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How to Succeed as a Clinician Educator Grand Rounds April 12, 2007 Neil A Kurtzman, MD Grover Murray Professor University Distinguished Professor Texas.

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1 How to Succeed as a Clinician Educator Grand Rounds April 12, 2007 Neil A Kurtzman, MD Grover Murray Professor University Distinguished Professor Texas Tech University Medical Center

2 What is a clinician educator? What is a clinician educator? Any clinician who teaches medicine Any clinician who teaches medicine A clinician teacher who doesn’t earn his keep from grants or practice A clinician teacher who doesn’t earn his keep from grants or practice This is a problem we’ll come back to This is a problem we’ll come back to

3 A clinician whose main focus is teaching A clinician whose main focus is teaching Undergraduates Undergraduates Residents Residents Fellows Fellows Other physicians Other physicians Is a clinician educator a new track? Is a clinician educator a new track?

4 Just as music student studies Bach, Mozart, and Beethoven without expecting to equal them, it’s useful to study the great clinician educators of the past Just as music student studies Bach, Mozart, and Beethoven without expecting to equal them, it’s useful to study the great clinician educators of the past I’ll pick two I’ll pick two One from the 19 th century One from the 19 th century One from the 20th One from the 20th

5 William Osler 1848-1919 William Osler 1848-1919 Donald Seldin 1920- Donald Seldin 1920- ? 21 st century ? 21 st century

6 The Four Doctors The Four Doctors Sargent 1905 Sargent 1905 William Osler

7 Born Ontario, Canada Born Ontario, Canada Originally planned to enter the ministry Originally planned to enter the ministry MD McGill University 1872 MD McGill University 1872 Started first journal club ever as a student Started first journal club ever as a student Chair of Clinical Medicine U of P 1884 Chair of Clinical Medicine U of P 1884 Chief of Staff Johns Hopkins Hospital 1889 Chief of Staff Johns Hopkins Hospital 1889 First Professor of Medicine 1893 First Professor of Medicine 1893 Regius Professor of Medicine, Oxford 1905- 1919 Regius Professor of Medicine, Oxford 1905- 1919

8 Started the first medical residency Started the first medical residency Wrote the first modern textbook of medicine Wrote the first modern textbook of medicine Brought third year students to the bedside Brought third year students to the bedside Inveterate prankster Inveterate prankster Prodigious reader Prodigious reader Embodies the ideal of the humanistic physician Embodies the ideal of the humanistic physician

9 “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”

10 Donald Seldin 1995

11 Born Brooklyn, NY 1920 Born Brooklyn, NY 1920 BA NYU 1940 BA NYU 1940 MD Yale 1943 (first in his class) MD Yale 1943 (first in his class) PG training under John Peters (his most important influence) at Yale PG training under John Peters (his most important influence) at Yale Instructor at Yale 1948 following two years in the Army Instructor at Yale 1948 following two years in the Army

12 John Peters – Seldin’s mentor

13 Testified against the Nazi doctors at Nuremberg – 1946 Testified against the Nazi doctors at Nuremberg – 1946 Associate Professor Southwestern Medical School – 1951 Associate Professor Southwestern Medical School – 1951 Chairman 1952 – 1987 Chairman 1952 – 1987 Still Professor of Medicine Still Professor of Medicine

14

15 Both rose to important positions at an early age Both rose to important positions at an early age Both extremely well educated Both extremely well educated Neither did cutting edge research, though many of their students did Neither did cutting edge research, though many of their students did Both built departments from scratch Both built departments from scratch Both seem to have mastered virtually all of medicine Both seem to have mastered virtually all of medicine Similarities and Differences

16 Both placed great value on the importance of research at the medical university Both placed great value on the importance of research at the medical university Both had enormous impact on their schools Both had enormous impact on their schools Both inspired generations of students Both inspired generations of students Their students became leaders of American Medicine at all levels Their students became leaders of American Medicine at all levels

17 Both were legendary teachers Both were legendary teachers Osler a bedside teacher Osler a bedside teacher Seldin best in the conference room Seldin best in the conference room Seldin spent his entire career at one institution Seldin spent his entire career at one institution Osler friendly and avuncular Osler friendly and avuncular Seldin sharp, intolerant of ignorance Seldin sharp, intolerant of ignorance

18 Osler warm Osler warm Seldin outwardly cool, but actually encouraging and supportive once you got his attention Seldin outwardly cool, but actually encouraging and supportive once you got his attention Seldin a ruthlessly accurate judge of talent which he separated from personality Seldin a ruthlessly accurate judge of talent which he separated from personality

19 Both attracted the brightest students, but for different reasons Both attracted the brightest students, but for different reasons Osler a prolific writer Osler a prolific writer Seldin preferred speaking to writing Seldin preferred speaking to writing He talked in paragraphs He talked in paragraphs Terrified students while attracting the best of them Terrified students while attracting the best of them

20 His lasting achievement is his students His lasting achievement is his students Though he repeatedly insisted they were no better than any others Though he repeatedly insisted they were no better than any others And they weren’t And they weren’t Thus he must have had a special impact on them Thus he must have had a special impact on them Hence the importance of a great clinician educator Hence the importance of a great clinician educator

21 Enrico Fermi 1901 – 1954 Enrico Fermi 1901 – 1954 Professor of Physics at 24 Professor of Physics at 24 Nobel Prize for Physics at 37 Nobel Prize for Physics at 37 Built the first atomic reactor Built the first atomic reactor Known for the brilliant simplicity with which he solved problems Known for the brilliant simplicity with which he solved problems Fermi reasoning Fermi reasoning

22 Both Osler and Seldin were great educators though very different Both Osler and Seldin were great educators though very different An educator succeeds when he inspires students to learn on their own An educator succeeds when he inspires students to learn on their own Which is the only way you really learn anything Which is the only way you really learn anything This is especially important in medicine since most of what you learn as a student is outdated when you complete graduate training This is especially important in medicine since most of what you learn as a student is outdated when you complete graduate training

23 While you can’t make a silk purse out of a sow’s ear it takes skill to make one out of silk While you can’t make a silk purse out of a sow’s ear it takes skill to make one out of silk So how does one become a clinician educator? So how does one become a clinician educator? Often happens by accident Often happens by accident No one path No one path

24 There’s no standard widely accepted definition of what a clinician educator is There’s no standard widely accepted definition of what a clinician educator is There’s no obvious way to pay for them There’s no obvious way to pay for them They don’t get grants and generate indirect costs They don’t get grants and generate indirect costs When they’re educating they’re not generating clinical revenue When they’re educating they’re not generating clinical revenue

25 Thus, it’s easy for them to be seen as an economic drag on the department Thus, it’s easy for them to be seen as an economic drag on the department That’s because the medical school is unlike any other component of the university That’s because the medical school is unlike any other component of the university Clinical faculty are not paid to teach Clinical faculty are not paid to teach They’re expected to generate income while working for less money than they could make in practice They’re expected to generate income while working for less money than they could make in practice

26 There’s a word for this There’s a word for this Crazy Crazy There has to be a non-economic reward for this There has to be a non-economic reward for this Recognition Recognition Making a difference Making a difference

27 Each department of medicine will have to decide what defines a clinician educator Each department of medicine will have to decide what defines a clinician educator How will he be paid? How will he be paid? How many does the department need? How many does the department need? How many can it afford? How many can it afford? How much of a subsidy will the other faculty be willing to provide? How much of a subsidy will the other faculty be willing to provide?

28 How will we know if he’s doing a good job? How will we know if he’s doing a good job? What’s expected of him? What’s expected of him? The purpose of a university is the acquisition and transmittal of knowledge The purpose of a university is the acquisition and transmittal of knowledge We seem to have concentrated on the former at the expense of the latter We seem to have concentrated on the former at the expense of the latter

29 2006

30 “Clinician educators are poised to do collaborative clinical and translational research but are still under pressure for clinical productivity.” “Clinician educators are poised to do collaborative clinical and translational research but are still under pressure for clinical productivity.” As of 2000 at least half of all medical schools affirmed the values of their faculty’s educational activity, with many schools providing detailed advice to faculty members as they assembled their best educational materials for promotion packets (AAMC website) As of 2000 at least half of all medical schools affirmed the values of their faculty’s educational activity, with many schools providing detailed advice to faculty members as they assembled their best educational materials for promotion packets (AAMC website) No mention of money No mention of money

31 Everybody wants clinician educators Everybody wants clinician educators No one really know how to define them No one really know how to define them No way to pay for them No way to pay for them

32 I can only suggest how this business should be organized I can only suggest how this business should be organized But until there’s a national consensus on what a clinician educator is nothing will happen But until there’s a national consensus on what a clinician educator is nothing will happen Until there’s money there’ll be no consensus Until there’s money there’ll be no consensus

33 Medicine is being suffocated by paperwork and over-administration Medicine is being suffocated by paperwork and over-administration Medical education is setting the paper on fire Medical education is setting the paper on fire A lecture at our school by a noted medical historian failed to gain CME credit because the paper work was unsatisfactory A lecture at our school by a noted medical historian failed to gain CME credit because the paper work was unsatisfactory Today a clinician teacher is apt to spend more time preparing objectives and questions than teaching Today a clinician teacher is apt to spend more time preparing objectives and questions than teaching

34 Not only is the perfect the enemy of the good Not only is the perfect the enemy of the good But the good has become the enemy of the good But the good has become the enemy of the good How much making things better can we stand? How much making things better can we stand? We never ask before we regulate We never ask before we regulate

35 A cadre of clinician educators would find more support for a subsidy if they assumed this administrative burden A cadre of clinician educators would find more support for a subsidy if they assumed this administrative burden CME should be run by clinician educators CME should be run by clinician educators Perhaps the IRB as well Perhaps the IRB as well These would lessen the amount salary required from clinical work These would lessen the amount salary required from clinical work Should make both operations more palatable to all faculty Should make both operations more palatable to all faculty

36 Clinician educators, in the main, should be generalists Clinician educators, in the main, should be generalists But they should pursue scholarship But they should pursue scholarship Which I will define as excluding studying education Which I will define as excluding studying education

37 He who can, does; he who cannot, teaches - GB Shaw He who can, does; he who cannot, teaches - GB Shaw He who can’t do either teaches teachers – anonymous He who can’t do either teaches teachers – anonymous He who can’t do either, teaches Gym – Woody Allen He who can’t do either, teaches Gym – Woody Allen I give no credit for studying studying I give no credit for studying studying

38 Thus a clinician educator should study something peculiar to medicine Thus a clinician educator should study something peculiar to medicine Clinical trials Clinical trials Scholarly reviews Scholarly reviews Collaborative research with laboratory based colleagues Collaborative research with laboratory based colleagues Meta-analyses Meta-analyses Outcomes research Outcomes research

39 Medical economics Medical economics Ethics Ethics Politics Politics Clinical vignettes for basic science textbooks Clinical vignettes for basic science textbooks Test questions and evaluations Test questions and evaluations Anything but education Anything but education

40 Curriculum Curriculum We have to have one We have to have one Except when we don’t Except when we don’t James Scholar Program at the University of Illinois James Scholar Program at the University of Illinois

41 Harry Jacobson ’72 Vice Chancellor for Medical Affairs Vanderbilt University

42 Melvin Laski’76 Professor of Medicine TTUHSC

43 Write the best one you can and then resist the urge to scrub it for a new one Write the best one you can and then resist the urge to scrub it for a new one Why do medical schools constantly rewrite their curricula? Why do medical schools constantly rewrite their curricula? I would advise that a curriculum can be rewritten only after the dean’s been on the job for 10 years I would advise that a curriculum can be rewritten only after the dean’s been on the job for 10 years

44 No Department of Education No Department of Education No heavy administrative structure No heavy administrative structure No certifying processes No certifying processes What not do

45 Dear FASEB Society Member Colleagues: Dear FASEB Society Member Colleagues: A final decision concerning NIH’s budget in FY2007 will be made in the next 24 to 48 hours. Congress is hearing from you, but we need you to make one last plea to your Members of Congress. Please take a moment to read below for a summary of the issue, as well as the specific action that you can take to make a difference. Background Information – NIH is in Danger of being Flat Funded in FY2007: Congressional leaders have indicated that they plan to fund most agencies at their FY2006 funding levels. This action would result in NIH being flat-funded in FY2007. Flat funding NIH in FY2007 would actually amount to a three percent reduction (in inflation-adjusted terms) for the agency. The Opportunity – A Small Amount of $$ is Available to Redistribute: Senators Tom Harkin (D-IA) and Arlen Specter (R-PA) are making a final case to identify NIH as a priority program. Congressional leaders are planning to increase funding levels for the programs and agencies they regard as priorities. The elimination of congressional earmarks is allowing for this redistribution of funds. At one time, it appeared that the odds of NIH receiving a significant increase in FY2007 were not high, but it is becoming increasingly evident that the research community’s message is being heard on Capitol Hill. REQUIRED ACTION: CONTACT YOUR SENATORS AND REPRESENTATIVE The fact that Congress plans to redistribute dollars to our nation’s most important priorities provides us with one last opportunity to push for an increase in NIH’s budget for FY2007. Please take a moment to contact your Senators and Representative in the next 24 to 48 hours. We must apply pressure to our legislators, and let them know that there is a vital need to increase NIH’s budget in FY2007. Therefore, it’s important that you urge your Senators and Representatives to tell their Congressional leaders that NIH is an important priority for our country, and that supporting NIH results in scientific breakthroughs and discoveries that promise to improve the health and the quality of life for millions of people. A final decision concerning NIH’s budget in FY2007 will be made in the next 24 to 48 hours. Congress is hearing from you, but we need you to make one last plea to your Members of Congress. Please take a moment to read below for a summary of the issue, as well as the specific action that you can take to make a difference. Background Information – NIH is in Danger of being Flat Funded in FY2007: Congressional leaders have indicated that they plan to fund most agencies at their FY2006 funding levels. This action would result in NIH being flat-funded in FY2007. Flat funding NIH in FY2007 would actually amount to a three percent reduction (in inflation-adjusted terms) for the agency. The Opportunity – A Small Amount of $$ is Available to Redistribute: Senators Tom Harkin (D-IA) and Arlen Specter (R-PA) are making a final case to identify NIH as a priority program. Congressional leaders are planning to increase funding levels for the programs and agencies they regard as priorities. The elimination of congressional earmarks is allowing for this redistribution of funds. At one time, it appeared that the odds of NIH receiving a significant increase in FY2007 were not high, but it is becoming increasingly evident that the research community’s message is being heard on Capitol Hill. REQUIRED ACTION: CONTACT YOUR SENATORS AND REPRESENTATIVE The fact that Congress plans to redistribute dollars to our nation’s most important priorities provides us with one last opportunity to push for an increase in NIH’s budget for FY2007. Please take a moment to contact your Senators and Representative in the next 24 to 48 hours. We must apply pressure to our legislators, and let them know that there is a vital need to increase NIH’s budget in FY2007. Therefore, it’s important that you urge your Senators and Representatives to tell their Congressional leaders that NIH is an important priority for our country, and that supporting NIH results in scientific breakthroughs and discoveries that promise to improve the health and the quality of life for millions of people. Click Here to View Alert Click Here to View Alert Click Here to View Alert Click Here to View Alert Leo T. Furcht, M.D. Leo T. Furcht, M.D. FASEB President FASEB President Should you wish to not receive future FASEB action alerts, please reply to this email with the word “unsubscribe” in the subject line. Should you wish to not receive future FASEB action alerts, please reply to this email with the word “unsubscribe” in the subject line.

46 Background Information – NIH is in Danger of being Flat Funded in FY2007 Background Information – NIH is in Danger of being Flat Funded in FY2007 From FY 98 to 06 the NIH Budget has increased 110% From FY 98 to 06 the NIH Budget has increased 110% Now $28.7 billion Now $28.7 billion How much should the NIH budget be? How much should the NIH budget be? Apparently 100% of GDP Apparently 100% of GDP

47 What’s the real mission of the NIH? What’s the real mission of the NIH? Eternal youth and immortality Eternal youth and immortality Which is why everybody loves it Which is why everybody loves it What would happen is all research stopped What would happen is all research stopped In the developed world – very little In the developed world – very little

48 But what if education stopped? But what if education stopped? Nothing would work Nothing would work Compare the budget for medical education with that of the NIH if you want to see what people really value Compare the budget for medical education with that of the NIH if you want to see what people really value

49 [T]he clinical scholar, the academic core of the department, is an individual who advances first-rate clinical science and at the same time is competent in clinical medicine and in teaching. Donald Seldin 2003

50 The ideal college is Mark Hopkins on one end of a log with a student on the other. The ideal college is Mark Hopkins on one end of a log with a student on the other. James A Garfield (Later US President) 1871

51 “Every man who is educated at all, is, and must be self-educated….It is for the want of understanding this properly, that expectations are entertained of instructors….Young men will not set themselves efficiently at work until they feel that there is an all important part which they must perform for themselves, and which no one can do for them…. It is his (an instructor’s) power to give an impulse to the minds of his pupils and induce them to labor.” “Every man who is educated at all, is, and must be self-educated….It is for the want of understanding this properly, that expectations are entertained of instructors….Young men will not set themselves efficiently at work until they feel that there is an all important part which they must perform for themselves, and which no one can do for them…. It is his (an instructor’s) power to give an impulse to the minds of his pupils and induce them to labor.” Mark Hopkins 1836

52 The medical school must establish a culture of excitement in biomedical science The medical school must establish a culture of excitement in biomedical science There are many healers in society, but the only healer who brings medical science to the patient is the physician There are many healers in society, but the only healer who brings medical science to the patient is the physician The clinical educator must demonstrate the meaningful application of medical science to medical students The clinical educator must demonstrate the meaningful application of medical science to medical students

53 When you care for the sick there are ethical and humane constraints When you care for the sick there are ethical and humane constraints Only the clinician educator can demonstrate the artful interaction between ethics and medicine and between compassion and technology Only the clinician educator can demonstrate the artful interaction between ethics and medicine and between compassion and technology Borrowed from Seldin 2003

54 Institutional loyalty Institutional loyalty The alumni often have it The alumni often have it But the faculty and the school seem to have lost it But the faculty and the school seem to have lost it If we’re going to have a culture of excitement about biomedical science we’ll have to find it (loyalty) If we’re going to have a culture of excitement about biomedical science we’ll have to find it (loyalty)

55 Thus there is no one right way to be a successful clinician educator Thus there is no one right way to be a successful clinician educator Each physician who succeeds in this path will have to find his own way Each physician who succeeds in this path will have to find his own way Perhaps the old model of a clinician who does research and teaches is still the best. Perhaps the old model of a clinician who does research and teaches is still the best.

56 Thank you Sandra Thank you Sandra

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