Among those who help educate medical students and residents in psychiatry, there are many whose principal career path is not in medical education and who are not salaried by the programs within which they teach. Oftentimes, such faculty members are called volunteers. Questions that arise among academicians concerning these individuals include the following: How can we improve the teaching quality and readiness of voluntary faculty? How can we integrate the voluntary faculty with the core faculty? A study group of the Association for Academic Psychiatry (AAP) began exploring these questions and others at the instigation of then-AAP-President, Michelle Riba, M.D., in 2000. This article presents a faculty education demonstration project that emerged from the AAP project.
A review of the literature reveals that practices of individual institutions are diverse regarding volunteers (1) and are made more complex by workforce issues such as contractual understandings, tenure, retirement, and the like (2).
Attention to past and prospective contributions of community-based clinical educators is present in the literature (3, 4), stretching previous definitions of medical academic expertise (5—7). Increasing demands to do direct patient care in the face of shrinking revenues for all clinicians (8), a decrease in the growth rate of average clinical faculty salaries (9), and reported concern over the ability to remain active in teaching and achieve research goals in the face of managed care penetration (10) are all features of the current teaching environment (11—13). Thus, there are significant and continuing pressures within academic medical centers to enhance educational efforts during this time of increasing constraints on spending and demands for greater clinical productivity. Similar pressures are present for practicing physicians in the communities and may lead to less available teaching time (14). Still, some community practitioners crave the opportunity to associate themselves with a stimulating educational enterprise. Other potential educators are employed within academically affiliated health care institutions in roles not directly delivering health care or in nonuniversity-based training sites that encourage employees to teach.
Further changes in medical education include shifts from hospital-based learning to the ambulatory setting and from lecture-based learning to learning clinical skills in a small-group as well as approaches derived from understanding medical students and residents as adult learners (15—19). The shifts in style and locus of medical education also carry with them questions of the quality of education delivered and support of both students and their teachers (20, 21). Given these shifts, what implications are there for volunteer and more traditional faculty members? A number of publications discuss the need to cement a good working relationship between academic medical centers and the clinical settings within which trainees learn (22—29).
We hypothesized that appropriate faculty development projects may begin to address some of our questions regarding volunteer faculty members: their motivation for teaching and their willingness to participate in focused educational efforts (particularly with regard to clinical teaching and evaluation). We also imagined that such projects would serve as a reward, in the sense that we could demonstrate that we accepted our volunteers as colleagues and assumed they wished to be more successful in their roles as educators.
Faculty Development for Volunteer Faculty in Psychiatry
This project was conducted within a mid-sized community (approximately 200,000 urban/suburban), which draws patients from rural southwest Michigan (approximately 800,000) in addition to the more local metropolitan area. The psychiatry residency program is one of eight postgraduate programs and is loosely affiliated with a land-grant university medical school, for which the community is one of five community campuses. In addition to the medical community, the city houses a university (approximately 30,000 students) and a small, private, liberal arts college, some of whose faculty members collaborate on projects with the program. Upper-class medical students spend their 2 clinical years in the communities working their way through required clerkships and many of their fourth year electives. Approximately 20 students rotate through a required 8-week psychiatry rotation. Sixteen residents are trained in a 4-year psychiatry residency program.
There are 11 full-time equivalent core faculty positions in the department of psychiatry involved with teaching and performing clinical duties in activities such as inpatient and outpatient psychiatry, partial hospitalization, child and adolescent inpatient and partial hospitalization, and addiction, geriatric, and psychosomatic psychiatry. This core faculty produces the majority of didactic teaching and much of the clinical teaching in addition to patient-care responsibilities. Community practitioners in a number of disciplines have significant interactions with residents and students. These community-based practitioners are local psychiatrists, other medical specialists, psychotherapists, social workers, psychologists, agency administrators, nursing staff, administrators, crisis workers, and case managers from community mental health facilities, as well as university educators from fields such as ethics, psychology, social work, and health policy. Approximately 50 of these individuals are identified as community faculty and have appointments at various levels as clinical faculty in the medical school.
The faculty development workshops described in this study occurred in the Fall of 2001 and the Spring of 2003. A psychiatric master educator was employed to present a faculty development workshop. Each expert educator presented an early morning session during our Tuesday grand rounds, followed by an informal teaching session with residents. During the afternoon, the master educator facilitated a workshop with core and community volunteer faculty on a topic selected to provide instruction in current theories of medical education (topics for both years were built around clinical teaching). The following morning was spent with core faculty alone, facilitating a workshop on the development of clinical teaching programs.
Continuing medical education (CME) credit (3½ hours) was awarded for participation in the afternoon workshops, and evaluations were distributed for completion at the time of the workshop, with a more comprehensive survey being mailed within 3 weeks of the experience.
Surveys were collected, tabulated, and summarized. About one-third of the voluntary faculty (approximately 60 individuals) attended the workshops. Sixty-eight percent (N=30) completed surveys. Attendees represented the following disciplines: psychiatry, neurology, psychology, nursing, social work, mental health administration. t1 shows written comments from the survey. Establishing or revitalizing connections with other faculty was mentioned by nine attendees and specific helpful content of the workshops was mentioned by 13. Four attendees complained of competing time demands. Optimism regarding changing teaching style or behavior was expressed by 13 attendees. For the tabulated questions (Likert scale: very much = 5, not at all = 1), virtually all questions (for both the 2001 and 2003 workshops) relating to the workshop experience as a positive mode of presentation and the time spent as worthwhile, with indirect benefits, drew scores of 5 (predominant) or 4.
A significant burden of education during the clinical years falls naturally to those providing direct care to patients, whether they are directly recruited into a teaching role or not. If the educational experience is to be more directed, with designated learning goals and expectations rather than an immersion in patient care (with the medical school assuming that education somehow happens), the health care provider becomes a significant educational figure by default (a faculty member?). A danger is that this individual, without the guidance of the educational institution, may interact with the student as he or she remembers being dealt with during his or her own training. Recent literature on medical education strives to reverse some of the more negative models promulgated in this way, presenting strong arguments for more aggressive reading of the literature and for faculty development.
From the perspective of the volunteer, other variables may come into play, including differences in motivation and expectation. Among practitioners, there are individuals for whom being involved with students is an important part of their work in medicine (30, 31). For some, it may be a way of giving back. For others, it may present an ongoing opportunity for being immersed in education, for being reminded of important issues and emerging constructs that are relevant to their experience of medical practice. Rewards may come in the course of relationships with students as preceptors, through the accumulation of knowledge gleaned in clinical encounters, through interaction with more formal aspects of the students’ curriculum, or from combinations of these factors.
Faculty development projects might be best viewed within the context of this study. The two workshops described were fairly well-attended and enthusiastically endorsed by the participants, as reflected by the comments. Over the few months following each session, various participants referred to the workshops and to changes they had made in their teaching as a result. Specific comments cited various aspects of the content: techniques of delivering educational material, learning styles, giving feedback in constructive ways, the concept of formative versus summative feedback, and the like.
After the initial workshop in 2001, there was a noticeable increase in presentations in the department built around models of small-group learning and a diminution of noninteractive lectures.
Limitations of this pilot study include its small size and the limited scope of one department. Qualitative analysis of comments of respondents limits generalizability and does not necessarily provide a thorough exploration of potential responses. Extending this model to other programs and utilizing a more structured evaluation instrument at follow up would be expected to elicit more useful data. However, our study suggests that faculty development projects for community and core faculty encourages collaboration between groups and departmental cohesiveness, enhances teaching, and becomes a meaningful aspect of continuing education.
The author thanks the AAP leadership, paritcularlly Michelle Riba, M.D. Phil Muskin, M.D., Donald Hilty, M.D., Ed Silberman, M.D., Laura Roberts, M.D., Don Fidler, M.D., and Carole Berney and the AAP Task Force for Volunteer Faculty members, including Dave Carlson, M.D., Greg Gorton, M.D., Charlotte Guest, M.D., Nathan Smith, M.D., Clark Terrell, M.D., and Jim Thompson, M.D.
The author also thanks members of the FACAAFS list-serve and Ivan Silver, M.D., Paul Rodenhauser, M.D., and Michael Liepman M.D. for their help.