Medical student education in psychiatry depends on salaried and volunteer faculty to serve as teachers and mentors. Traditionally, these activities have occurred by implicit “social contract” in which teaching is not reimbursed (1). Recent trends, however, have hurt this contract.

With the emergence of managed care, academic medical centers are increasingly focused on economic competitiveness and clinical productivity. As a result, faculty have less time for teaching and research (2–6). Concurrently, medical school education has expanded teaching needs. Curricula have reduced lecture hours and increased small group and clinical experiences. Clinical teaching has diminished in inpatient settings and expanded in outpatient settings. These changes require more teachers.

Academic departments are challenged by the need to promote teaching in this climate of diminished resources. Some departments have increased hiring of “clinician-educator” faculty, while others have increased the teaching requirements for a volunteer faculty appointment. These efforts are not always sufficient in meeting departmental teaching needs. Psychiatry departments must consider new strategies for recruiting, retaining, and rewarding salaried and volunteer faculty.

The literature on rewarding volunteer teaching faculty for medical student education comes primarily from family medicine, general internal medicine and pediatrics, with little input from psychiatry. A variety of findings have been reported, with no clear consensus. Though faculty report that they teach for personal satisfaction, love of teaching and altruism, they are frequently more willing to teach if offered some form of recognition (7–11). Continuing medical education (CME), and deferral of CME fees emerge as the most valued incentive, followed by gifts and services such as library privileges and e-mail access (8, 9, 11).

The issue of financial reward is complex and reflects ambivalence. In one survey of clinical faculty, 45% requested some form of recognition, but two thirds suggested that this should not be monetary (7). In another study assessing motivation for teaching among primary care volunteer faculty, approximately one third of respondents assigned “payment for teaching” the lowest possible score while another one third assigned “payment for teaching” the highest two possible scores (8). Several authors warn that this data reflects old values and that modern physicians may increasingly require payment to reflect monitoring of their productivity (1, 6). A 2000–2001 report documents that in fact 40/125 medical schools pay some or all voluntary faculty for participating in educational programs (12).

Promotion is crucial to faculty retention, including those in the relatively new “clinician educator” tract. By 1996, nearly three fourths of medical schools had a distinct promotional track for clinician-educators (13). Currently, 80% of clinician-educator tracks are untenured and only 34% provide unqualified professorial titles (13). In a 1996 survey, schools with clinician-educator promotion tracks rated teaching skills and clinical skills as the most important promotion criteria. While clinician-educators needed only half as many peer-reviewed publications for promotions as faculty on alternative tracks, the average requirement was 5.7 publications (14). In a 1997 Association of American Medical Colleges survey, 71% of schools with clinical scholar tracks required evidence of scholarship, though this was variously defined (13).

Levinson and Rubinstein (15) argue that traditional criteria for promotion such as publication are ill suited to assess the clinician-educator. Others assert that teaching scholarship must be defined broadly to include educational innovations such as course development. These endeavors should be documented in a teaching portfolio that is submitted as part of the promotion dossier (16, 17). The Association of Surgical Educators has developed criteria for an “educator’s pyramid” of accomplishments and suggests the academic rank commensurate with each level (18). A subsequent report found that documentation using this model was generalizable to promotion of nonsurgical teaching faculty (19).

In summary, the primary care literature suggests that a variety of incentives can be helpful in promoting the recruitment and retention of educators, including monetary and nonmonetary rewards, recognition, and attention to the unique promotion needs of clinician-educator faculty. The authors have pooled our experiences in medical student and psychiatric education and administration and have come up with a number of additional recommendations. What follows is a list of recommendations the authors believe might be useful to others in psychiatry education to promote the recruitment, retention, and reward of teaching faculty.

Encourage Active Participation of Department Chairs

Psychiatry Chairs must be visible as medical student educators. This undercuts potential faculty bias that residency education is the only important teaching endeavor and is a powerful rebuttal to faculty resistance. A reluctant Chair can be reminded that an active and engaging presence is a good recruiter of medical students into the residency program.

Enforce Service Requirements for Volunteer Faculty Appointment

The roster of volunteer faculty should be reviewed and requirements for continued appointment be enforced. At one of our institutions the chairman sent letters to inactive volunteers asserting the need for department service and asking for areas of interest. Names of volunteers interested in education were forwarded to the medical student and residency training directors. Follow-up enabled the medical student director to expand independent practice teaching sites. Nonresponsive volunteers lost faculty appointments.

Expand Traditional Teaching Services and Explore New Venues for Teaching

Psychiatry departments should place trainees in novel clinical settings such as Assertive Community Treatment (ACT) programs where medical students participate with traveling psychiatrists and outreach teams on patient care home visits. Students may also be assigned to community private practices. One of us has had good results in assigning students to independent practice sites of volunteer faculty who are nearing retirement. These faculty are less concerned with building their practices and more open to mentoring students. Expanding teaching venues both increases clinical opportunities for medical students and makes it easier for faculty to teach by bringing students to their workplaces.

Provide Faculty Development for Teachers

Departments and medical schools should support consistent standards in education by providing faculty training in teaching methods, evaluation, and emerging areas of educational attention such as clerkship competencies. By “training the trainers,” good faculty development can provide both guidance and support for teachers while at the same time enhancing the overall quality of an educational program. In one study, these goals were consistent with faculty preferences for further training (20). One example of a faculty development program, offered at the University of Texas Medical Branch in Galveston as part of the Robert Wood Johnson Foundation’s Generalist Physician Initiative, includes the following components (personal communication, Constance Baldwin):

As time is a scarce resource, the Galveston model is noteworthy for piggybacking teaching exercises onto other educational events and for off-campus teaching.

Support or Help Establish Teaching Academies

As of 2003, 21 medical schools across the country have established academies, and more are in development. Created to support the educational mission of a medical school, academies promote educational collaboration, encourage educational innovation, support faculty development, mentor junior faculty, and assist in the promotion and tenure process (21, 22). All of the academies recognize full-time faculty for teaching excellence, and some also recognize contributions from volunteer and clinical faculty (22). Membership selection varies from a rigorous peer review process to acceptance of application by any teaching faculty member. The academy supports efforts to retain and reward faculty through its educational resources, its advocacy for career advancement and the prestige it confers upon education.

Attend to Career Goals for Teaching Faculty

Junior faculty hired on clinician-educator tracks should receive promotion requirements as part of their employment packet and be offered a faculty mentor to help formulate a career development plan. Teaching faculty should be taught how to create, organize, and use a teaching portfolio to support a promotion (16, 23). Departments should encourage efforts to create peer-reviewed evaluations of meritorious contributions to education. Such award programs have been reported from the Mayo Clinic (24) and Baylor College of Medicine (25) and establish objective measures of excellence in support of educational endeavors.

Establish and Support Teaching Awards

Teaching awards should be established and bestowed at major department/medical center functions. Medical students should be urged to nominate psychiatric faculty for school-wide teaching awards. Every psychiatry department should be aware of the Nancy C.A. Roeske Certificate of Excellence in Medical Student Education, given by the American Psychiatric Association Committee of Medical Student Education. Both full time and volunteer faculty are eligible to be nominated, and it is an excellent means of rewarding a dedicated teacher. Departments should establish medical student teaching awards recognizing excellence for full time and volunteer faculty as well as for residents. Schindler et al. describe a system whereby faculty contributions to education are identified, given a point scale value, and recorded on an Excel spreadsheet. All participating faculty are invited to a dinner and those with outstanding scores receive awards (26).

Use Departmental, University and Medical Center Resources for Volunteer Faculty Rewards

Fees for departmental or medical center CME programs should be waived. Departments should advocate for the opportunity for volunteer faculty to participate in group malpractice and health insurance programs and other university-based rewards such as tuition waivers for university courses, access to university libraries, computer usage including e-mail, athletic facilities, parking and day care. Collegiality should be fostered by including volunteer faculty in departmental social events for medical students such as dinners at the medical student director’s or Chair’s home for the psychiatry interest group.

In this era of diminishing resources, few faculty will have the capacity to volunteer their time as easily as they could in the past. To meet the growing needs of medical student education, departments of psychiatry will have to develop a creative body of innovative approaches to engage faculty in the educational mission. No one solution exists. For each school, different circumstances will prevail. Ultimately, academic leaders must acknowledge the inherent value of teaching to the academic enterprise and delegate sufficient resources to recruit, retain, and reward educators for the essential work that they perform.