.ucla.edu/ archive/misc/emsurvey/survey.htm. Outcome Measures Demographic and job information were obtained in the following areas: sex, educational preparation, professional rank and responsibilities, academic productivity, clerkship characteristics, availability of faculty development programs, career goals, and job satisfaction. Primary Data Analysis Demographic data were analyzed with descriptive statistics. Multivariate regression analysis was conducted to explain variation in research productivity and job satisfaction. Our rationale for these multivariate analyses stems from our stated second objective of evaluating the determinants of research productivity and job satisfaction among clerkship directors. Our model follows closely, data permitting, the multivariate analysis presented for internal medicine clerkship directors.1 With regard to the measurement of the dependent variables in the multivariate analysis, we believed it would be more informative to combine the 5 productivity measures into a single index and the 5 job satisfaction measures into a second single index. With respect to research productivity, it seems reasonable that the activities we have identified are highly complementary (eg, grant activity and peer-reviewed publications). Similarly, the job satisfaction measures in combination capture an underlying overall feeling of satisfaction with the clerkship director position, and it is unlikely that any one can have an overwhelmingly significant effect in the absence of all the others. We elected to create our indices by entering our measures of research productivity and job satisfaction into a factor analysis and forcing a 2-factor solution. The resulting factor loadings were then combined with our productivity and satisfaction measures to predict values for the 2 common factors for each respondent. The resulting predicted common factors become our indices of research productivity and job satisfaction. It is important to note that we use the factor analysis strictly as a numeric procedure for creating weights to combine our measures into single indices. Because we force a 2-factor solution, we do not consider Eigen values, scree plots, or other procedures to assess the number of common factors, nor do we attempt to interpret the factor loadings.

RESULTS Methods of Measurement The authors developed a data collection instrument to describe emergency medicine clerkship directors. Some questions on academic training and scholarly productivity were configured on the basis of existing literature about core-clerkship directors in other medical specialties.1,5,7 Other questions that were specific to emergency medicine were written by the Volume 45, no. 3 : March 2005

One hundred eleven (82%) of 136 of the clerkship directors replied. Demographic information describing the personal and professional attributes of clerkship directors and their working conditions are described in Table 1. Clerkship directors are predominantly men, and only 21.6% have attained an academic rank beyond assistant professor. Only 22.4% of the directors have held their positions longer than 5 years. To prepare for Annals of Emergency Medicine 263

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Emergency Medicine Clerkship Directors Table 1. Demographics, training, workload, and support: emergency medicine clerkship directors (n=111). Demographics and Training

Mean or Percentage (SD)

Age Sex Male Female

72.1 27.9

Rank Instructor Assistant professor Associate professor Professor No academic appointment

10.8 61.3 18.0 3.6 6.3

Years as clerkship director 1–2 2–5 6–10 O10

45.0 32.4 17.0 5.4

Previous roles held in emergency medicine Chief resident Associate residency director Residency director Clinical director Research director Chair of department No previous roles held

36.9 0 6.3 9.9 4.5 1.8 40.5

Emergency medicine board certified? Yes No

95.5 4.5

Fellowship in medical education? Yes No

36.0 64.0

College degree or credential in education? Yes No

12.7 87.3

Fellowship in emergency medicine subspecialty? Yes No

6.3 93.7

Support No. of hours per week clinical load is reduced*

38.9 (7.0)

2.7 (2.3)

Formal training for role as clerkship director No formal training Brief description of job Extensive mentorship Handbook or written guidelines

37.9 47.7 9.9 4.5

Provided ongoing professional development? Yes No

40.5 59.5

Provided administrative support staff? Yes No

93.7 6.3

*The median hours of work and interquartile range are 0 and 5 hours, respectively.

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a leadership position in medical education, 36.0% of the respondents report completing a fellowship in medical education (American College of Emergency Physicians/Emergency Medicine Fellowship or medical school–based fellowship), and 12.7% report that they have obtained a college degree or formal credential in secondary or elementary education. Of this 12.7% with a formal background in education, more than half were also in the group who completed a fellowship in medical education; 6.3% of the respondents reported fellowship training in an emergency medical subspecialty (eg, toxicology, emergency medical services, pediatric emergency medicine). Clerkship directors thought that they received minimal support as defined in Table 1. Although most receive adequate administrative and secretarial support, their clinical hours are reduced by an average of only 2.7 hours per week from their department’s baseline hours to perform their teaching and administrative duties. Nor does it appear that directors receive much formal training for their positions. Only 14.4% of respondents received extensive mentorship or written guidelines on how to conduct their job duties. Career academic achievements are reported in Table 2. These outcome measures include an accounting of scholarly and creative activities, various dimensions of respondents’ job satisfaction, and their perceptions of the value of the clerkship director position. Most clerkship directors have 5 or fewer scholarly publications, and a little over one quarter of the respondents have ever received a research grant. Of the job satisfaction measures listed in Table 2, perhaps the most noteworthy is the one related to respondents’ plans for the future. As shown, more than 63% indicated a desire to continue as clerkship director 5 years from now. Most respondents agreed or strongly agreed with positive statements about support from supervisors and the value of the clerkship director position. One salient exception is the question pertaining to the value of the role of the clerkship director relative to that of the residency director. Only 48% responded favorably. The measures of success are further explored in relation to characteristics of the clerkship directors and their work environment in Table E1 (available at http://www.mosby.com/ AnnEmergMed). In this section, we seek to explain variation in scholarly publications and variation in job satisfaction. As shown in Table 2, we consider 5 measures of scholarly productivity and 5 indicators of job satisfaction. Table E1 gives the results of our multivariate regression explaining the predicted common factor we are calling research productivity. Because predicted common factor scores are standardized, the coefficient estimates are interpreted as the effect of that variable on the common factor measured in standard deviations. Column 1 of Table E1 gives the coefficient estimates when demographic characteristics alone are used to explain research productivity. As shown, more experience and a higher academic rank increase the research productivity factor score by 0.235 and 0.394 of an SD, but neither coefficient is Volume 45, no. 3 : March 2005

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Table 2. Productivity, job satisfaction, and perception (n = 111). Measure Scholarly productivity Publications (peer reviewed) None 1–5 6–9 R10 Ever received a grant Yes No Textbook chapters None 1 2–5 O5 Involved in educational research Yes No Involved in noneducational research Yes No Job satisfaction and perception of value Plan to be clerkship director 5 y from now Yes No Strong support from immediate supervisor Strongly disagree Disagree Agree Strongly agree Colleagues value role of clerkship director Strongly disagree Disagree Agree Strongly agree Job responsibilities play important part in selection of future ED residents Strongly disagree Disagree Agree Strongly agree Role as important as residency director Strongly disagree Disagree Agree Strongly agree


24.3 54.1 9.0 12.6 27.9 72.1 35.1 11.7 36.0 17.1 63.1 36.9 73.0 27.0

63.1 36.9 2.7 9.0 42.3 46.0 1.8 17.1 57.7 23.4

1.8 5.4 38.7 54.1 9.0 43.2 33.3 14.4

ED, Emergency department.

subspecialty. In addition, the coefficient for higher academic rank becomes statistically significant. In Table E2 (available at http://www.mosby.com/ AnnEmergMed), we display the results in which the dependent variable is the job satisfaction factor score. As shown, job satisfaction appears to be unrelated to demographic characteristics and training. Instead, it appears that job satisfaction depends on the level of support one receives within one’s department. An increase of 1 hour of reduced clinical load is associated with a 0.055-SD increase in the job satisfaction factor score. Ongoing professional development also increases job satisfaction. A ‘‘yes’’ response to the ongoing professional development question is associated with an increase of 0.404 SDs in the job satisfaction factor score.

LIMITATIONS We tried to incorporate all known clerkships in emergency medicine in the United States, including multiple electives at the same medical school. It is possible that we missed available electives if they were not listed on the common list we used. In addition, we received 82%, not 100%, of the survey responses. Our study analyzed the scholarly productivity of clerkship directors by asking them to choose categoric variables. We may have obtained more accurate and more descriptive results by asking clerkship directors to give exact numbers of peerreviewed publications and dollar amounts of their grants, along with the sources of funding (eg, medical school, foundation, federal). Different organizational structures of individual departments were not measured; thus, we are not able to provide a comparison of the chain of command as it relates to clerkship directors. We did not separate clerkships into residency-affiliated or unaffiliated, nor did we distinguish between community- and university-based clerkships. Other limitations of our multivariate analyses must also be considered. As in all multivariate analyses, concern can be expressed about right-hand-side variables left out of the model. Research productivity and job satisfaction are complex, and we have attempted to explain variation in these measures with a relatively small number of explanatory variables. Moreover, even among the variables we do measure, there are limitations imposed by the way the questions were asked. We may have asked, for example, where individuals received their fellowships, college degrees, and credentials and when this training was received.

DISCUSSION statistically significant at the 0.05 level for a 1-tailed test. Similarly, sex has no effect on research productivity. In column 2 of Table E1, we add our measures of education and training. Controlling for demographic characteristics, a fellowship in medical education increases the research productivity factor score by 0.439 of an SD, whereas a fellowship in an emergency medical specialty increases it by 0.649 of an SD. Adding the support and workload variables in column 3 increases the effect of a fellowship in an emergency medicine Volume 45, no. 3 : March 2005

This study has provided an evaluation of the characteristics of the faculty members who serve as clerkship directors in emergency medicine. Compared with other specialties, those who direct the clerkship education programs in emergency medicine tend to be of more junior rank and identify a need for mentorship and increased release time to advance their academic careers as educators. Sixty-eight percent of internal medicine, 71% of surgery, 76% of pediatric, and 53% of obstetricgynecology clerkship directors are at the senior faculty level, Annals of Emergency Medicine 265

Emergency Medicine Clerkship Directors whereas only 21.6% of emergency medicine clerkship directors have attained that status.1,4,6,7 It is likely that senior-level clerkship directors are able to apply their expertise from previous administrative and leadership roles to the direction of their clerkships and can effectively discuss issues on an equal level with chairs and deans to negotiate on behalf of the clerkship. It is reasonable to assume that internal medicine, surgery, pediatrics, and obstetrics-gynecology have adopted the idea that the clerkship in their specialty is a priority that warrants experienced educators as their leaders. Because these specialties are core to the third-year curriculum, there may be high expectations for uniformity of the educational experience among sites and a high level of accountability to the accreditation of the entire medical school. In contrast, because emergency medicine has historically been an elective, the level of regulation of the educational program from medical school deans’ offices may have been less when compared with the core clerkships. A benefit of this situation is the freedom of choice for each emergency department to develop a unique experience, but we speculate that it may have set the stage for the issues that are the subject of this article. The job characteristics of a clerkship director have been described by Gorroll et al10 as ‘‘middle management’’ level with expectations of institutional leadership on a typical organizational chart. They recommend that the qualifications and time allotted to this role receive commensurate support. In our sample, it appears that many junior faculty assumed their roles with little or no training. It is inconceivable that this would happen in a business model. Adequate preparation for job skills such as personnel management, educational leadership, and curriculum planning and implementation are necessary to function successfully in a job with this degree of responsibility. In the current workforce, a minority has formal training in education, yet many are expected to conceive of and deliver high-quality educational experiences. A small portion of the educators are not board certified in emergency medicine, which likely represents the new faculty members who assume the role of clerkship director as their first academic position and have not yet qualified to take the board examination. Because emergency medicine is increasingly being taught in medical schools as a result of the recommendations of the Macy Foundation report11 and the Liaison Committee on Medical Education,12 there is a need to ensure that all faculty who are responsible for teaching medical students are prepared and supported adequately to fulfill this important role. Emergency medicine department chairs can engender support from the entire faculty to view medical student education as a priority. In our sample, clerkship directors had 2.7G2.3 hours per week available for their administrative duties. Fifty-seven (51.4%) had zero hours set aside for these duties. In contrast, internal medicine clerkship directors reported that 28% of their salary is derived from their administrative position.1 Surgical clerkship directors spend 35.6% of their time on teaching and 266 Annals of Emergency Medicine

Coates, Gill & Jordan administration.4 The role of emergency medicine residency director is afforded some reduction in clinical time in many programs. Protected time allows clerkship directors the opportunity to develop innovations for their courses.13 As academic faculty members, it is incumbent on clerkship directors to prioritize their academic progress and focus on scholarly activities.2,13-15 Because clerkship directors spend such a great amount of time developing and administering educational programs, they can focus their scholarly productivity on issues related to their teaching. In schools that offer a clinician-educator track, academic advancement may rely on quality and quantity of clinical teaching and course development and administration. In our sample, job satisfaction and traditional measures of scholarly productivity were related to release time and fellowship training. It makes sense that those who are well trained and have the time to engage in scholarly activities will derive more satisfaction from their jobs and be more productive than those who lack training or have no time set aside for training or academic pursuits. Even in the clinicianeducator track at schools where it is available, faculty must be engaged in at least some scholarly projects to advance to the senior academic ranks.16-19 In this time of limited budgets, there are many competing forces for the time and money necessary to provide the optimal environment for clerkship directors while balancing the needs of the academic faculty in each of the other functions of the department. The job requirements of clerkship directors require a significant amount of time in creating and maintaining quality educational experiences. Activities such as meeting with medical students are time consuming but necessary for proper orientation, observation, teaching, feedback, and evaluation.20 There is value in designing a new curriculum, but there is not a place on the typical format of the curriculum vitae to document this. Therefore, clerkship directors must be proactive in documenting their work. One avenue is the educator’s portfolio.14,17 Clerkship directors should participate in a forum in which innovations in education can be disseminated publicly to receive academic and public recognition. In addition, educators should be encouraged to participate in existing venues for sharing their creative works. Because the preponderance of clerkship directors is academically junior, the concept of mentorship takes on significant importance for this group. Support and guidance from senior faculty give individual clerkship directors valuable mentorship. In our sample, the majority of respondents indicated a desire to continue in their current role as clerkship director. Because of the rapid growth of emergency medicine as a specialty, advancement through the administrative ranks within departments of emergency medicine has prevailed, so that most clerkship directors who completed the survey were actually in their current roles for less than 5 years, which may explain why emergency medicine clerkship directors are composed of such junior faculty. As the job of clerkship director becomes more desirable, it is likely to be assumed by more midlevel and senior-level faculty. Besides the educational value of the Volume 45, no. 3 : March 2005

Coates, Gill & Jordan emergency medicine curriculum to all medical students, the existence of an emergency medicine rotation provides an avenue of recruitment to the specialty. Senior-level faculty will be more likely to interact successfully within the dean’s office at the home medical school about budgetary issues and can serve as proponents to extend the presence of emergency medicine into the earlier years of medical school. Recommendations d Emergency medicine faculty who are assigned to lead the medical student educational program should receive training in educational principles, including curriculum development and administration, clinical and didactic teaching methods, medical student evaluation and feedback approaches, and course management strategies. d Qualified mentors should be available to assist clerkship directors to foster their career development and ensure outstanding educational opportunities for medical students. d An ample amount of protected time should be available for clerkship directors to develop and improve their courses while attending to the needs of the medical student consumers of the educational experience. d For emergency medicine clerkships taking place in community hospitals, provisions should be made to ensure a uniform educational experience and support for these clerkship directors. In Retrospect A more thorough study of the training and work environment of successful clerkship directors may shed light on how to provide specific recommendations for new faculty in this role. We did not seek to include external evaluation measures of the clerkship directors, such as teaching or peer evaluations and winning of teaching awards. Although these measures are critical to the overall success of a faculty member’s career, we chose to focus our analysis on the most rigorous and traditional measures of scholarly productivity. Future study might include these measures of success, especially for faculty members on education career tracks. A similar query of the chairs of emergency medicine would provide an interesting perspective on the value and job expectations of the clerkship director and could be compared with the faculty responses. In summary, most emergency medicine clerkship directors are at the junior faculty level and receive little training or formal faculty development for their job responsibilities. A significant proportion of clerkship directors intend to advance their careers in the field of medical education. They could benefit from increased release time, formal faculty development programs, and mentorship opportunities to enable academic advancement and provide quality educational programs for medical students. We thank Zhen Gu, BS, and the UCLA Instructional Design and Technology Unit, David Geffen School of Medicine at UCLA, for support in developing the Web-based data collection instrument. Volume 45, no. 3 : March 2005

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Author contributions: WCC conceived of the study. WCC and RJ conducted research. WC, AMG, and RJ prepared the manuscript. WCC is the primary author of manuscript. AMG was the consultant for study design and analysis. RJ was responsible for contacting all clerkship directors and designing the data collection instrument with the assistance of a programmer. WCC takes responsibility for the paper as a whole. Funding and support: The authors report this study did not receive any outside funding or support. Publication dates: Received for publication April 7, 2004. Revision received September 7, 2004. Accepted for publication September 24, 2004. Available online January 19, 2005. Presented at the Society for Academic Emergency Medicine Western Regional Forum, Scottsdale, AZ, March 2003. Reprints not available from the authors. Address for correspondence: Wendy C. Coates, MD, Harbor–UCLA DEM, Box 21, 1000 W. Carson Street, Torrance, CA 90509-2910; 310-222-3500, fax 310-212-6101; E-mail [email protected]. REFERENCES 1. Hemmer PA, Elnicki DM, Albritton A, et al. The responsibilities and activities of internal medicine clerkship directors. Acad Med. 2001;76:715-721. 2. Beasley BW, Wright SM, Cofrancesco J, et al. Promotion criteria for clinician-educators in the United States and Canada: a survey of promotion committee chairpersons. JAMA. 1997;278:723-728. 3. Boyer EL. Scholarship Reconsidered: Priorities for the Professoriate. Princeton, NJ: Carnegie Foundation for the Advancement of Teaching; 1990. 4. Boehler ML, Rogers DA, Schwind CJ, et al. Who are the surgery clerkship directors and what are their educational needs? Am J Surg. 2003;185:216-218. 5. Fincher RE, Lewis L. Profile of medicine clerkship directors. Acad Med. 1997;72:S112-S114. 6. Greenberg L, Sahler OJZ, Siegel B, et al. The pediatric clerkship director: support systems, professional development, and academic credentials. Arch Pediatr Adolesc Med. 1995;149:916-920. 7. Magrane DM, Fenner D. A profile of directors of clerkships in obstetrics and gynecology in the United States and Canada. Obstet Gynecol. 1997;89:785-789. 8. Pangaro LN. Expectations of and for the medicine clerkship director. Am J Med. 1998;105:363-365. 9. Jablonover RS, Blackman DJ, Bass EB, et al. Evaluation of a national curriculum reform effort for the medicine core clerkship. J Gen Intern Med. 2000;15:484-491. 10. Gorroll AH, Morrison G, Bass EB, et al. Reforming the core clerkship in internal medicine: the SGIM/CDIM project. Ann Intern Med. 2001;134:30-37. 11. Josiah Macy, Jr. Foundation. The role of emergency medicine in the future of American medical care. Ann Emerg Med. 1995;25: 230-233. 12. Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Washington, DC: Association of American Medical Colleges; 2003. 13. Fincher RE, Simpson DE, Mennin SP, et al. Scholarship in teaching: an imperative for the 21st century. Acad Med. 2000; 75:887-894.

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Emergency Medicine Clerkship Directors 14. Kuhn GJ. Faculty development: the educator’s portfolio: its preparation, uses, and value in academic medicine. Acad Emerg Med. 2004;11:307-311. 15. Simpson DE, Fincher RM. Making a case for the teaching scholar. Acad Med. 1999;74:1296-1299. 16. Glassick CE. Reconsidering scholarship. J Public Health Manage Pract. 2000;6:4-9. 17. Coates WC, Hobgood CD, Birnbaum A, et al. Faculty development: academic opportunities for emergency medicine

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Coates, Gill & Jordan faculty on education career tracks. Acad Emerg Med. 2003;10: 1113-1117. 18. Marcdante KJ, Kliegman RM. Promoting clerkship directors: the importance of evidence. J Pediatr. 2002;141:1-2. 19. Elnicki DM, Hemmer PA, Udden MM, et al. Does being a clerkship director benefit academic career advancement: results of a national survey. Teach Learn Med. 2003;15:21-24. 20. Elnicki DM. Why what we do matters. Am J Med. 2001;110: 676-680.

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