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Teaching Awards and Reduced Departmental Longevity: Kiss of Death or Kiss Goodbye. What happens to Excellent Clinical Teachers in a Research Intensive Medical School?*

David C. Aron, MD, MS, John N. Aucott, MD, and Klara K. Papp, PhD

Departments of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH (DCA and KKP) and Park Medical Group, Johns Hopkins University School of Medicine, Baltimore, MD (JNA) and the Louis Stokes Cleveland Dept. of Veterans Affairs Medical Center, Cleveland, OH (DCA)

Abstract - Context: Although medical education is the unique mission of academic medical centers and medical schools, there is a perception that research is valued more than teaching.
Objective: To determine in a group of excellent teachers (1) job satisfaction; (2) differences in perceptions among those who remained in the department compared to those who left; and (3) where those who left went.
Design, setting, participants: Survey of all Department of Medicine "Clinical Teacher of the Year" award-winners in an academic medical center.
Outcome measurements: Satisfaction scale: 5=extremely satisfied to 1=extremely dissatisfied; perception scale: 5=valued most highly to 1=not valued at all).
Results: Thirteen winners (48%) left the department. Of the 10 in the clinical track 6 went into private practice. Award-winning faculty who remained in the department had significantly higher satisfaction ratings (mean+1SD) than those who left for all three activities – teaching (3.8+0.6 vs.1.8+0.7 [p < 0.001]), research (3.3+0.7 vs. 2.0+1.1 [p=0.003]), and clinical (3.5+0.5 vs. 1.7+0.7 [p < 0.001]). In general, winners were most satisfied with various aspects of teaching; areas of highest dissatisfaction related to support for education. Research was rated most highly and teaching least valued {Mean (StdErr)= 4.2(0.1) and 2.8(0.1)}. There were no differences in perceptions between award winners who left and those who stayed.
Conclusions: Teaching excellence is a perishable commodity. Greater effort is needed to retain the best clinical teachers within academic medical centers.

    Education is the mission that sets academic medical centers and medical schools apart from other entities such as non-teaching hospitals and research institutes. Dissenting voices notwithstanding, cogent arguments have been made to combine the important missions of research and clinical care with teaching.1 Educating physicians, as opposed to "basic" science researchers, requires clinical teachers. Given the increasingly competitive financial environment, there has been a reduction in time devoted to medical education by physicians in private practice. Likewise, the financial realities within medical schools and their affiliated academic medical centers have negatively affected teaching efforts of full-time faculty. Yet the need for talented clinical teachers remains and their recruitment and retention has necessitated a variety of approaches that range from emphasis on the intrinsic rewards of teaching to more tangible recognition and monetary rewards.2-7

    One study of two institutions indicated that half the faculty who taught in the clinical setting were not considered role models and numerous anecdotes suggest that there is a perception among medical school faculty that teaching is neither appreciated nor rewarded.8-10 Excellence in teaching, according to the AAMC, is considered in decisions of promotion and tenure, only if traditional criteria are unmet (emphasis ours).11 Clinician-educator faculty tracks with their own criteria for promotion and tenure have been established.12-14

    A survey of chairs of departmental promotions committees suggested that teaching is considered an important determinant of promotion and tenure,15 however, there is considerable skepticism among rank and file faculty members. A survey of family practice department leaders and associate professors revealed that while both considered publications to be the most important factor in decisions about promotion and tenure, associate professors ranked the importance of teaching significantly lower than did departmental leaders.16 Others have documented the perceptions that research counts far more than teaching.5,6,17-23 We recently showed that teaching excellence as evidenced by winning a "Teacher of the Year Award" was not associated with a survival advantage in the academic environment. In fact, short-term (3-year) "survival, " i.e. time of award to time of departure from the department was significantly decreased among teaching award winners.24 We found this ironic in a medical school with a reputation for having a longstanding commitment to medical education.25 This short term "survival" of those honored with this reward was significantly lower when compared to a contemporaneous sample of non-award-winning faculty even after adjusting for age, faculty rank, tenure status, and career track. However, we did not examine the reasons that award winners left the department.24-26 Questions have been raised about the implications of these findings.27 It is plausible that award-winning faculty may have been recruited by other academic departments of medicine and continued fulfilling careers in academic medicine. It is also possible that award winners changed career paths because of or in spite of their interest in teaching. The purpose of this study is to answer some lingering questions about these faculty members: (1) how satisfied were they with aspects of their profession at the time of the award? (2) were there differences in perceptions among those who remained in the department compared to those who left? and (3) where did award winners who chose to leave the department go and why?

Methods

    Sample: We studied winners of the "Clinical Teacher of the Year" award in the Department of Medicine at University Hospitals of Cleveland/ Cleveland Veterans Affairs Medical Center from 1977 through 1998. This award is based upon a vote by the housestaff of the combined University Hospitals of Cleveland/Cleveland Veterans Affairs Medical Center internal medicine residency program.

    Procedures: The Clinical Teacher of the Year Award is determined by housestaff vote. The department's chief residents call for a vote and distribute ballots through resident mailboxes. They tally results and use their judgment in either breaking ties or giving the award to more than one clinician in any given year. Residents are asked to consider faculty who have been outstanding in terms of housestaff education, taking the time to explain difficult concepts, committed to helping residents work through difficult cases while maintaining resident autonomy, stimulating residents' thinking, and serving as a positive professional role model. Medical students' opinions are not factored into this decision.

    Questionnaire: Two versions of the same questionnaire were constructed, one version was for award winners who subsequently left the department and another for those who remained. Respondents were asked to rate, using a Likert-type scale, the extent to which they were satisfied with various aspects of their position at the time of the award including teaching, clinical, and research activities, and other personal and interpersonal aspects.28 Similarly, they were asked to rate the importance of these in their decision to leave or stay (whichever applied) in the department. They were asked to rate their opinion of the extent to which each aspect of their academic duties (i.e. teaching, clinical care, and research) were valued by their division, the department, the school of medicine, and the hospital. Finally, the winners who left were asked in an open-ended fashion to comment on their reasons for leaving. Award winners were sent a single mailing in November 1998. Respondents were told that their perceptions as award-winning faculty were sought. No payment or incentive for completing the questionnaire was offered. The Institutional Review Board for Human Subjects approved this study.

    Statistical analyses were performed using SPSS 7.5 (SPSS, Inc., Chicago, IL). Means of scores were compared using non-parametric methods or ANOVA. Frequency data were assessed using the Chi square test or Fisher exact test.

Results

    The Clinical Teacher of the Year Award was given to 27 members of the full-time faculty of Case Western Reserve University School of Medicine. Three faculty received the award twice, and nine times the honor was given to two faculty the same year. Of the 27 winners, 24 (91%) were men and 3 (11%) were women.

    Fourteen winners (52%) remained in the department while 13 (48%) left. There were no significant differences between winners who stayed and winners who left in terms of age, gender, faculty rank and tenure status at the time of the award, career track (research vs. clinical) and generalist status (Table 1). Of the three in the research track who left, all went to other academic positions; of the 10 in the clinical track 6 went into private practice; 3 went to other academic medical centers and 1 took a high-ranking state government position (p=0.19, Fisher exact test).

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    The questionnaire was mailed once to all award winners. Responses were received from 24 winners (88.9%). Non-respondents (all male) were faculty who had left the institution and included two who had been in the clinical track and one in the research track. We compared overall satisfaction ratings for clinical, research, and teaching activities by averaging the ratings for all relevant items on the questionnaire (58, 92, and 52 items for clinical, research and teaching activities, respectively). Award-winning faculty who remained in the department had significantly higher satisfaction ratings (mean+1SD) than those who left for all three activities – clinical (3.5+0.5 vs. 1.7+0.7 [F=48.5; p < 0.001]), research (3.3+0.7 vs. 2.0+1.1 [F=11.3; p=0.003]), and teaching (3.8+0.6 vs.1.8+0.7 [F=58.4; p < 0.001]). Areas of the highest and lowest satisfaction are shown in Table 2. In general, winners were most satisfied with various aspects of teaching as compared with research or clinical activities. Areas of highest dissatisfaction related to support for education.

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    We assessed the winners’ perceptions about how their activities were valued by their divisions, department, and medical school (Table 3). Ratings ranged from 5=Most highly valued to 1=Not valued at all. Overall, research was rated most highly valued by the division, department, and medical school {Mean (StdErr)= 4.2(0.1)}. There were no significant differences in perceptions among the three units in valuing research [F=0.5; p=0.62]. Clinical activities/patient care was ranked in the middle in terms of its perceived value. These are perceived as valued by the department 3.6(0.2) and the division 3.8(0.2) but significantly less so by the medical school 2.4(0.2) [F=13.8; p<0.001]. Finally, teaching was perceived as least valued overall 2.8(0.1) and there were no differences among units in their perceptions about how teaching was valued by the divisions, department, and school [F=0.5; p=0.66].

RES30010.jpg (31885 bytes)

    We then compared the perceptions of award winners who left to those who stayed. There were no differences between these groups in how teaching and research were perceived to be valued by the division, department, and school (p values ranged from 0.17 to 0.65). Similarly, there were no differences in the perceptions about the value placed on clinical activities by the division (p=0.33) and department (p=0.47). However, award winners sho stayed felt that clinical activities were valued less by the school than did winners who left – 1.93(0.22) versus 3.00 (0.33) [F=7.80, p=0.011].

    When asked specifically about the most important reason(s) why those who left did so, many respondents cited common ones, e.g. better job opportunities and the desire to relocate for family reasons. Ten of the 13 respondents who left wrote comments on the survey form. Half these commented that they left the department specifically because of their own goals’ diverged from the goals at the division, department or hospital level. A representative sample of these comments are cited below:

"The goals of the Department of Medicine were no longer the same as mine—i.e., excellence in teaching, research and patient care. The Department of Medicine in conjunction with the hospital has set a priority only on financial success. Academics are essentially irrelevant. Subsequent to my departure, the situation worsened dramatically. This is heartbreaking."

"There were no clear-cut opportunities for career advancement and I was doubtful of the importance the Department of Medicine regarded a tenure career in teaching."

"A sense that my primary interest (teaching, education) was not and would not ever be the important mission of the department or division, despite the constant propaganda to the contrary."

"Unfair clinical assignments—I was on service seven months of the year. Also, I was lukewarm about my ‘mission.’ I did not see myself passionately fighting for the institution. When I sought advice about leaving or staying, all but the department of medicine chief advised that I leave and take the good opportunity that I was offered. Had older faculty advised that I stay, I might have.

"More challenging job opportunity with a better concordance of goals to mine."

Discussion

    Our study indicates that teaching is important to faculty who have been recognized for excellence in this area. This is reflected in respondents’ high levels of satisfaction with various aspects of teaching and high levels of dissatisfaction with the level of support and recognition for teaching. Moreover, the prevailing perception of award-winning faculty members was that neither the divisions, department, nor medical school valued teaching and there was little difference in perceptions between winners who left and winners who stayed in the department. Nearly half of the winners left the Department of Medicine; those in research left for other academic positions, 60% of the clinicians left for private practice. Among those who stayed, most were in the research track. These results raise serious questions about the institutional commitment to its core mission of education. Our study suggests that a mismatch exists between our most dedicated teachers and their perceptions of institutional rewards and values.

    Our study has several limitations. First, it is just a snapshot, albeit with a long exposure time, or observational study of the impact of not valuing education on academic medicine. Second, this study was limited to a single academic department of medicine in a research-intensive medical school and may not be generalizable to other departments. It is also important to note that University Hospitals and the VA Medical Center are affiliated with, but independent of, the medical school. Different arrangements exist at other institutions. Also, within the department, the sample size of winners was, by necessity, relatively small. Consequently, the study involved a long time period during which there were concurrent and marked changes in the health care environment as well as in leadership, i.e., different division chiefs, department chairs, and deans. It is also important to note that during this time period, the school of medicine as a whole rose from 33rd to 11th in ranking in terms of funding by the National Institutes of Health and the department of medicine rose to 10th. Third, we did not survey a control group of faculty. However, if education were an important goal, it is the best teachers who should be valued. Therefore, the award winners are the most appropriate population to study. Fourth, the survey, although based on a previously developed questionnaire, may have introduced bias because of its length. (Copies of the full questionnaire are available from the authors upon request). There may be potential problems with "recall" of motivations and perceptions years after the event and bias in responding to the questionnaire knowing its purpose. Finally, it is unclear whether the selection of Clinical Teacher of the Year Award Winners was unbiased or free of outside influence or politics. We do not know what proportion of housestaff participated in the vote nor the extent to which chief residents followed the recommendations of housestaff opinion. These limitations notwithstanding, we believe that our study raises serious questions about the structure for recognition, reward, and retention of clinical teachers and more broadly about the sociology of medical school.

    Our study is consistent with some of the findings of others. Keane surveyed 269 full- and part-time faculty at McMaster and asked them to rank from a list of fourteen items the three ‘tangible and intangible’ rewards that might be most effective in inducing them to participate in educational activity.29 Two of the three rewards most frequently cited were intangible personal enjoyment items: contact with learners (first in both groups) and positive feedback from peers and learners (third ranked by both groups). Similar responses were seen in our survey. However, in order to successfully accomplish the educational mission of the institution, greater recognition, reward, and support for teaching faculty must exist. Ramsden suggested that monetary reward and prizes may have symbolic value, but their direct effect on good teaching is negligible.30 He holds the position that recognition of efforts to improve teaching must begin by providing academic staff with the time outside their normal teaching and research duties. However, funding "protected" time is a very real form of monetary reward for teaching.

    An important issue about our study is its generalizability to other departments and other schools. We are convinced that our findings are not applicable solely to a single department in a particular medical school. The two university-wide teaching award at Case Western Reserve University are the Diekoff Award for Graduate Teaching and the Wittke Award for Undergraduate Teaching. Thirty percent of the winners of the former and thirty three percent of the winners of the latter have left the university. Although we do not know the reasons for their departure, the results point up a potential problem in retention of outstanding teachers. Moreover, the fact that teaching is valued less than research is not limited to this one medical school. For example, in his recent masterwork, Ludmerer described the central mission of the first revolution in American medical education as the creation of a stimulating learning environment to help assure that medical education would be graduate education rather than vocational training. In so doing, the medical school adopted the institutional values of the university. In this value system scholarship, i.e. research is more highly valued than teaching and specialized expertise more highly valued than breadth of knowledge of one’s field necessary for effective teaching in undergraduate medical school courses.31 That teaching in medical school is undervalued is not a new observation. For example, Muller writing in the report Physicians for the Twenty First Century stated: "Despite frequent assertions that the general professional education of medical students is the basic mission of medical schools it often occupies last place in the competition for faculty time and attention. Graduate students, residents, research, and patient care are accorded higher priorities.32 Calls for reform are not new, nor confined to the United States. A recent study analyzed calls for reform in medical education that occurred between 1910 and 1993, a total of 19 published reports.33 Across almost a century, calls for reform were strikingly similar and included suggestions for rewarding and improving teaching. This call has been repeated consistently to the present day.22,23,35 This issue is apparent on other continents.36-39

    We recognize that the activity of teaching may not contribute directly to the bottom line of the department, hospital, or medical school. In fact, quite the reverse is true. To a large extent, medical education costs have been subsidized by clinical income and unreimbursed contributions of time and effort.40 Both of these have been affected by the increasingly competitive business environment in which medical centers deliver health care, competing clinically with a sophisticated and organized group of community physicians in order to survive economically. Medical education is a social good. The successful achievement of this mission depends upon its clinical teaching faculty. However, our data indicate that teaching excellence is a perishable commodity. As pressures in the contemporary practice of medicine increase, preserving faculty time and talent becomes vital for the health of the academic medical center and in fulfilling its central roles. While we recognize that even in the current environment there continues to be a great deal of good teaching going on, greater effort is needed to retain the best clinical teachers within the academic medical center.

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Reference

Aron DC, Aucott JN, Papp KK. Teaching awards and reduced departmental longevity: Kiss of death or kiss goodbye? What happens to excellent Clinical teachers in a research intensive medical school? Med Educ Online [serial online] 2000;5:3. Available from URL http://www.med-ed-online.org.

Address correspondence to:

David C. Aron, MD, MS
Education Office 14(W)
Louis Stokes Cleveland Dept. of Veterans Affairs Medical Center
10701 East Blvd.
Cleveland, OH 44106

Tel: 216-421-3098
Fax: 216-231-3427
e-mail: david.aron@med.va.gov

 

Medical Education Online Editor@Med-Ed-Online.org