Expectations of an Emergency Medicine Clerkship Director Robert L. Rogers, MD, David A. Wald, DO, Michelle Lin, MD, Leslie S. Zun, MD, Theodore Christopher, MD, and David E. Manthey, MD
Abstract The clerkship director (CD) serves as a faculty leader within a school of medicine and plays a vital role in the hierarchy of undergraduate medical education. Collectively, CDs across specialties serve a multitude of roles and are responsible for clerkship administration, curricular development, teaching, mentoring, and advising students. The emergency medicine (EM) CD has a vitally important role to play in the future development of medical students. EM CDs should be valued and supported, because they often represent our specialty within the medical school and play a vital role in training the physicians of tomorrow. Opportunities and resources must be made available to CDs to run and maintain a successful EM clerkship, while also balancing their clinical duties and academic endeavors. In addition, EM CDs need support from their respective medical schools and departments to run highly successful medical student rotations. This article was prepared with the objective of establishing the importance of the EM CD, defining the job description of the CD, explaining the importance of adequate release time to perform the role of the CD, and describing the necessary resources and support for the position. With EM becoming an increasingly popular and integral rotation for medical students, it is likely that additional emphasis will be placed on the role of the EM CD. This reference document serves as a template for the job description and expectations of an EM CD. ACADEMIC EMERGENCY MEDICINE 2011; 18:513–518 ª 2011 by the Society for Academic Emergency Medicine
T
he clinical clerkship is fundamental to the process of educating medical students in all medical schools. Regardless of the health care setting, whether it is inpatient, outpatient, or the emergency department (ED), the clinical experience of medical school revolves primarily around direct patient care, primarily during clerkships. The clerkship director (CD) serves as a faculty leader within the school of medicine From the Department of Emergency Medicine, The University of Maryland School of Medicine (RLR), Baltimore, MD; the Department of Emergency Medicine, Temple University School of Medicine (DAW), Philadelphia, PA; the Department of Emergency Medicine, San Francisco General Hospital (ML), San Francisco, CA; the Department of Emergency Medicine, Finch University ⁄ Chicago Medical School (LSZ), Chicago, IL; the Department of Emergency Medicine, Jefferson Medical College (TC), Philadelphia, PA; and the Department of Emergency Medicine, Wake Forest University School of Medicine (DEM), Winston-Salem, NC. Received August 18, 2010; revisions received October 17 and October 25, 2010; accepted October 28, 2010. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: Richard Lammers, MD. Address for correspondence and reprints: Robert L. Rogers, MD; e-mail:
[email protected].
ª 2011 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2011.01063.x
and plays a vital role in the hierarchy of undergraduate medical education. Collectively, CDs across specialties serve a multitude of roles and are responsible for clerkship administration, curricular development, teaching, mentoring, and advising students. To provide opportunities for a successful academic career, and to promote job satisfaction, faculty who view undergraduate medical education as a career, not merely a stepping stone to further career advancement, should be nurtured and supported at the departmental and medical school level.1–3 This article has been prepared by a task force comprised of members of the Academy of Clerkship Directors in Emergency Medicine (CDEM) and the Association of Academic Chairs of Emergency Medicine (AACEM). This article has been reviewed and endorsed by the executive committees of CDEM and AACEM. Brief reviews have been published regarding emergency medicine (EM) CD characteristics; however, we set forth with the goal of further describing the role, expectations, and resources required for the EM CD to be a successful academician.4 THE IMPORTANCE OF THE CD Undergraduate medical education and the teaching of future physicians is the principal mission of medical schools and one of the most important and unique
ISSN 1069-6563 PII ISSN 1069-6563583
513
514
charges of the academic medical center. CDs play a pivotal role in developing and maintaining the quality of the educational experience for medical students. In recent years, with the combination of the growth of EM as a specialty, a renewed emphasis on the structure of the senior year of medical school, and a growing appreciation of the importance of teaching students about common urgent and emergent conditions, medical schools have increasingly incorporated an EM clerkship as a mandatory part of the clinical curriculum. EM is now recognized as one of the eight members of the Alliance for Clinical Education (ACE), along with core third-year clerkships in family medicine, internal medicine, neurology, obstetrics ⁄ gynecology (OB ⁄ GYN), pediatrics, psychiatry, and surgery. Clerkship directors have the unique opportunity to have a positive and enduring impact on medical students at a time in their careers when they are most impressionable. Interactions with faculty who serve as professional role models can have long-term effects. Most medical students will choose alternative career paths, but almost all will interact with emergency physicians on a regular basis in the future. By providing an educational experience and a friendly work environment, EM CDs can play a vital role in shaping the perception of the specialty of EM and our role in the health care system for future physicians. The CD often serves as the ‘‘face,’’ or principle representative, of the specialty to the students and medical school hierarchy.2 For this reason, our specialty must recognize the value of the position of the EM CD and how to support him or her in managing a successful clerkship, maintaining career longevity, and remaining academically productive. An important issue affecting the role of the CD is whether the EM rotation is an elective or a mandatory clinical experience. The decision to make a rotation elective versus mandatory is usually made by the leadership of the school of medicine. By definition, mandatory rotations typically involve a greater number of students taking the rotation and may include supervision and oversight of multiple clinical training sites. The CD will generally need to complete more student evaluations, provide feedback to more students about their performance, administer more tests, be responsible for more final grades, and adhere to the Liaison Committee on Medical Education (LCME) accreditation standards. In addition to the differences between an elective and a mandatory rotation, another very important consideration is whether the rotation is for third- or fourth-year medical students. When third-year medical students rotate in the ED, many of them have not completed all of their core third-year clerkships. Thus, a CD must be prepared to appropriately alter the educational goals and objectives to match the needs of a third-year medical student. Fourth-year medical students have, in general, completed all of their core clerkships and have a broader medical knowledge base to start the EM rotation. At institutions where both third- and fourth-year medical students rotate in the ED, it may be necessary to have curricula that address differences in knowledge and experience between third- and fourth-year students. Clerkship directors are leaders in medical education, and it is extremely important for them to be engaged
Rogers et al.
•
EXPECTATIONS OF AN EM CLERKSHIP DIRECTOR
and actively involved in scholarly activities. Involvement in these activities can include attending important educational meetings (e.g., the Association of American Medical Colleges [AAMC] annual meeting, Council of Emergency Medicine Residency Directors Academic Assembly, CDEM, and the Society for Academic Emergency Medicine annual meeting), staying up to date with current issues pertaining to medical education, generating scholarly publications, or participating in clinical or educational research. In addition, participation in educational committees at the departmental, medical school, or national level is important to foster the CD’s faculty development and leadership abilities within the field of medical education. LONGEVITY AND ACADEMIC RANK OF EM CDS VERSUS OTHER SPECIALTIES Although an experienced and expert educator may be best suited to oversee a clinical clerkship, CDs in EM rarely have these characteristics. In a recent survey of EM CDs, it was noted only 22% were at the rank of associate professor or higher, compared to 68% of internal medicine CDs, 71% of surgery, 76% of pediatric, and 53% of OB ⁄ GYN CDs who were at this senior faculty level.4–10 Longevity in the CD position has also been an issue for EM CDs. It has been reported that 45% of EM CDs have held their position for only 1 to 2 years and fewer than 25% for longer than 5 years.4 This is in contrast to CDs in other fields of medicine who have traditionally held their present position for 5 to 8 years. A recent survey revealed that CDs in the core specialties held their role as CD for an average of 7 years with family medicine and OB ⁄ GYN for slightly less than 5 years.11 A follow-up survey of EM CDs is under way by CDEM, which should provide current data on the characteristics of the EM CD. It is unclear as to why there is a high rate of turnover for EM CDs. Perhaps there are issues related to job satisfaction, career advancement, or lack of protected time for clerkship administration and the pursuit of scholarship. PROTECTED TIME FOR THE CD ROLE Medical educators in academia are often balancing clinical responsibilities along with their administrative duties, teaching, and the pursuit of scholarship. Leaders in medical student education across many specialties have stated that the role of the CD and residency program director (PD) are and should be viewed as comparably valuable positions.4,12 These two positions arguably serve distinct but parallel roles in the frameworks of undergraduate and graduate medical education, respectively.13 Each provides equivalent leadership along different ends of the spectrum of medical education. However, compared to EM PDs, EM CDs are younger, more likely to be junior faculty, and currently receive less protected time.4,14 As reported in a recently published faculty salary survey, EM PDs work an average of 17 clinical hours per week, whereas CDs typically carry a greater clinical work load.4,15 Residency
ACAD EMERG MED • May 2011, Vol. 18, No. 5
•
www.aemj.org
Table 1 Roles and Responsibilities of the Emergency Medicine CD12 • Provide a high-quality educational experience that meets departmental, medical school, and Liaison Committee on Medical Education objectives. • Set expectations, roles, and responsibilities for student involvement in patient care activities. • Adhere to departmental and medical school expectations, guidelines, and timelines. • Advise and mentor students in the residency application process. • Provide letters of recommendations for students applying to residency. • Generate faculty and resident teaching evaluations on an as-needed basis. • Evaluate program effectiveness and implement changes as needed. • Develop, review, and update a set of educational objectives for the clerkship ensuring that the clerkship objectives correspond with the institutional objectives (ED-1). • Establish a system to specify the types of patients or clinical conditions that all students must encounter, monitor the experiences to verify compliance, and remedy any identified gaps. This oversight can be at the clerkship or institutional level (ED-2). • Make known the objectives of the educational program to all faculty, residents, and others with direct responsibilities for medical student education (ED-3). • Ensure comparable educational experiences and equivalent methods of evaluation across alternative instructional sites (ED-8). • Ensure that residents who supervise or teach medical students are familiar with the educational objectives of the clerkship and are prepared for their roles in teaching and evaluation (ED-24). • Ensure that the student learning experiences throughout a required EM clerkship are supervised by members of the medical school’s faculty (ED-25). • Set the standards of achievement for the EM clerkship (ED-29). • Design and implement a system of formative and summative evaluation of student achievement (ED-30). • Evaluate each student early enough during the clerkship to allow time for remediation (ED-31). • Provide narrative descriptions of student performance and of noncognitive achievement as part of evaluations in required clerkships when teacher–student interaction permits this form of assessment (ED-32). • Attend clerkship director, year 3 ⁄ 4 committee, and curriculum development committee meetings as required by institution. • ED-25, etc. = LCME educational directive number (http://www.lcme.org/functions2010jun.pdf) CD = Clerkship Director.
director longevity has been directly related to the presence and importance of protected time for PDs.14 The same argument may hold true for CDs. Furthermore, compared to CDs from other specialties, EM CDs receive less release time for clerkship administration and teaching.16 In a study by Coates et al.,4 EM CDs reported receiving on average only 2.7 hours per week of a reduced clinical work load. More than half reported that they had no release time set aside to perform clerkship administration. Based on a recently published review, protected time for the CD varies across specialties.16 Percentage of faculty time set aside for clerkship administration and teaching ranges from a low of 7% (EM) to a high of
515
48% (family medicine). Various national CD organizations have made recommendations for the time required for the role of CD. The Clerkship Directors in Internal Medicine recommend that a 25% full-time equivalent (FTE) should be considered a minimum estimate of time to perform clerkship administration. If time for teaching and scholarly pursuits is included, a minimum of 50% FTE should be expected.17 The Association of Directors of Medical Student Education in Psychiatry recommends that the CD should be allocated 20% of FTE for clerkship administration, 25% for direct teaching, and an additional 10% for educational research, for a total of 55% time release.18 ACE, a national, multidisciplinary group of CDs and medical student educators, has recommended 25% time for clerkship administration and 25% time for teaching and the pursuit of scholarship for a total release time of 50%.12 CDEM and AACEM support the recommendations from these national CD organizations in recognizing the need for a reduction in the clinical load for CDs to perform their job. The ACE recommendation, however, may not apply to all EM clerkships, because they vary significantly in student volume, clerkship structure, and administrative workload. Some CDs are responsible for a high-volume mandatory rotation, which oversees more than 200 medical students annually. Others may oversee a selective or elective rotation with 80–120 students annually, and still others may oversee a low-volume experience as a clinical site director or a CD for a small, community-based EM elective. Release time from clinical responsibilities should be adjusted according to the amount of work needed to ensure an educational and engaging EM experience for students. In general, a lower amount of release time would be expected for lower volume rotations. The role of a CD can be compared to that of a residency director. The American Accreditation for Graduate Medical Education requires that PDs at 3-year residency programs with at least six residents per year have at least 50% protected time. Compare this to an institution with a mandatory EM clerkship that has 100 fourth-year students (eight per month) rotating through each year, yet the CD may have no protected time. Residency director longevity has been directly related to the presence and importance of protected time for PDs.14 The same argument should hold true for CDs. Release time from clinical duties to perform the administrative roles and responsibilities of the CD position should also take into consideration support for other academic pursuits, such as research, teaching, writing, and publications. In addition to release time set aside for clerkship administration and teaching, protected time should be available for the CD to engage in other academic scholarly activities. Data from a 2006–2007 study conducted by ACE showed that release time from clinical duties enhanced overall academic productivity.19 DEFINING THE ROLE OF THE EM CD Although some preliminary recommendations regarding the EM CD role have been published, there is no
516
Rogers et al.
standardized or widely accepted job description for this position.4 In 2003, ACE published a landmark statement entitled ‘‘Expectations of and for clerkship directors.’’12 The authors, at that time representing seven core CD organizations, provide a detailed job description and duties of the CD. This included qualifications, support, and time allocation required to fulfill the CD responsibilities. Because this statement was developed before CDEM joined ACE, an EM representative was not part of this effort. The principles and recommendations, however, are applicable to the CD of a mandatory or high volume EM clerkship.16 Medical student educators in other specialties have developed similar expectation statements outlining the job description of the CD. The LCME is recognized by the U.S. Department of Education as the accrediting body for programs of medical education leading to the M.D. degree in the United States and in collaboration with the Committee on Accreditation of Canadian Medical Schools for Canadian medical education programs. The LCME accreditation standards guide and govern the medical school and the CD in performing his or her duties. By incorporating the expectations set forth by ACE and the educational standards of the LCME, we have created guidelines outlining the roles and responsibilities of the EM CD (Table 1). Characteristics and essential skills of an EM CD are also presented (Table 2).
Table 3 Recommended Support for EM CD12
WHAT SUPPORT DOES THE EM CD NEED TO SUCCEED? To run a clerkship efficiently, the CD needs both departmental and institutional support (Table 3). From the department, the CD requires support from his or
Table 2 Characteristics and Essential Skills of an EM CD12 • Be board-certified or board-prepared in the specialty of EM. • Have experience and comfort with clinical supervision and classroom instruction. • Have skills and experience in formative and summative evaluation. • Be able to advise and supervise remediation for students with academic problems. • Be enthusiastic about medical student education and regard undergraduate medical. Education as a central focus of career development. • Be able to provide career guidance to medical students regardless of specialty choice. Essential Skills • Interpersonal skills to effectively communicate with medical students, EM faculty, and residents, community training sites, and the medical school administration. • Excellent written and verbal communication skills. • Computer skills necessary to communicate via e-mail, develop and maintain student reports and other documents, prepare and analyze spreadsheets, and work with Web-based scheduling and evaluation programs. • Problem-solving, conflict resolution, and decision making skills. • Time management and organizational skills. CD = Clerkship Director.
•
EXPECTATIONS OF AN EM CLERKSHIP DIRECTOR
• Sufficient release time to perform clerkship administration, teach medical students, and pursue scholarly activities. This should include opportunities to attend national academic meetings and faculty development courses. • Adequate training in educational principles (curriculum development and administration, bedside and didactic teaching methods, and evaluation and feedback approaches). • Mentorship from qualified faculty members in career development. • Support from faculty as well as departmental and medical school leadership in the teaching and evaluation of students. • Clerical and administrative support to run the clerkship. • Membership in the CDEM. CD = Clerkship Director; CDEM = Clerkship Directors in Emergency Medicine.
Table 4 Description for the EM Clerkship Administrator Position12 The primary responsibilities and essential skills for the clerkship administrator include, but are not limited to the following: Responsibilities • Serve as the first contact liaison to the medical students, EM faculty, residents, community training sites, and medical school administration. • Provide administrative support for the clerkship and CD, such as coordinating meetings and conference calls, reserving lecture space, and obtaining audiovisual equipment as needed. • Communicate directly with the CD regarding all clerkship and medical student related matters. • Manage the daily operations of the clerkship, prioritize tasks, and resolve issues as they arise. • Be familiar with all clerkship paperwork, policies, and guidelines. • Recruit faculty or residents for medical student teaching as needed. • Prepare all clerkship related materials for distribution. • Prepare, organize, and collect end-of-clerkship material (course and faculty evaluations, patient encounter logs, etc.). • Maintain complete and accurate files for each student. • Maintain a confidential file of medical student grades. • Provide reports on a semiannual or as-needed basis. • Help prepare departmental letters of recommendation. • Prepare documents as needed for LCME accreditation. Essential Skills • Interpersonal skills to effectively communicate with medical students, EM faculty, residents, community training sites, and the medical school administration. • Excellent written and verbal communication skills. • Computer skills necessary to communicate via e-mail, develop and maintain student reports and other documents, prepare and analyze spreadsheets, and work with Web-based scheduling and evaluation programs. • Problem solving, conflict resolution, and decision-making skills. • Time management and organizational skills.
her chairperson and faculty colleagues. Support from the chairperson may assist the CD in further engaging other faculty and may help set the tone within the
ACAD EMERG MED • May 2011, Vol. 18, No. 5
•
www.aemj.org
Table 5 Resources for the EM CD • Alliance for Clinical Education (ACE; http://www.allianceforclinicaleducation.org) s Expectations of and for clerkship directors s Guidebook for Clerkship Directors, 3rd ed. (4th ed. in development) • Association of Academic Chairs of Emergency Medicine (AAMC; http://www.aamc.org) s Careers in medicine s MedEdPORTAL s Medical school objectives project s Recommendations for clinical skills curricula for under graduate medical education • Clerkship Directors in Emergency Medicine (CDEM; http://www.saem.org/cdem) 20 s Consensus publication on the EM clerkship curriculum s Digital instruction in EM cases (in development) s EM clerkship primer s Medical Student Educator Handbook, 1st ed. (2nd ed. available fall 2010) s Self-study modules (http://www.cdemcurriculum.org) • Liaison Committee for Medical Education (LCME; http://www.lcme.org) s Accreditation standards CD = Clerkship Director.
department regarding the importance of undergraduate medical education. Another type of support to encourage faculty to aid in and improve their medical student teaching is found in some institutions that incorporate medical student teaching evaluations in salary incentive matrices. At some institutions, faculty receive incentives for the amount of time they spend teaching medical students. Although many institutions have not developed ways to incentivize teaching of medical students, some have made great strides in recent years to reward faculty who frequently teach. Within the medical school, emphasis and recognition must extend beyond the department to the institution’s promotion and tenure committee. It may also be necessary for the institution to provide support in the form of information technology and faculty salary support to further justify a reduction in one’s clinical work load and salary personnel support for a clerkship administrator. Table 4 describes the role of the clerkship administrator. On the national level, our specialty’s support of the EM CD has materialized with the formation of the Academy of CDEM in May 2008. RESOURCES FOR THE EM CD Various national organizations such as ACE, the Association of AAMC, CDEM,20 and the LCME can all serve as resources for CDs and medical student educators (Table 5). CONCLUSIONS Emergency medicine clerkship directors play a vital role in medical student education. Opportunities and resources must be made available to clerkship directors to run and maintain successful EM clerkships, while also balancing their clinical duties and academic
517
endeavors. With EM becoming an increasingly popular and integral rotation for medical students, it is likely that additional emphasis will be placed on the role of the EM clerkship director. EM clerkship directors should be valued and supported, because they often represent our specialty within the medical school and play a vital role in training the physicians of tomorrow. This reference document serves as a template for the job description and expectations of an emergency medicine clerkship director. This article has been prepared by a task force composed of members of the Academy of Clerkship Directors in Emergency Medicine and the Association of Academic Chairs of Emergency Medicine.
References 1. Marcdante KJ, Kliegman RM. Promoting clerkship directors: the importance of evidence. J Pediatr. 2002; 141:1–2. 2. Elnicki DM. Why what we do matters. Am J Med. 2001; 110:676–80. 3. Elnicki DM, Hefner J, Hemmer PA, et al. Does being a clerkship director benefit: results of a national survey. Teach Learn Med. 2003; 15:21–4. 4. Coates WC, Gill AM, Jordan R. Emergency medicine clerkship directors: defining the characteristics of the workforce. Ann Emerg Med. 2005; 45: 262–8. 5. Sierles FS, Magrane D. Psychiatric clerkship directors: who they are, what they do, and what they think. Psychiatr Q. 1996; 67:153–62. 6. Hemmer PA, Elnicki DM, Albritton TA, et al. The responsibilities and activities of internal medicine clerkship directors. Acad Med. 2001; 76:715–21. 7. Boehler ML, Rogers DA, Schwind CJ, et al. Who are the surgery clerkship directors and what are their educational needs? Am J Surg. 2003; 185:216–8. 8. Greenberg L, Sahler OJ, Seigel B, et al. The pediatric clerkship director: support systems, professional development, and academic credentials. Arch Pediatric Adolesc Med. 1995; 149:916–20. 9. Magrane DM, Fenner D. A profile of directors of clerkships in obstetrics and gynecology in the United States and Canada. Obstet Gynecol. 1997; 89:785–9. 10. Goefert AR, Phelan SP, Cliver SP, et al. An evaluation of trends in obstetrics and gynecology clerkships in the United States and Canada. Am J Obstet Gynecol. 2004; 191:354–8. 11. Alliance for Clinical Education. National Survey of Clerkship Director Demographics, Resources, and Professional Life [panel presentation]. Available at: http://www.allianceforclinicaleducation.org/ 2008AAMCPanel.pdf. Accessed Mar 4, 2011. 12. Pangaro L, Bachicha J, Brodkey A, et al. Expectations of and for Clerkship Directors: a collaborative statement from the Alliance for Clinical Education. Teach Learn Med. 2003; 15:217–22. 13. ACGME. Emergency Medicine Program Requirements. Available at: http://www.acgme.org/acWebsite/RRC_110/110_guidelines.asp. Accessed Mar 4, 2011.
518
14. Beeson MS, Gerson LW, Weigand JV, Jwayyed S, Kuhn G. Characteristics of emergency medicine program directors. Acad Emerg Med. 2006; 13:166–73. 15. Kristal SL, Randall-Kristal KA, Thompson BM. The Society for Academic Emergency Medicine’s 2004– 2005 emergency medicine faculty salary and benefit survey. Acad Emerg Med. 2006; 13:548–58. 16. Margo K, Gazewood J, Jerpbak C, Burge S, Usatine R. Clerkship directors’ characteristics, scholarship, and support: a summary of published surveys from seven medical specialties. Teach Learn Med. 2009; 21:94–9.
Rogers et al.
•
EXPECTATIONS OF AN EM CLERKSHIP DIRECTOR
17. Pangaro LN. Expectations of and for the medicine clerkship director. Am J Med. 1998; 105:363–5. 18. Association of Directors of Medical Student Education in Psychiatry. Clerkship Director Position Paper. Available at: http://www.admsep.org/positionpaper.html. Accessed Mar 4, 2011. 19. Ephgrave K, Margo KL, White C, et al. Core clerkship directors: their current resources and the rewards of the role. Acad Med. 2010; 85:710–5. 20. Manthey DE, Ander DS, Gordon DC, et al. Emergency medicine clerkship curriculum: an update and revision. Acad Emerg Med. 2010; 17:638–43.
