It is argued that the basics sciences are essential prerequisites to the effective practice of medicine (1–3). The American Association of Medical Colleges (AAMC) states that understanding scientific principles provides physicians with both the rationale for the practice of medicine and the framework for incorporating new knowledge into their practice (4). Medical schools are thus charged with the task of providing students with the tools to interpret and incorporate continuously new scientific knowledge into practice (5).
While the perceived importance of science to medical practice has increased, the actual position of scientists within medical schools has grown more tenuous. Curricular reforms such as early clinical exposure, the adoption of problem-based learning and increased self-directed study mean that the teaching of scientific principles is delivered “in context,” embedded, often implicitly, in clinical courses and rotations, rather than delivered in stand-alone basic science preclerkship courses (6, 7). Translating complex scientific ideas into clinically relevant teachings takes on greater importance particularly in departments of psychiatry, where there are whole programs of research in sciences related to mental illness that were completely unknown when most clinical teachers were residents.
Despite the pedagogical implications of these curricular shifts, research has largely focused on developing and evaluating specific methods for teaching basic science principles, with less consideration given to who is best equipped to teach science—scientists who generate the principles or clinicians who may use them in practice (6–9). Furthermore, very little attention has been given to how faculty development can be used to foster better integration of science and clinical teaching (7, 10). Our study explored the social dimensions of the science and clinical teaching interface in a large department of psychiatry, in order to understand the opportunities and barriers that might be associated with collaborative teaching approaches. We studied the interaction of faculty who participated in a 1-year program designed to encourage interaction between scientists and clinical teachers. Our institutional case study (11) illuminated some important factors that enable or impede the integration of science and clinical teaching which other large departments of psychiatry may find relevant.
The department of psychiatry at the University of Toronto is comprised of over 600 faculty members, 130 residents, 75 fellows, and more than 15 affiliated teaching hospitals and clinics. Twenty faculty members (10 scientists and 10 clinical teachers) voluntarily signed up for the Pedagogical Partners Program (PPP). Participation in the PPP was not linked to promotion or annual review and there was no evaluation of individual performance of participants. All participants consented to take part in the research study.
The PPP program is described in detail at http://www.utpsychiatry.ca/DivisionsAndPrograms/PedagogicalPartnersProgram.pdf, and thus we provide only a short description here (Table 1). The goal of the program was to identify barriers and develop strategies for advancing the integration of basic science into clinical teaching. The sessions were hosted by members of the research team (BH, MM) and by an invited facilitator chosen for his or her charisma, ability to engage faculty members from both science and clinical backgrounds, and expertise in education.
Participants were partnered—one scientist with one clinical teacher. They were given an overview of the clinical pedagogical approaches employed in undergraduate teaching and worked with assigned partners on a variety of structured activities such as case writing, creation of examination scenarios, etc. Participants were also encouraged to engage in three optional activities: coteaching with or observing the teaching of their partner, keeping a reflective diary of their experiences during the PPP, and participating in other departmental educational activities. The optional activities allowed participants to explore ways to collaborate without feeling overburdened with structured exercises. The PPP curriculum encouraged interaction and reflection on how teaching, course development, and assessment tools could be enhanced through collaboration. Scientists had the opportunity to develop understanding of clinical pedagogies and improve their knowledge translation skills. Conversely, clinical teachers were offered the opportunity to develop an appreciation of scientific approaches and methodologies, and to enhance their ability to integrate new knowledge into their teaching and assessment activities.
Ethnographic participant observation was used to study participant interactions (11). At every session one of us (MM) made extensive field notes about how the sessions were experienced by participants, as well as of the large group discussions, which were conducted like focus groups. The field notes provided rich context for understanding the experiences and attitudes of participants as captured in the pre- and postsurveys. The surveys were not administered to measure the effectiveness of specific elements of the faculty development, but rather used to explore the social construction of the science/clinical teaching interface through the experiences of participants and to capture any changes in their activities or attitudes following participation in the PPP. The surveys focused on participant demographics, involvement with teaching, and attitudes as to what sciences were considered relevant to clinical teaching. They generated both qualitative and quantitative data. Additional sources of data included reflective diary entries, curricular materials created during the exercises, and a set of formal recommendations for improving the integration of science and clinical teaching in the department generated during the last session. The qualitative data collected were analyzed using the meaning condensation method, and triangulated with the descriptive statistics generated from the surveys (12).
The participant group was diverse, with an even gender split and representation from all academic ranks, including seasoned teachers, education administrators, and individuals with very little educational experience. Similar diversity was noted in the research backgrounds of the participants which included both clinical and scientific expertise in a broad range of fields such as genetics, health systems, and cross-cultural anthropology.
Among the 10 self-identified basic scientists, there were three psychiatrists (M.D.-Ph.D. or clinician scientists) and two social scientists. Initially we used the term “basic scientist” to refer to members of faculty who spent most of their time generating scientific knowledge. As our analysis proceeded, it became clear that using the term “basic scientist” was too narrow, and served to obfuscate important differences among the scientists. We subsequently used the terms “scientists” and “clinical teachers” to refer to our two groups.
The majority of participants (14/20) were junior in rank and had been with the department 10 years or less (12/14). Most were involved in some way with undergraduate teaching (preclerkship teaching, student supervision, examinations, etc.). A small number had significant responsibilities including educational administrative roles. None of the most active teachers were scientists. Most of the female participants (7/10) self-identified as basic science researchers.
Motivations and Starting Points
Most scientists joined the Pedagogical Partners Program (PPP) in order to explore teaching opportunities and learn more about clinical teaching approaches. By contrast, clinical teachers wanted to improve their ability to incorporate new scientific knowledge into their teaching and to develop strategies to engage students in learning about science. A few participants from both groups expressed an explicit desire to forge new collaborations that would bridge professional boundaries.
Figure 1 shows the percentage of time spent on an average week by participants on clinical work, research, teaching, or administrative tasks. Most of the clinical teachers divided their time across the four categories with a clear investment in clinical work and teaching. By contrast, the scientists engaged primarily in research activities (84.1% compiled average) while clinical teachers hardly did at all (7.2% compiled average). Scientists reported minimal involvement in teaching and administration. A nominal amount of clinical work (9.5% compiled average) was reported by two of the three self-identified scientists who also had medical training. There was no meaningful change in the distribution of activities in the postsurvey.
From the outset it was clear that, despite belonging to the same department, the two groups did not identify with each other’s professional spheres. Some participants articulated how cutoff they felt from their respective counterparts. Very few of the clinical teachers had met the scientists prior to the PPP, or had heard of their work. Similarly, when discussion turned to bedside and clinical teaching, it became apparent that many scientists were unfamiliar with the medical curriculum and had little experience with the pedagogical methods employed. Terminology such as the difference between a “clerk” and a “resident” needed to be explained. We observed significant anxiety regarding issues of knowledge translation on the part of scientists and of difficulties “keeping up to date” with emerging science on the part of clinicians. Some participants reflected in their diaries an increasing awareness of the different world views that characterized the two groups. One clinician noted, “My experience thus far has been that researchers think quite differently than clinicians—more reflective, logical, rigorous …” Similar statements were also made in large group discussions and both accentuated and reinforced the distance between the scientific and clinical worlds.
Participants frequently made reference to a concept of “relevance” in constructing arguments about what should be taught and by whom. This appeared to function as a form of social negotiation of boundaries. Specifically, in several conversations it was argued that when a basic science becomes “clinically relevant” it then ceases to be basic science. Through such interactions a boundary was created around the clinical setting limiting the participation of scientists in clinical teaching to their ability to render their research relevant to clinical practice. It also explicitly made the scientists responsible for translating the science they generate into clinically relevant knowledge or applications. Most of the scientists resisted this definition of relevance, drawing attention to conceptual contributions that shape overall knowledge in the field of psychiatry, that are not yet linked to a tangible or practical clinical application. While debates of what constitutes relevant knowledge to clinical practice are not new, effects of such attitudes are integral to our understanding of how barriers to integration of science and clinical teaching are socially constructed.
Results from the pre- and postsurveys further elucidated how the notion of “relevance” acts as a barrier to integration. We asked participants what they thought constituted the five most relevant sciences underpinning medical education. Twenty-three different subjects were listed from a wide variety of domains and disciplines in the presurvey. The majority of participants listed pharmacology as the single most important subject followed closely by genetics and physiology. Topics such as neuroscience, epidemiology, sociology, anthropology, philosophy, ethics, statistics, neurology, and math were listed less frequently. When the responses were organized in terms of the disciplinary categories used by the University of Toronto for their course calendar as a percentage of total responses, a hierarchy appeared (Figure 2). Subjects in the category of life sciences were considered more important for medical education than subjects in the natural sciences, social sciences or the humanities. Results on the postprogram survey were very similar.
As the program progressed differential views and experiences within the scientist group began to emerge. It appeared that the clinical teachers did not perceive the social sciences as relevant to clinical practice, even though four of the 14 programmatic divisions in the department are staffed largely with social science researchers. This was not unlike what was happening in the department more broadly. One social scientist described the frustration of being repeatedly turned down by education directors when offering to become more involved with teaching programs because there was no obvious place in the curriculum to contribute his expertise.
Participants also identified structural problems related to the organization of research and teaching in the medical school. While most felt that teaching was gaining ground as a legitimate career choice, research was perceived by all to be the dominant route to a successful career. Participants agreed that the medical school had done much to improve the student experience and to align the curriculum with community needs. However, they felt that these changes had not ameliorated the problems of integrating science and clinical teaching. With the emphasis placed on maximizing clinical and community exposures for students, the sciences were perceived to have lost space in the curriculum, displacing scientists as teachers. Scientists reported that their job descriptions did not include formal teaching requirements and that their salaries were, for the most part linked to hospital payrolls. Thus, while there were expectations about teaching related to their academic appointment (for annual review and promotion), these requirements were not linked to remuneration and created tension with regard to prioritization of activities. Finally, participants noted that prior to the PPP “integrated teaching” was not formally modeled, developed or rewarded in the department.
During the final session, participants collectively made recommendations to improve the integration of science and clinical teaching in the department:
1. Recognize integrated teaching by encouraging partnerships at all levels of training;
2. Encourage doctoral-level students and research fellows to teach;
3. Attract Ph.D.-prepared faculty to educational leadership positions;
4. Establish a basic science panel of experts to function as a resource to education committees;
5. Use technology to strengthen access to scientific knowledge generated in the department;
6. Create forums to disseminate research such as knowledge translation rounds.
The recommendations aimed to bridge the perceived distance between the production of new knowledge by scientists and the training of physicians by clinical teachers. The first three recommendations specifically targeted the perceived “invisibility” of scientists from the clinical teaching domain and aimed to create pathways for the participation of scientists in clinical training. Participants embedded the idea of partnerships between scientists and clinical teachers, citing specifically their positive partnership experiences during the PPP. The final three recommendations targeted the needs of clinical teachers to develop effective ways of accessing and assessing new knowledge relevant to clinical practice.
The scientists and clinical teachers in our study shared the common goal of integrating their expertise in order to improve the education of future physicians and psychiatrists. However, as our case study revealed, the literal and metaphorical distance of scientists from the clinical setting presents a challenge. This distance has been conceptualized in the sociological literature as the basic science-clinical teaching “rift” and has been shown to have structural (13, 14), economic (14, 15), gender (15, 16), and cultural (17) dimensions. Our study made visible, for the first time in our department, several dimensions of this rift. In very practical terms, the “rift” is most aptly captured in Figure 1, in that scientists and clinicians have significantly different work priorities and responsibilities. Research continues to be the dominant mode for academic promotion, thus discouraging professional interactions between scientists and clinicians around teaching issues. At the level of faculty interaction, the scientist-clinician rift manifests as a general unfamiliarity of each other’s worldviews, work experiences, professional expectations and approaches to teaching. The issue of bridging the rift and overcoming barriers to integration became even more nuanced when we considered the diversity among scientists themselves (18, 19). Poignantly, after completing the PPP, the social scientists did not list social science courses among the five most important subjects to teach medical students in the postsurvey responses. Nor was social science specifically mentioned in the overarching recommendations generated by the group. Our ongoing research has revealed that there are problematic attitudes among our faculty toward social science research, which arise from unfamiliarity with social science research methodologies and epistemologies. The idea of “relevance” as “applicability to clinical practice,” which emerged so prominently during the PPP, has considerable implications for the social scientists working in our department and for the take-up of their work. For example, they may be inadvertently disadvantaged by a focus on curriculum and faculty development that embeds a “basic science” versus “clinical teaching” dichotomy. We made this mistake initially, and it was only through the course of this project that we came to understand that there are important tensions and rifts within science and among scientists themselves that must also be attended to.
Following the Pedagogical Partners Program, the department committed itself to further studying these issues, to implementing the many recommendations, to launching new programs of faculty development including one specifically targeted to address the issues of social scientists, and to empirically research the effectiveness of partnered learning and teaching.
The authors wish to thank Dr. Glenn Regher for his helpful feedback and comments. At the time of submission, the authors disclosed no competing interests.