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Emergency Medicine An Academic Career Guide

Edited by: Daniel Handel, MD, MPH and Douglas McGee, DO


F O RWA R D

Now in its third edition, the Academic Career Guide was first published in 1992. With this edition, it was our hope that the chapters would follow the natural progression of an academic career, so that as you advanced, the latter chapters would become increasingly relevant. We hope you will find we have been successful in this regard. As our specialty has matured, it is interesting to note that academic Emergency Physicians now hold positions in the upper echelons of academia, and the thought of an Emergency Physician as a medical school dean is no longer a novelty. It is now important for the leaders who have blazed these trails to prepare those who will follow in leadership roles within the house of medicine. It is our intent for this guide to serve a wide range of audiences, from the medical student considering Emergency Medicine, to the EM resident pondering a career in academics and the faculty members there to offer guidance to both. Looking across the spectrum that is academics, this should provide some sort of guidance for everyone. This Academic Career Guide was written and created through the persistent efforts of the SAEM Graduate Medical Education Committee. We would also like to thank and acknowledge Glenn Hamilton and Ellen Weber for their meticulous edits of the final version. We hope you find this guide informative and engaging, and that is serves as yet another example of the Society’s mission to advance the specialty of emergency medicine. Sincerely, Dan Handel, MD, MPH and Doug McGee, DO SAEM GME Committee

Emergency Medicine: An Academic Career Guide is also available on the SAEM web site, www.saem.org


SAEM ACADEMIC CAREER GUIDE 2007, 3RD EDITION TABLE OF CONTENTS

Chapter 1:

The History of Academic Emergency Medicine .......................................................1

Chapter 2:

Making the Decision: Academics vs. Community Practice ......................................5

Chapter 3:

Choosing Academics and How to Plan Your Residency ...........................................7

Chapter 4:

The Importance of a Fellowship: Jump Start Your Academic Career .....................10

Chapter 5:

The “Academic Skill Set” .......................................................................................13

Chapter 6:

Creating a Healthy Career- Time Management, Wellness, and Mentoring.............15

Chapter 7:

Teaching and Education – Academics as a Clinical Educator ................................18

Chapter 8:

Pursuing the Medical Student Educator Career Pathway .......................................23

Chapter 9:

Pursuing the Residency Director Career Pathway ..................................................29

Chapter 10:

Pursuing the Investigative Scientist Career Pathway: How to Write and Be Successful in the Grant Application Process...........................................................33

Chapter 11:

Clinical Director- Running an Academic Emergency Department .........................38

Chapter 12:

Assistant Professor- Laying the foundation for an academic career, the early attending years ........................................................................................................41

Chapter 13:

Associate Professor- Taking the next step...............................................................43

Chapter 14:

Becoming a Full Professor- Top of the Ladder? .....................................................46

Chapter 15:

The Medical School- Becoming a Dean and Beyond .............................................49

Chapter 16:

The Future of Academic Emergency Medicine.......................................................52


CHAPTER 1

THE EARLY HISTORY OF ACADEMIC EMERGENCY MEDICINE (1968-1976) By Glenn Hamilton, MD, Chair, Department of Emergency Medicine, Wright State University, Dayton, OH, and Immediate-Past President, SAEM This chapter recalls the earliest years of academic development within the forming specialty and adds a few insights from my own experience. Its purpose is to demonstrate the founders of Emergency Medicine had a clear understanding and commitment to academics. The seeds of our current academic status were sown early in the specialty’s development. My time as an academically-oriented emergency physician closely paralleled the development of the specialty. It began in 1969 with a chance encounter with Charles Frey, MD. He was a surgeon at the University of Michigan who spoke to a few firstyear medical students about the potential opportunities in a new developing field. He directed the Emergency Room-Surgical at University Hospital. It was then on the 4th floor and linked to the ground floor ambulance entrance by a small, frustratingly slow elevator. He spoke of the newly formed University Association for Emergency Medical Services (UA/EMS), an organization lead predominately by surgeons. Dr. Frey was its first president and guided UA/EMS toward two common goals; improved patient care in the ED and establishing an academic orientation in the field of Emergency Medicine. His views and vision drew a few medical students along for the ride; I had the opportunity to be one of them. The text we used at the time was Flint’s “Emergency Treatment and Management,” a small, thick, practical book first published in the 1950s. Curiously, it was uniquely strong in toxicology, and weak in multiple areas that are assumptions for us now.

In the late 1960s and early 70s, the traditional specialtybased academic and practice medical community cared little about what was happening in the Emergency Department. Unsupervised activities that would never be allowed to occur on the wards happened daily in the ED with rarely a second thought or concern by academic chairs or hospital leadership. The “pit” was another world entirely, a distant place to be visited as little as possible. Early on there was an interesting dichotomy between private practice and academic physicians regarding their view of Emergency Medicine. For physicians in private practice, as long as patients weren’t being “stolen,” they were generally willing, although not completely trusting, to allow someone to let them sleep or remain in the operating room or office. The emergency physician wasn’t a “real hospital staff member” with a real practice, but their existence and occasional contribution was acknowledged. To academic physicians, the ‘pit’ was a dead end and waste of one’s talents. Both groups viewed the Emergency Department as where you started or ended your practice, or a place to be exiled if you were impaired or incompetent. In the summer of 1970, I spent a 6 week summer clerkship in northern Michigan, Lake County was the poorest county in the State. The two physicians staffing the Emergency Department at the small Lake County Community Hospital were 75 and 78 years old, respectively. They alternated 12-hour shifts, 5 days a week, and were on call when other physicians in the county weren’t available to cover. They made about $10/hour. They were wonderfully practical, welcoming, and had 100 years of medical practice between them. When in doubt, they simply did whatever book they had said, or went with their ‘gut.’ That was evidence enough. In the 1970s, the Emergency Department in Lake County typified much of the specialty, particularly in rural settings.

It was both rare and unique that Dr. Frey, an academic surgeon, would take such an interest in Emergency Medicine. His peers surely believed he was contaminating a successful academic career in Surgery. He later moved away from Michigan to the University of California-Davis, and pursued more surgical pursuits, but his influence was indelible for a few.

In the Beginning

With this background, one can see why the concept of academic Emergency Medicine was so foreign to most academic chairs and institutions. It was as if a new life form was trying to arise from the most neglected part of the hospital – the unspeakable or laughable “pit.” This growth was viewed by many in academic medical centers as similar to a malignancy; something requiring surgical removal or irradiation, something to be eradicated.

The origins of academic EM were always tied directly to improving patient care. Excellence in training and its impact on quality of practice issues were always foremost in the minds of the founders of the specialty. Most of the early practitioners realized they were continually being placed between a “rock and a hard place” in the ED. The “rock” was growing patient need: the “hard place” was the specialist’s expectation the physician in the ED could either do nothing, or nearly anything with a little telephone guidance. Academic Emergency Medicine had its origins in the clear need for better training for those who were choosing to practice in this new specialty. The need persists today, and despite our many gains, precipitous declines in the quality of care still occur within our nation, especially in inner city or in rural settings.

Pressures built during the 1960s that pushed Emergency Medicine forward, at least from the clinical practice perspective. Lessons in trauma care learned in Korea and Vietnam, recognition of safety needs and injuries on the highways, (well represented by the 1966 publication of Accidental Death and Disability: the Neglected Disease of Modern Society from 1


in the hospital. These early academic settings, even with highly varied experiences for their trainees, became the nidus for the rest of the specialty training programs. By early 1975, over thirty Emergency Medicine training programs existed throughout the country.

the National Academy of Sciences), changes in expectations of the population (mobility, expanded coverage insurance, McDonald’s mentality), and physicians’ attitudes (decrease of general practice, rise of specialists, change in insurance); all brought more attention to Emergency Medicine. Patient volumes in the Emergency Department increased gradually. By the 1960s, a few physicians, especially those identified in Alexandria, Virginia and Pontiac, Michigan began formulating plans to organize a private practice around the ED. Academic EM had several more years before gestation, but its seeds had been sown – rooted in patient need and practice demand.

Recognition of residency training in a formal sense did not come easy. In 1972, the AMA Council on Education rejected the first Proposed Essentials for Residency Training in Emergency Medicine. In 1973, the officers of ACEP created their own approval process as part of the ACEP Graduate Education Committee. This process was replaced and enhanced in 1975 by the Liaison Residency Endorsement Committee (LREC); jointly sponsored by ACEP, UA/EMS, and the American Board of Emergency Medicine. This Board was not yet part of the established American Board of Medical specialties Criteria for an endorsement of a residency program included a minimum of two years of faculty supervised training in the Emergency Department (24-hour faculty supervision was still several years away), graded responsibility, experiences on non-Emergency Medicine services, and some form of didactic curriculum. The beginnings of the Accreditation Council on Graduate Medical Education approval process were in place several years before formal ACGME recognition occurred.

Getting Organized The American College of Emergency Physicians (ACEP) came together in Lansing, Michigan in August, 1968. As espoused by its first chairman, John Wiegenstein, MD, the organization had two primary goals. Economic issues came first, but education and the need for training were next. The concept of establishing a new specialty was introduced during the first national meeting in Arlington, Virginia in the fall of 1968. The steps that incorporated the “Evolution of a Specialty” (Figure 1) were presented, and the importance of the academic development of Emergency Medicine was understood, and for the most part embraced by those early leaders. By 1969, the first Scientific Assembly occurred in Denver, Colorado, and educational programming became a central feature of ACEP. By 1970, the second Scientific Assembly in Las Vegas had over 600 attendees and the organization moved to a more solid footing with a business meeting, a committee structure, agendas, and organized voting. Led by RR Hannas, MD, one of the early founders, the College established the Commission on Education. In 1971, this body published the Proposed Essentials for a Residency Training Program for Emergency Physicians. Although initially rejected by the American Medical Association Council on Medical Education, it represented Emergency Medicine’s first foray into formal graduate medical education training.

Emergency Medicine Research The UA/EMS deserves credit for integrating the concept of research in Emergency Medicine. Academic surgeons who directed Emergency Departments, some willing, some angry, and some lost, were the backbone of this fledgling organization. Since an academic appointment was required for membership, individuals interested in research and teaching were brought into the fold. Unfortunately, the prevailing surgical attitude tended to be exclusionary and elitist at a time when ACEP was welcoming new members from a variety of backgrounds, training and experiences. It’s easy to see why a number of UA/EMS members did not embrace the idea of new residency training programs in EM. If EM were to go forward, many thought the model should be a surgical subspecialty linked to trauma. This was re-enforced in 1979 during my first faculty applicant interview, after training in EM at Denver General, with James Mackenzie, the ER Director at the University of Michigan. When asked what I could bring to the institution, my reply was, ‘Well, we’re the only two individuals with a background and orientation in EM.’ His reply, ‘No, I’m a surgeon, you’d be alone.’ My alma mater was scratched from the list. Several more years passed before it fully recognized the value of the specialty.

The First Steps Toward Academics: Graduate Medical Education (GME) Graduate Medical Education in Emergency Medicine had several geographic beginnings in the early 1970s: a fellowship at Massachusetts General Hospital and Emergency Medicine residencies at the University of Cincinnati, Medical College of Pennsylvania, the University of Southern California, the University of Chicago, and the University of Louisville. Each had its growing pains, fits and starts, and problems, but each had common elements: a resident willing to be ‘first,’ faculty member(s) who willingly supported the resident’s effort, a rudimentary curriculum, and most importantly, a clear commitment that this was not to be a one-time experiment. Year by year, class by class, the early mid-seventies saw early residency training programs steadily develop, always with the goal of improving the experience, and more clearly defining the role of the emergency physicians and residents-in-training

UA/EMS and ACEP continued their tentative and somewhat arms length relationship for much of the early 1970s. ACEP’s membership was growing, but its leadership was still ambivalent about its academic direction beyond education and training. UA/EMS was relatively stagnant, but closely linked to academics and dominated by a surgical view of the new specialty. Interestingly, the two organizations began sharing administrative services in Lansing in early 1973. 2


UA/EMS evolved slowly and leaders with a background in surgery but a vision in Emergency Medicine came forth. Many were program directors of EM residencies like David Wagner, MD (Medical College of Pennsylvania) and Ron Krome, MD (Wayne State University). My first encounter with this group was in 1971, when UA/EMS was meeting at the University of Michigan. Although the details have faded, my most vivid recall was seeing Ron Krome on stage presenting either as part of the conference or as a Grand Rounds. Michigan was dominated by older gentlemen physicians who made their mark in the post-WWII era. Long white coats, grey hair, and pipesmoking (permanently defined in my memory by William D. Robinson, MD, Chair of Medicine) were the rule of the day. And in front of this assemblage stood Dr. Krome, young, black hair combed back, street-smart from downtown Detroit. He spoke, not on a surgical topic, but on drug use and abuse to a previously sheltered crowd. At the University of Michigan, the rheumatologists ruled the institutional hierarch. So to them, this was a foreign topic given by a person from at least two completely separate worlds – Downtown Detroit (only 4 years after the 1967 riots) and Emergency Medicine. I considered it one of the best presentations I’d heard to date.

The book, “Emergency Medicine: Anytime, Anywhere, Any Place” (1) describes the Society of Teachers of Emergency Medicine (STEM) as being created through ACEP as a 501c3 organization. This status allowed it to become a member of the Council of Academic Societies within the American Association for Medical Colleges (AAMC). It was a means of clearly associating Emergency Medicine with the academic bastion in the house of medicine. It also placed an ACEP-linked organization in that role, rather than having UA/EMS serve in that capacity. The link to the AAMC had a slow gestation. Ten years later there were still few emergency physicians who understood its potential value. A few forward thinking academicians moved Emergency Medicine toward the AAMC nearly at our inception. It would be nearly another twenty years before the AAMC reciprocated in a significant manner. For those interested in education, especially graduate medical education, there was no home like STEM. This was a friendly collegial group of EM-oriented individuals who wanted to improve the educational quality of Emergency Medicine, especially through residency training. There was a palpable difference between the reception one felt between UA/EMS and STEM. The former was still dominated by surgeons with a surgical “pecking order” mentality. Pedigree meant far more than it deserved, and the negative hierarchical and judgmental perceptions of “who was doing what work or who was getting funded by whom” was already creeping in. STEM couldn’t have been more different. It was a small group of people who wanted to bring the best we could offer to students at all levels of training. There was a sense of meritocracy – one was given due credit for what each person brought to the table. The arrogance was nil, and the acceptance high.

Another academic milestone was the publication of the Journal of the American College of Emergency Physicians (JACEP) in 1972. ACEP was clearly moving toward a broader examination of the scientific basis of the new specialty, and the Journal was its first foray. The early issues, with JAMA-like art on the cover contained primarily summary and descriptive articles, combined with “Art versus Science” and “the scientific basis of EM” debates and discussions. By current standards, the academic work was rudimentary and with limited “rigor.” Still, the authors were sharing their experience, writing on topics for which there were no previous references. They introduced early decision-making algorithms, presented evolving “best practices” of the era, and began to convey the concept of emergency services to a broader group of physicians, at least those who were reading. Importantly, the JACEP began a regular, monthly, national-level communication of thoughts and ideas to emergency physicians who had operated in relative isolation up until that time.

A First Recognition in the House of Medicine – 1975

New Organizations Form as the Footprint Broadens

1.

The immediate initial recognition, evaluation, care and disposition of patients with acute illness and injury.

2.

The administration, research and teaching of all aspects of emergency medical care.

3.

The direction of the patient to sources of follow-up care, in or out of the hospital as may be required.

4.

The provision when requested of emergency, but not continuing, care to in-hospital patients.

5.

The management of the emergency medical system for the provision of pre-hospital emergency care.

1975 was a watershed year for the “non-specialty” of Emergency Medicine for many reasons. There were four active organizations in place representing the in-training, educational, research and clinical aspects of the field. Academic links were being initiated, and a maturing journal was in place. Importantly, the AMA House of Delegates approved a permanent Section of Emergency Medicine in 1975 and accepted standards for Emergency Medicine residencies. The AMA defined an emergency physician as a physician trained to engage in:

The Emergency Medicine Residents’ Association (EMRA), a natural outlet for the expanding number of residents, organized in 1974. Its primary goal was to provide representation to ACEP and UA/EMS. ACEP especially understood and embraced this relationship, actively provided administrative support to EMRA, and included resident liaisons to committees, and eventually the Board of Directors. This early commitment established a constructive symbiosis between the two organizations, a relationship that continues to this day. 3


This definition had been derived from the definition laid down by the still-new ACEP just a few years earlier. By 1975-76, Emergency Medicine was poised for its next big push. It needed to become a specialty, and for the next 14 years Emergency Medicine’s leaders made that goal an active, singular pursuit.

embracing 24/7 arms of the Wayne County General ER on the outskirts of Detroit. Tired of Internal Medicine, I stepped willingly into that embrace as the ED director. Without formal training, but a clear sense of liking the ‘action,’ the County and its charity wards was typical of the ‘new frontier’ of EM. Sixty thousand plus visits, a medical and surgical “side,” a detox unit on the side, and with only one 28 year-old attending (me), the environment reflected just how far the yet undefined specialty had to go. This ‘opportunity’ was typical of what was out there in the real world.

Conclusion 1975-76 was selected as the closing year for this “in the beginnings” introductory chapter for two reasons. First, it’s an essential year for formal recognition of the then-to-be specialty. Interested, capable and committed individuals had moved the field forward in the short span of less than a decade, poising it for its current success. The rest of the story is aptly summarized in the “History of Emergency Medicine” text.

The primary foci that initially drove the specialty included an unfilled patient demand, an ill-conceived recognition that the “pit” could be improved, the need to continually improve the science. This frontier drew individuals willing to jump into the fire and try to solve problems, present and future. Even today, with all the knowledge, academic success, and institutional recognition we’ve known, it is those basic traits that continue to move us forward.

The other reason is that 1975 begins my own formal saga in Emergency Medicine, so it’s a good place to stop. Pre-Denver General, Cincinnati, and Wright State, there opened the ever

Figure (Reprinted with permission, American College of Emergency Physicians)

EVOLUTION OF A SPECIALTY

Definition of Content Research Body of Knowledge

Graduate Training Programs

Catalyst: The Specialty Organization

Continuing Education Standard Maintained Exams Standards Met

Medical School Role Departments

Standards Boards

4


CHAPTER 2

MAKING THE DECISION: ACADEMICS VS. COMMUNITY PRACTICE By Lane C. Patten, MD and Felix Ankel, MD, Regions Hospital/HealthPartners Institute for Medical Education, St. Paul, MN

Criteria for bonuses and promotions are usually determined on achievements beyond clinical responsibilities and are typically based on the institution’s promotions and tenure policies. They are often based on publications and/or contributions to education. Tenure track positions within an academic institution often have set requirements in order to advance from assistant professor to associate professor to full professor. These requirements may include procuring a certain amount of extramural research funding or publishing a certain number of scholarly works, including original research, textbook chapters, or other articles within the EM literature. While peer reviewed publications were the benchmark against which all academic value was measured, many institutions have broadened the definition of “scholarly work” to include broader measures of contributions. These may include clinical teaching, curriculum development, recognized “expertise”, and mentorship.

ac·a·dem·ic: Of, relating to, or characteristic of a school, especially one of higher learning. Of or belonging to a scholarly organization. Based on formal education. com·mu·ni·ty: A group of people living in the same locality and under the same government. A group of people having common interests. A group viewed as forming a distinct segment of society. Similarity or identity. Sharing, participation, and fellowship. Career goals will largely dictate the type of practice an emergency medicine resident chooses. Emergency Medicine training in its infancy was largely focused on training qualified physicians for community practice. Academic emergency physicians quickly evolved to meet the teaching, research, and administrative and leadership goals of the specialty. Between 1992 and 1998, 32 new academic departments and 36 new residency programs came into being to meet this need.[1] Between 1991 and 2001, the proportion of academic departments of Emergency Medicine at medical schools increased from 42% to 66%.[2] A 1998 survey of physicians graduating from US allopathic EM residencies shows 70% of respondents were in community practice, 62% of respondents taught residents, and 36% of respondents taught Emergency Medicine residents.[3] All established EM residencies will prepare a resident to practice in a clinically-demanding community Emergency Department. But because well-established pathways into an EM academic career now exist, a resident can choose between pathways that lead to a community-based career or an academic career. So, the first important career question for a resident to answer is: Academics versus Community Practice? The type of practice that a resident desires will help them to plan their residency years and help them to find appropriate mentoring. While the origins of these pathways can be found early in training, they are not mutually exclusive. When a resident has a clearer idea of their desired career, the pursuit of either pathway can begin.

In a 2000 study by Neacy, et al., 43.8% of residents from established programs were interested in an academic career,[5] a significant increase from previous studies. Many factors were reported to play a role in this increase, such as exposure to research mentors, access to research funds, and the opportunity to learn basic research skills. As a traditional academic career will require competition for research funds as well as regular publication, the resident will be best served to learn the fundamentals of research early in their residency training. As research is an integral part of the career of an academic emergency physician, residency is a good time to become involved in a research project. Projects can range from basic science to clinical research, but all will give the resident exposure to the processes required to initiate and complete a study and submit a publication. Exposure to fundamentals of statistics as well will enhance most resident research endeavors. Resources available to the resident interested in a career in Academic Emergency Medicine are numerous. As residents are likely training in an academic institution, there will be many mentors available to the resident among their own faculty. Membership and participation in national Emergency Medicine organizations will also give the resident a wide and well-known group of practitioners from whom to choose as mentors.

What is academic practice? Academic practice may mean different things to different people. The scope of an academic practice can be variable, but certain components are considered keystones: clinical practice, teaching, and research. Although clinical shifts are an important element of this type of practice, academic emergency physicians devote significant amounts of their time to nonclinical duties. The American Board of Emergency Medicine defines an academician as a practitioner who spends more than 40% of their time engaged in a combination of academic writing, clinical and didactic teaching, and research.[4] Most academicians are associated with a teaching hospital and are core faculty at an Emergency Medicine residency program. Academic emergency physicians generally have a set amount of protected time for their academic endeavors.

Teaching is another key portion of the career of an academic emergency physician. Opportunities to hone the resident’s skills as an educator during residency include mentoring and teaching medical students who rotate through their program. Depending on the training environment, the resident may also be able to participate in teaching opportunities with their local EMS, participating in ACLS or ATLS instructor courses, or teaching in community programs such as the Red Cross. While assessing career choices, the resident should determine whether 5


When, if ever, is it too late to choose academics?

education is an area of practice they enjoy and to which they can devote their energy.

The short answer is that it is never too late. However, the initial development (during residency or fellowship training) and continual reinforcement of the essential skills for success in academics will serve to better prepare you if you decide to pursue academics at any point in the future. As mentioned, not all academic EPs settled on such a career pathway immediately after graduation. There are several physicians who successfully made the shift from community practice to academics. In fact, successful program directors and departmental chairpersons have initiated their careers outside of “traditional” academics.

Academics is a field that highly values education and training beyond the usual Emergency Medicine residency. Many leaders in academic Emergency Medicine endorse fellowship training beyond the 3-4 year residency training. Fellowship training can last from 1-3 years and is offered in many different academic subspecialties. Accredited fellowships include the subspecialties of toxicology, pediatric emergency medicine, hyperbaric medicine and sports medicine. Non-accredited fellowships are available in ultrasound, Emergency Medicine Services and prehospital care, education, clinical and basic science research, and health services research.

Emergency Medicine, especially academic Emergency Medicine, is a relatively small community. Promotions are often based on publications and/or measures of success as an educator. Networking can be crucial when attempting to get a job within academic Emergency Medicine. This may make going from community to academic practice slightly more difficult than the reverse, as you may not have these opportunities.

What is community practice? Community practice generally refers to a career based on clinical practice. According to the American Board of Emergency Medicine, clinical practitioners spend more than 50% of their time on clinical duties.[4] Although practitioners in community practice may also have other responsibilities such as administration or quality improvement; their primary responsibilities are to clinical practice. Community practice varies widely based on the size of the community as well as the resources available to the hospital. The best resources available to those residents who wish to go into community practice are the community-based emergency physicians in the area of the residency as well as the community practitioners in the area in which the resident wishes to practice. If the resident is not training in a community-hospital based residency program or an urban program that offers community hospital training too, an elective rotation at a community hospital may allow them to evaluate this practice type first hand.

References:

Compensation is based on different things for a community emergency physician compared to an academic emergency physician. Salary for the community practitioner is often based on how many clinical shifts worked, as well as how long a physician has worked with the particular group or institution. Bonuses and promotions are often based on partnership status, clinical productivity, or quality and patient satisfaction measures.

Are you still undecided? Residency is a perfect time to explore both career paths. As Emergency Medicine expands as a specialty, there have become more “hybrid” types of careers emerging. Some practitioners have focused on education and have embarked on “educator” career tracks. Some practitioners have focused on research and have done fellowships in research to strengthen their skills and increase their publications. Some practitioners have embarked on careers that would be traditionally considered “community practice” but have also involved the education of residents or medical students.

6

1.

Stern SA, Kim HM, Neacy K, Dronen SC, Mertz M. The impact of environmental factors on emergency medicine resident career choice. Acad Emerg Med. 1999. 6(4):26270.

2.

DeSantis M, Marco CA. Emergency Medicine residency selection: factors influencing candidate decisions. Acad Emerg Med. 2005. 12(6):559-61.

3.

Hall KN, Wakeman MA. Residency-trained emergency physician: their demographics, practice evolution and attrition from emergency medicine. J Emerg Med. 1999. 17(1):7-15.

4.

Reinhart MA, Munger BS, Rund DA. American Board of Emergency Medicine Longitudinal Study of Emergency Physicians. Ann Emerg Med. 1999. 33(1):22-32.

5.

Neacy K, Stern SA, Kim HM, Dronen SC. Resident perception of academic skills training and impact on academic career choice. Acad Emerg Med. 2000. 7(12):1408-15.


CHAPTER 3

CHOOSING ACADEMICS AND HOW TO PLAN YOUR RESIDENCY By Jonathan E. Davis, M.D., Associate Program Director, Department of Emergency Medicine, Georgetown University Hospital and Washington Hospital Center, Washington, D.C. and Joanne L. Oakes, M.D., Associate Program Director, Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX.

Choosing Academics

all, future generations learn their clinical skills primarily from academic EP’s. The time to fine-tune clinical skills is during residency training. It is important to not let this core aspect of training suffer in lieu of obtaining other academic skills.

Why academics? As discussed in Chapter 2, there are many reasons why an emergency physician (EP) may choose an academic career pathway. Some enter residency with the notion that academics is without hesitation the only path for them, while others pursue an academic tract at a later time. In some instances, this decision may be made following the completion of residency or fellowship training. For others, this decision may be made after years of community or other non-academic practice.

2.

Teaching Skills – As mentioned, scholarly activity involves the dissemination of knowledge. Teaching is one form of dissemination. Clinical (or bedside) teaching skills are learned primarily through the supervision and mentoring of junior residents, interns and medical students. In addition, didactic teaching skills are crucial for academic success. The adage “practice makes perfect” rings especially true regarding oral presentation skills. Experience gained with presentations early in your career will serve you well in future academic endeavors. Another essential component of the didactic skill set includes facility with Powerpoint® (or similar) presentation software.

3.

Research Skills – Discovery through research (whether clinical, educational or bench) is another essential academic skill. How much research is needed as a resident? There is no perfect answer to this question: ask ten academicians, and you are likely to get ten different responses! It is most important to gain exposure to (and comfort with) the discovery process. For instance, rudimentary knowledge of study design, institutional review board (IRB) processes, data collection, data analysis, as well as experience with bringing it all together in paper (or abstract) format are all essential components. However, whether this involves a small-scale clinical project or in-depth experimentation in the laboratory remains highly individualized.

4.

Writing Skills – Articulating your thoughts in writing is essential to the effective dissemination of knowledge. The greater the experience with medical writing, the better prepared you are for future academic success. Writing skills are necessary not only for abstracts and papers, but also for grant applications. Even if research per se is not your interest, writing skills can be learned and refined by authoring review articles, textbook chapters, or by serving as an editor.

5.

Administrative Skills – There are many administrative skills that are useful to the academician. An exceptional way to gain experience is to get involved with the administrative

The “Totipotent” Emergency Physician One strategy to ensure that the doors to all potential EM career pathways remain open is to strive to become a “totipotent” EP during the course of residency training. The foundations of success in academics are excellence in both clinical EM and in “scholarly activities.” Scholarly activity involves the dissemination of knowledge through a variety of mechanisms, including teaching, writing and research. Residency training is the time to lay the initial foundation in all of these areas, a foundation that can be built-on and continually referred to in the future. Can you do academics from either a 3 or 4-year training program? The long-standing controversy regarding the pros and cons of the three versus four-year EM training format continue to linger, and are well beyond the scope of this chapter. The important, take-home message is that success in academics is feasible with either format. One caveat is that it may be difficult for a graduate of a three-year training program to obtain a first-year faculty position at a four-year program. However, the majority of training programs (approximately 85% as of this writing), hence the majority of academic faculty positions, are of the three-year format. In addition, this potential sticking point resolves after completion of one year of practice (or a year of fellowship training) following graduation from a three-year program.

How to Plan Your Residency Obtaining the necessary tools for success in academics Residency is the time to acquire the requisite academic tools including: clinical, teaching, research, writing, administrative, and “people” skills. 1.

Clinical Skills – The most fundamental aspect of emergency practice remains excellence in patient care; this is equally important for the academic emergency practitioner. After 7


process by way of committee work, whether at the local (residency program, hospital), regional or national level. In addition, working towards, and achieving, committee leadership positions is a great way to further refine your skills. 6.

some heartache with all the hard work, but most former chief residents walk away from the experience with great insight into the pros and cons of an academic career.

Differences in planning strategies based on three vs. fouryear training format

“People” Skills – Although all of the aforementioned skills are essential, it is difficult (if not impossible) to effectively utilize any of them without effective “people” skills. Mentors are a great resource in this regard; many of these skills can be learned and refined by example. Involvement with EM organizations affords great opportunities for networking with other physicians, which may stimulate ideas or open the door for collaboration on all sorts of academic projects.

The particular curricula of training programs differs not only between EM 1-3, 1-4 and 2-4 format programs, but also among individual programs of the same format. Despite these differences, the Residency Review Committee in Emergency Medicine (RRC-EM) carefully monitors all programs, and ensures that, regardless of program format, all graduates will possess the skills and knowledge essential to the practice of EM. Success in academics is not tied to a fourth year of residency or to fellowship training; the requisite skill set for success in academics can be readily achieved during a threeyear residency. The goal is to build one’s academic skill set during residency, regardless of program format. Electives during residency that may add to one’s academic skill set might include a medical student teaching month, research and/ or writing projects, ultrasound or advanced electives (such as difficult airway management, ENT, Ophthalmology), or other areas of interest (such as International EM, EMS, disaster medicine, or an additional critical care focus). A four-year format may provide additional time for refinement of academic skills through additional elective time. However, many would argue that the three year format followed by fellowship training would prove equally (if not more) effective by allowing for academic skill development within a particular niche in EM.

Chief residency – pros and cons While many of the skills described above can be gained through many opportunities during residency, serving as the Chief Resident can be one of the best ways to develop these skills and gain expertise in many of the areas simultaneously. The decision to pursue a chief residency position can be difficult, as the position will vary from program to program. The “pros” of any chief position are numerous. You will gain valuable experience with schedule preparation and residency issues, from remediation and discipline to policy making and quality improvement. You will have opportunities to use and improve teaching, communication and writing skills. Opportunities for publications or work on clinical or research projects with faculty members may be available. The chief is viewed as a leader among his or her peers, a resident advocate, and a problem solver. The position may involve a stipend or other form of additional compensation.

Choosing good mentors A mentor is “a wise or trusted counselor or teacher.” For the Emergency Medicine resident, an upper level resident or a faculty member serves in the mentor role. A good mentor is willing to share knowledge from prior experiences with leadership, administration, research, and clinical teaching, and direct mentees to additional resources for learning. Start first within your residency program. Who are the leaders? Who are the great communicators or teachers? Who are the researchers? Who presents nationally and publishes? Who will give good, usable constructive feedback for your career journey? Seek out these people with your questions formulated and goals pondered in advance. Participation in national organizations, such as EMRA, ACEP, AAEM and SAEM, also provides countless opportunities for mentorship through presentations, forums, networking, and collaboration.

The “cons” of a chief year include questions of time and “the hassle factor.” The first question to answer is, “Will this be worth my time?” Some chief positions are funded as an additional year after graduation, with the chief functioning as a junior faculty member in addition to performing administrative duties, sometimes combined into an administrative fellowship. Some critics feel this format delays entry into other “niche” fellowships or into the workforce. Other chief positions are incorporated into the final year of residency, combining the rigors of senior year with additional leadership demands. The senior-as-chief role may create tensions among peers with the same level of training and may add significant time demands to training, requiring strong organizational skills. “The hassle factor” for you as chief is the knowledge that you are often the first person to hear from faculty, residents, program directors, and off-services when problems arise. Some view this as troubling, while others view this as invaluable experience.

Graduate degrees – pros and cons Obtaining a graduate degree in public health, epidemiology, education, research, business or law (to name a few) may be advantageous to one’s academic EM career, as it creates a focus for future work, whether for teaching, research, funding or writing. You will develop expertise in one particular area

Overall, the learning and leadership opportunities offered through participation as a chief resident are vast. There may be 8


as you pursue your thesis or project(s), and gain invaluable opportunities for lifelong mentorship and collaboration with experts outside of EM. As an expert, you may be called upon to participate in local, state, or national policy-making, committees, or teaching. An additional degree is also considered an advantage in the competitive academic job market.

exposure to the entire academic skill set, is typically the most productive approach given the inherent rigors of residency training. This will prepare you for future success should you ever choose to pursue an academic career pathway.

The disadvantages of pursuing a graduate degree include the time commitment required of the degree program and the monetary costs associated with the degree, similar to questions regarding the benefits of fellowship training. Does the pursuit of the degree require that you leave EM for a significant period of time? Is there adequate protected time to achieve your goals? Will the time away from potential income be repaid through job satisfaction later? The decision to pursue a graduate degree will ultimately be determined by an individual’s career goals and interests. While not for everyone, those who choose to pursue a graduate degree to complement a career in EM often find they have gained unique skills to enhance career satisfaction in the academic EM world. Fellowships – pros and cons The pros and cons of fellowship training in EM are discussed in detail in Chapter 4.

Conclusions When a candidate pursues a career in academic medicine, it is important to tailor the curriculum vitae appropriately to highlight those experiences which demonstrate an ability to succeed in the academic environment. Again, academic advising and mentoring is essential. Interviews should ideally be scheduled in the first half of the final year of residency, as most positions start July 1st, and some positions may be highly sought after. This also allows for several different interviews and travel, as well as second visits if necessary. One important factor to consider is the academic work environment. Are faculty members using their abilities to the fullest? What career paths are possible at the institution? How much support is there for innovative and new ideas? Is startup funding available for new projects? How are the faculty rewarded for their efforts? What is the promotion structure like? What is the turnover rate? What is the mission of the department? Comparing how these values measure with those of the candidate are pivotal to finding a position that is a good fit for the candidate. The foundations of success in academics are excellence in both clinical EM and in scholarly activities; both of these skill sets can be developed during Emergency Medicine residency training. Residency training is the time to lay these initial foundations, which can be built on and continually referred to in the future. The requisite academic skill set includes clinical, teaching, research, writing, administrative, and “people” skills. Focusing on skills of particular interest to you, while gaining 9


CHAPTER 4

THE IMPORTANCE OF A FELLOWSHIP: JUMP START YOUR ACADEMIC CAREER By David S. Howes MD, Professor and Residency Program Director, Section of Emergency Medicine, University of Chicago, Chicago, IL, and William Northington MD, Emergency Medical Services Fellow, University of Pittsburgh, Pittsburgh, PA Fellowship training may necessitate a delay in earning a large salary and it may be difficult for a senior resident to turn away from clinical practice with fewer work hours and a larger salary. Compensation packages may vary greatly, particularly when the fellowship is not an ACGME accredited fellowship. Once free of the traditional housestaff pay scale, non-accredited fellowships may offer higher salaries. It is important to appreciate that fellowship training in Emergency Medicine does not often lead to the substantial salary increases that accompany subspecialty certification in other primary care specialties. The majority of fellowship-trained Emergency Physicians will continue to work clinical hours in the Emergency Department in addition to practicing in their specialty area in order to sustain a viable income.

The number and variety of fellowships in Emergency Medicine has grown substantially over the last two decades in response to broader areas of interest. Witness the popularity of International Emergency Medicine in the last five years and more importantly, the recognition by graduating residents that the skill set of a successful academic physician may not completely be provided by an Emergency Medicine residency training program. It may also be a response to the marketplace: graduates of fellowships have more to offer than graduates straight out of training and are able to obtain an academic faculty position because of this. After all, the fellowship training period offers an emergency physician dedicated time to further develop one’s skills in an area of interest, gain training in the medical, educational and scholarly aspects of that interest, and allows one to establish an area of expertise within the broader field of Emergency Medicine. For a good overview of whether a fellowship is right for you, review the Fellowship section of the new SAEM website at www.saem.org.

Further analysis might suggest that fellowship training may qualify the graduating fellow for an academic position in which the work hours, though often longer than in the private sector, are a balance of clinical hours spent working with residents and medical students, and time spent pursuing academic interest. Though there are no long term studies assessing the career satisfaction of fellowship trained Emergency Physicians; it is likely that the payoff in fellowship training includes the perception that there is longevity in an academic environment and the prestige associated with training medical students and resident physicians. Contributing to the body of knowledge in Emergency Medicine through research also contributes to career satisfaction.

The two most important elements that a fellowship provides is the time to pursue an area of interest and a relationship with a more senior faculty member(s) in order to effectively pursue an educational goal. A fellowship also allows an emergency physician to identify and develop a niche. A fellowship program allows young physicians to pursue specific interests and acquire a specific skill set during protected time with a reduced number of clinical shifts. These programs also provide an established mentor who will help guide and shape the fellow into a developing academician. Desirable fellowship programs may allow the pursuit of a post-baccalaureate degree to complement the additional training. Depending on the area of interest and the institution, the degree earned is typically at the Master’s level in an area that complements the Emergency Medicine area of interest, e.g. pursuing an MBA is a sound strategy for the physician who is completing an Administrative Fellowship, a Master in Health Professions Education is perfect for the person seeking expertise in medical education, an MPH or MS for Research, etc.

Types of Fellowships Five fellowships are approved by the ACGME and recognized by the American Board of Medical Specialties (ABMS). Completing these fellowships allows access to the ABMS board certification pathway in Hyperbaric and Undersea Medicine, Hospice and Palliative Care, Pediatric Emergency Medicine, Sports Medicine, and Toxicology. Since many other fellowships do not lead to ACGME accreditation, what is the benefit of undertaking one of these programs? Fellowship training may not be a prerequisite to holding a job in one of these specific fields (e.g. many EMS medical directors have not completed an EMS fellowship), but the fellowship offers specialized training that will provide relevant experience in the field and better prepare the fellow for a job in that field. Most fellowships last one to two years. Pediatric Emergency Medicine is a minimum of two years and is often three years in length. The Pediatric Emergency Medicine Fellow often has the opportunity to pursue an advanced degree in an associated graduate school. For an extensive listing of fellowships offered, please visit the Fellowship Catalog on the SAEM website.

Fellowships in Emergency Medicine vary a great deal from site to site and there are no standardized curricula for most fellowship experiences except those accredited by the Accreditation Council for Graduate Medical Education (ACGME). Completing an ACGME accredited fellowship allows a candidate to seek board certification in that specialty. The Society for Academic Emergency Medicine has published guidelines for Emergency Medical Services and Research Fellowships but there is no requirement that programs follow these formats. 10


Academic Emergency Medicine/Medical Education/Faculty Development

EMS fellowships also allow the fellow substantial exposure to aeromedical transport, disaster medicine, wilderness medicine, and tactical/special operations.

Dedicated time as an academic fellow offers the opportunity to work clinical shifts in an Academic Emergency Department overseeing residents and medical students. It also allows protected time for dedicated didactic teaching, pursuing research interests, or other academic endeavors in a setting that fosters academic productivity. The opportunity to pursue a Master’s level program in medical education, such as a Masters in Health Professions Education (MHPE), makes this an option for the academically inclined graduate who would like to work in an academic setting but does not have a more narrowly defined topical interest. This type of fellowship is an excellent preparation for a faculty position. Their length varies from one to two years.

Hyperbaric Medicine Fellowships in hyperbaric medicine include training and education in hyperbaric physiology and diving medicine. The fellow learns the clinical indications and applications of hyperbaric medicine for decompression sickness, non-healing wounds, soft tissue infections, and carbon monoxide poisoning, and many other uses. International Emergency Medicine International Emergency Medicine fellowships train physicians to evaluate emergency health needs in a country where emergency healthcare systems are lacking. Fellows will focus on providing humanitarian assistance and relief, developing emergency systems, or reporting to international mass-casualty/disaster events. The fellowship often requires international travel and most fellows pursue an MPH or similar advanced degree.

Administration Training in administration exposures the fellow to the inner operational workings of an Emergency Department, including oversight of issues such as personnel management, budgeting, equipment acquisition, interdepartmental relations, and the role of the medical staff and the hospital administration. Candidates often seek an MBA or MPA in order to enhance their skills in relating to the modern, complex, business model that drives most hospital administrators today.

Pediatric Emergency Medicine Pediatric Emergency Medicine fellowships offer training in the care of all ill and injured children seen in an Emergency Department. Training occurs primarily in a Pediatric Emergency Department but may also include rotations in pediatric intensive care units or on medical and surgical pediatric subspecialty services. Although the core objective of the pediatric emergency fellowship is to develop clinical skills, most allot protected time for research and teaching activities.

Critical Care Critical Care Medicine is the multidisciplinary care that deals with the stabilization, treatment, and management of patients with life-threatening illness. Board certified in critical care medicine (through The American Board of Medical Specialties) is not currently available to individuals who have completed an Emergency Medicine residency prior to completing a critical care fellowship. There are several fellowships that will accept Emergency Medicine trained individuals (a list of which is available through the ACEP section of Critical Care Medicine at http://www.acep.org. Slightly over half of all the critical care programs that responded to an ACEP survey accepted Emergency Medicine trained individuals. Most emergency physicians who have completed critical care training are able to secure positions in which they are able to utilize this additional specialty training despite a lack of critical care board certification. There are many EM/Critical Care trained physicians holding positions at academic institutions and several serve as medical directors of intensive care units in their hospitals.

Hospice and Palliative Care In late 2006, 10 specialty boards within ABMS joined to support the development of specialized training and certification in this field. ABEM was one of them. Criteria for training are being developed, and materials for evaluation are anticipated in 2008. Research Basic and clinical research in Emergency Medicine provides a framework of understanding for which the future of our specialty may be based. The goal of most research fellowships is to impart knowledge of how to perform scientifically sound research. Fellows expect to have protected time to conduct research and access to a suitable mentor to enable the fellow to complete a research project(s). The fellow will often pursue an advanced degree and learn to write grant proposals and produce manuscripts of original research acceptable for publication in peer-reviewed journals.

Emergency Medical Services (EMS) Additional training in Emergency Medical Services offers the fellow further experience in prehospital emergency care, including the design and operation of an EMS system, education of prehospital providers, and participation in the administrative and financial aspects of an EMS system. EMS fellows will often serve as Medical Director for smaller EMS services or assistant Medical Director for larger city EMS services. Many

There are also opportunities in health services research concerning the organization, management, financing, and performance of health and medical systems. These programs 11


are typically open to individuals in most fields of healthcare and are normally not affiliated with a particular academic Department of Emergency Medicine. Some of the more wellknown programs include the Robert Wood Johnson Clinical Scholars Program (http://rwjcsp.stanford.edu/index.html), The Veterans Administration Research and Development (http:// www.research.va.gov/programs/hsrd.cfm), and Academy Health (http://www.academyhealth.org/), among others. Sports Medicine Although Sports Medicine often focuses on the nonoperative management of musculoskeletal sports conditions, it also involves the evaluation and treatment of any medical state affecting an athlete (including chronic conditions or acute situations that are not related to sports). Practice opportunities range from serving as a team physician to office-based practice. When researching a sports medicine fellowship, find out if the program accepts emergency physicians; several sports medicine programs are open only to those who have completed orthopedic or family medicine residencies. Toxicology Toxicology programs last at least two years and train fellows in the biochemistry, pharmacology, and toxic effects of pharmaceutical and environmental compounds. Training revolves around the recognition of clinical manifestations, differential diagnosis and management of various poisonings. Other opportunities often include working with a poison control center and experience with occupational and environmental toxicology. Ultrasound Emergency ultrasound is a rapidly growing field. Fellows will become well versed in trauma ultrasound, emergency ultrasound in pregnancy, emergency echocardiography, abdominal aortic aneurysm, biliary ultrasound, renal ultrasound, and procedural ultrasound and often explore novel and experimental uses for ultrasound. They also expect to be credentialed in performing and interpreting ultrasounds and often teach and oversee other individuals in the training of ultrasound use. This is just a partial listing of some of the fellowships offered. Additionally, there are programs in forensics, medical informatics, disaster research and management, geriatrics, injury control, policy, neurological, and cardiovascular emergencies. Details pertaining to each specific program can be found at under the Fellowship Section of the SAEM website.

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CHAPTER 5

THE “ACADEMIC SKILL SET” By Michele Dorfsman, MD, Assistant Professor of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA

Ask any senior resident interested in a career in academic emergency medicine why they want to pursue such a career path and you’ll often here, “I like to teach residents.” That overly simplified perspective is precisely why most faculty were initially attracted to an academic career. While clinical teaching is a very important aspect of a career in academic emergency medicine, there are many more skills that are required. The purpose of this chapter is to describe the common skills required of academic emergency physicians no matter their area of focus or role in the Emergency Department.

important for an educator to reflect on teaching methods and focus on their role as the role of the learner changes. Setting expectations for the learner and giving effective feedback, as well as learning how to assess performance are essential skills. Lecture and presentation skills are also important to the academic physician. Although most educators agree that the lecture format is not the most effective means of transmitting principles, it is still the most common method of teaching in academic Emergency Medicine. Computer skills are increasingly essential, as most lectures are now given on computerized programs given in a slide format. Skill in performing internet searches, medical database searches, and basic statistical procedures is essential in preparing these presentations. Speaking skill and style can be honed during lectures to small groups of residents and attendings during residency, and this experience is excellent training for academic presentations later on in a career, whether it be at national meetings, guest lectures, or lectures within the institution. In addition, it provides an opportunity to work on writing and effective communication skills. Many of the formal training opportunities described above also focus on teaching skills, lecturing skills, curriculum development and slide-making skills.

A broad understanding of what a career in academic Emergency Medicine actually looks like is critical to success. Many emergency physicians have what might be better described as a “job” rather than a career; shifts are scheduled, patients are evaluated and treated, and shifts are ended. A “career” in Emergency Medicine is one crafted by a deliberate plan that is aimed at acquiring skills, achieving academic milestones, and building a set of achievements. While the career emphasis or specific role in the academic department may vary, some skills are basic to all faculty. Most academic institutions expect a considerable amount of teaching from faculty members. Clinical teaching can be very challenging in the field of Emergency Medicine, as there are constant clinical pressures, as well as learners with varying levels of experience in the Emergency Department. The challenge is to provide outstanding care while providing instruction and meeting the learners’ needs. These skills are best acquired over time, and can be modified with experience. While outside the scope of this discussion, there is a body of literature available discussing concepts of adult learning and effective teaching principles. Motivated instructors will review this body of literature in order to become efficient and effective clinical educators. There are also courses available in this realm, such as the American Association of Medical College (AAMC) courses on faculty development opportunities in education at the national meeting which is open to medical school and teaching faculty. The Society for Academic Emergency Medicine (SAEM) has many resources in this area, such as the “Innovations in Emergency Medicine Education Exhibits” at the national meetings. The Medical Student Educators Interest Group from SAEM holds meetings during each national meeting, where educational issues are discussed in detail. The American College of Emergency Physicians (ACEP) and the Emergency Medicine Foundation (EMF) hold a Teaching Fellowship program for two weeks during each year. The Council of Residency Directors (CORD) offers a program devoted to education each year. Other opportunities lie in volunteering to be a clinical skills instructor for medical students or being a medical student advisor or mentor. It is

Effective communication skills are mandatory for the successful academician. Even if these skills do not come naturally, it is possible to cultivate them by associating with other successful academicians. Individuals who associate with successful educators and researchers are likely to become successful themselves. These relationships teach the learner about the informal network that supports productivity, and provides insight into the inner workings of professional organizations. It is ideal to develop these skills early in an academic career and foster them by participating in academic tasks within the residency program. These tasks may be as simple as participating in lecture series, in-training exam reviews, journal clubs, or by serving on residency committees. While formal professionalism training is not available in many residencies, these skills can be learned by modeling and identification of suitable mentors. Reading and writing skills are essential to the academic physician, whether they be primarily involved in clinical teaching, didactics, research, or administration. Some of these skills are acquired through review of the current medical literature. Evidence based medicine courses can help with both the reading of the literature, as well as critical assessment, which can improve the junior faculty member’s own writing skills. Promotion in academia often depends upon quality publications, whether it be bench or clinical research, or educational literature and research. Critical reading and writing skills are best learned at the residency level or better yet, earlier. 13


Nearly all academic emergency physicians are required to engage in some sort of research activity as part of their broader measure of scholarly work. For those physicians interested in research, developing research skills early in a career can be very helpful; identifying a mentor involved in research is critical. A basic, simple research project soon after joining as a new faculty member is a wonderful way to gain experience with the Institutional Review Board process. It provides experience in understanding the difficulties of developing, implementing, analyzing, and preparing a research project. It forces some study of statistical methodology and data analysis. It provides an opportunity to work on reading and writing skills. It also provides an opportunity for an oral presentation or poster presentation both locally and at a national meeting level, where speaking skills can be practiced. It also provides an opportunity to become proficient with computer media. The exposure to Emergency Medicine academicians through research presentations during residency is unparalleled. There are many formal mechanisms to gain additional expertise and acquire additional research skills. The Emergency Medicine Basic Research Skills Workshop sponsored by ACEP and EMF is an example of such training. Ideally, the time to prepare for an academic career is as early as possible. Keeping an open mind and jumping on opportunities to teach, to do research, to get administrative experience, and to learn to be an excellent communicator are helpful in beginning to acquire the “academic skill set.�

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CHAPTER 6

CREATING A HEALTHY CAREER- TIME MANAGEMENT, WELLNESS, AND MENTORING By Flavia Nobay, MD, UCSF School of Medicine, San Francisco, CA, and Andrew Donnelly, MD , University of Oklahoma College of Medicine, Oklahoma City, OK Creating a healthy career in medicine is a challenge. The demands of Emergency Medicine in particular require a strategic approach to time management, a workable balance between professional and personal responsibilities, finding outstanding mentorship and recognition of the risks of burnout. These issues will be explored with the goal of assisting you to develop an approach to your own wellness. Although there is plenty of soft and hard science related to wellness during your career, when it comes down to it, all of the science in the world cannot describe personal experience. So relax knowing that you are the best judge of your experience, and largely in control of your own wellness. Recognizing this is empowering and can help you create the best experience possible as a professional in EM.

milieu of “no pain, no gain” in residencies compounds these factors. In “Wellness for the Emergency Medicine Resident,” Ellison notes multiple factors that influence wellness. Most of these are not specific to EM training only, but can be extrapolated to all stages in a career: • Competition with other residents for procedures and learning opportunities • Lack of experience with essential negotiation skills • Low status in the hospital hierarchy due to the relative youth of EM as specialty • Lack of time to rest, socialize, and eat optimally during busy shifts • Isolation from social support due to geographic and scheduling constraints

Definition Wellness is a broad term that has a vast array of meanings for each and every person. Instead of having it defined for you, you should try and spend a quick moment defining if for yourself. If this seems difficult, don’t worry too much, as it will evolve and change as you do. If you are at a dead end in defining wellness, then try this definition: wellness is a combination of things and it usually implies a healthy mind and body that has depth and resilience. For an Emergency Medicine physician, this will clearly wax and wane as you go through different stages of your professional life from training to a stable job.

• Loss of camaraderie resulting from shift work • Briefness of relationships with ED patients • Difficult interactions with ED staff [2] Given the myriad of challenges to achieving wellness, why is it that many people go through their careers with apparent ease and have gratifying long-term experiences? This is where the “science” of wellness gets hazy and the recommendations become a combination of personal philosophy, group consensus, and objective data.

It is important to note that wellness is not static, so not “being well” at one stage does not foreshadow disaster ahead. Sometimes, wellness can just be the middle ground between euphoria and despair. So, if you are still stuck in finding a definition, the second edition of this Career Guide defined Wellness in EM as “those skills, attitudes and beliefs that allow one to enjoy practicing EM for a long period of time, while at the same time allowing balance in one’s life.”[1] It is important to remember, long-term wellness isn’t just the absence of unhealthy feelings, burnout or impairment, but it is the active involvement of self in things that rejuvenate and revitalize you, such as families, friendships, hobbies, spirituality and exercise.

Balancing Personal and Professional Responsibilities There are a few principles that most wellness experts advocate and should be noted. Weiner groups them into five major categories: relationships, religion/spirituality, self-care, work, and approaches to life.[3] The following principles of “wellness” are taken from a mix of personal experience, wellness literature and expert advice. Create a long-term vision of your life. This will help to ensure that you aren’t overwhelmed by the tumult and confusion of the current moment. It will also construct a roadmap upon which a sense of accomplishment and progression can be charted. This implies the use of realistic goals and sacrifices to obtain your long-term vision.

Challenges to Wellness Although it is certainly possible to achieve, there are many challenges to maintaining a sense of wellness during your career as an emergency physician. The EM experience has certain attributes that can undermine wellness. The nature of our jobs is to witness tragedy on massive scales, violence on a daily basis, and to be exposed to a host of nasty illnesses that are frequently undifferentiated when first encountered. Prolonged shift work is frequently cited as a cause of sleep disorders and the general

Connect to your colleagues. Talk to and get to know your co-workers as people, not just as fellow physicians. The feeling of connection is what molds and creates the intimacy of our experience. Without this intimacy, our goals and purposes are sometimes lost or unstructured. 15


Enjoy what you do. Maybe not all the time, perhaps not even the majority of time, but at least some of the time; being able to laugh and see the moment as humorous is paramount in dispelling intermittent feelings of anxiety, self-doubt, and ennui.

you do this for yourself except you! Physicians are masters of delayed gratification, but it is impossible to expend the energy it takes to be an excellent medical professional without fueling. Taking “time” implies you know what fuels you; talking to a friend, reading non-medical literature, playing music, exercising, etc.

Physical well-being. It is clear from science and personal experience that physical activity outside of your professional work is critical for the success of your EM progress. Physical activity can involve anything from a “hardcore” exercise routine to a gentle walk and stretching. Whatever you do will be an improvement to your life. Physical activity will improve your ability to cope with the sleep disturbances that are common among shift workers. A quiet, dark place to sleep during daylight hours is more important for emergency physicians than in almost any other field. If you are on a string of nights, make sure your day sleep is protected and ensured. Incorporate a diet that keeps your body both nourished in a wholesome manner and well hydrated.

Be realistic. You probably will not have time to do everything you would like and still get adequate sleep. Avoid overburdening your schedule. Expect to re-claim certain interests during the less stressful times in your life. Invest in a time management tool. The tools of modern medicine such as personal handheld devices, computer programs, and internet fueled programs can be critical to your organizational success. It is critical to choose one method that works for you and your family and become a master at its manipulation. Multiple programs that do not interconnect your life will lead to confusion and a loss of time. There are countless books aimed at time management skills and optimizing your free time, peruse through them to find one that works best for you.

Keep in touch with friends and family who you are close to. They are a voice of reason and support that will succor the non-medical side of you. Neglecting this part of you could result in disconnecting you from your life before medicine. If you don’t feel comfortable using a personal acquaintance, find a professional to discuss the ramifications of this massive experience in your life.

Avoiding Burnout There are many definitions of burnout, but the most comprehensive one is a “syndrome of emotional exhaustion, depersonalization and a sense of low personal accomplishment that leads to ineffectiveness at work.”[4] Burnout may present with frank changes in personality or as subtle changes that only the most intimate friends/partners may notice. Regardless of the external presentation, burnout must be watched for with vigilance, as this will insidiously affect your long-term career and choices. There are many manifestations of physician burnout:

Immediate family. Creating and maintaining a healthy bond with your spouse and children during residency is a difficult, yet obtainable goal; time management skills are critical. Being available for both occasional unstructured downtime and being present for important life events (birthdays, anniversaries, graduations, etc.) with your family is paramount. It can at times be remarkably hard to shed the “work person” and inhabit the “family person” role, but it is essential nonetheless. A mentor or friend who has gone through this same process can be invaluable as a resource in this regard.

• Loss of interest in work • Feelings of fear, avoidance, isolation, anger, and, ultimately, loathing for work

Time Management

• Fatigue, exhaustion, inability to concentrate, anxiety, insomnia, irritability

All of us have developed time management strategies. Still, the demands of our careers are unique and present challenges that we may not have confronted before. Time management is one of the most under-taught skills in residency and beyond.

• Increased use of alcohol and drugs • Headache, back or neck ache, abdominal distress, nausea, malaise

Make plans: Down time is precious. There is nothing wrong with spending it in your pajamas in front of the television from time to time, but sometimes a pro-active approach is required to fit in activities that are critical to your sense of self. Create things to look forward to: from putting your child to sleep to traveling abroad. Anything you enjoy should be thought about as a reward. Refuel your sense of self as often as you can. Remember this race is a marathon, not a sprint.

• Anxiety, divorce, broken relationships and disillusionment [5] The fundamental problem with burnout is that the people experiencing the feelings are too disconnected to recognize them as symptoms; friends, families and colleagues are often the first to notice burnout. If you are being asked about it from more than 1-2 people, you should heed the warnings and start talking to those that may be a resource for you. There are multiple resources available for you to use to identify burnout in

Take time for yourself. This could be as little as five minutes, or it could be as long as the weekend. No one will advocate that 16


either yourself or a colleague and multiple resources available to help you. However, the critical first step is to recognize and take ownership of the feeling. Without this step, it is difficult to rectify the situation.[6, 7] If you are curious about your own sense of burnout, the ACEP website (www.acep.org) has a burnout evaluation scale, developed by the ACEP Wellness task Force as a screening and educational tool. Alcohol and drug dependence is a special concern. A study of EM residents indicated a similar rate of alcohol abuse and a lower rate of other substance abuse when compared to other specialties but a similar rate to the general population.[8] Anyone who is suspected of substance abuse should be immediately reported to superiors or hospital-based committees so that an intervention can be made to prevent harm to self or to others. Psychiatric illness may also present early on in one’s career given the age and the work hours. Fatigue and emotional stress may accelerate the disease processes of depression, anxiety, and other psychiatric disorders. Emergency physicians who are women experience unique stressors because of their gender. Without a doubt, patients will bluntly and subtly consider you differently. For example, you may be called “honey” and not “Dr. X”. Staff will often times have different expectations of you than of your male colleagues. This can add to the burden and stress of your job. Motherhood, in particular, is a difficult role to balance with professional duties. Things that may help negotiate this challenge include: • Finding a mentor who has had similar experiences • Setting realistic expectations for yourself • Learning to set limits and that sometimes it’s OK to say “no”

Conclusion Emergency Medicine is a field that brings great professional satisfaction, but has specific issues particular to it that can cause increased stressors compared to some other fields. Identifying potential pitfalls and actively working to avoid them will help ensure a healthy and longstanding career in the Emergency Department.

References 1.

Perina, DG, Chisholm CD: Physician wellness in an academic career. SAEM Academic Career Guide, 2nd Edition, 2000 (www.saem.org/publicat/chap12.htm).

2.

Ellison DM: Wellness for the emergency medicine r e s i d e n t . h t t p : / / w w w. a c e p . o r g / N R / r d o n l y r e s / C5A9A793-1924-49ED-A516-EE06AFCAB217/0/ wellnessBookResidentWellness.pdf.

3.

Weiner EL, Swain GR, Wolf B, Gottlieb M: A qualitative study of physicians’ own wellness-promotion practices. Western J of Medicine. 2001; 174:19-23. 17

4.

Maslach C, Schaufeli WB, Leiter MP: Job burnout. Annual Rev Psychol. 2001; 52: 397-422.

5.

Birnbaum A, Haughey M: Can you be an EM resident and still experience “Wellness”. http://www.saem.org. Resident Handbook. Academic Resident.

6.

Bintliff S; The adult APGAR: An Instrument To Monitor Wellness. http://www.acep.org/NR/rdonlyres/ 2E85A0D4-FEF8-40D9-94F2-F9640CC0B50C/0/ wellnessBookAdultAPGAR.pdf.

7.

Maslach C, Jackson S, Keiter M: Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, Ca: Consulting Psychologist Press; 1996.

8.

McNamara RM, Sanders AB, Ling L et al: Substance use and alcohol abuse in emergency medicine training programs by resident report. SAEM Residency Survey Task Force. Acad Emerg Med 1994 Jan- Feb; 1(1) 47-53.


CHAPTER 7

TEACHING AND EDUCATION – ACADEMICS AS A CLINICAL EDUCATOR By Christopher S. Weaver, MD and Anthony J. Callisto, MD, Indiana University School of Medicine, Indianapolis, IN

observational study of the learner, and inherent, intangible characteristics of the teacher. Residents must be under the supervision of faculty at all times. This gives the faculty member the opportunity to provide focused teaching and quality feedback for each case. This ongoing teaching and assessment of the resident is one of the primary responsibilities of clinical educators and allows them to hone the residents’ skills in each of the six core competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communications skills, professionalism, and systems-based practice.

Those entertaining a career in academic Emergency Medicine may choose to focus on research, service, or teaching. By focusing your academic career on teaching, you can contribute in many ways to the education of the entire healthcare system, including medical students and resident physicians. When considering a teaching-based academic career, you should evaluate several topics: how to identify possible areas to focus teaching excellence, how to identify faculty development opportunities and become an accomplished teacher, how to embark on a mentor relationship, and how to achieve promotion and tenure. This chapter will discuss these topics and aid in the approach to the professional development required for success in an academic career with teaching as the focus.

Emergency Medicine residents are adult learners and provide a unique challenge to the clinical educator. Certain characteristics of the clinical educator have been elucidated as being more appropriate to the adult learner.[3] Residents enjoy working with people who possess certain inherent personality traits. These include being approachable, available, and possessing infinite calm and patience in difficult situations. Utilizing the format of teaching smaller “learning bites” and providing timely feedback are additional means of being an effective bedside teacher. Directing the student’s learning is always an attractive option; however, utilizing questions instead of directing promotes interest in learning. The primary means by which most faculty members evaluate clinical competence is actually based on indirect measures such as verbal presentation skills, perceived interest in learning, and the accuracy of patient assessments. However, it is well established that one-onone direct observation of the resident provides a much better impression of the learner’s performance and needs as opposed to indirect modalities.[4] The fact that EM faculty are on site and working with the residents 24 hours a day provides a distinct advantage for Emergency Medicine in teaching and evaluating each of the competencies.

Clinical Teaching in the ED Every emergency physician has an opportunity to teach at the bedside. The audience may include various learners: EM residents, residents of other specialties, medical students, nurses, or paramedics. Over twenty centuries ago, Hippocrates stepped out of the classroom to practice medicine at the bedside based on the value of direct observation. The father of modern day bedside teaching, Sir William Osler said, “Medicine is learned at the bedside and not in the classroom; the best teaching is that taught by the patient himself.” The Emergency Department (ED) is a wonderful venue for bedside teaching. It provides a large number and variety of patients representing all socioeconomic groups and presenting with problems representing all subspecialties. Emergency physicians have the opportunity to interact not only with a variety of physicians at different levels of training, but also the entire healthcare team. To be a successful clinical educator, you must understand the learner’s perspective. Emergency Medicine educators have the opportunity to directly supervise third and fourth-year student clinical activity evaluating undifferentiated patients in the ED. This creates the opportunity to improve bedside clinical skills including the recognition of life-threatening conditions and the treatment of a broad range of common acute problems. Emergency Medicine offers what no other specialty offers: clinical decisions based on limited information, differentiation of unknown complaints, resuscitation skills, and the initial approach to and management of limb- and life-threatening illness.[1] Medical school curricula may also provide an opportunity for more specialized electives such as: toxicology, sports medicine, emergency medical services, hyperbaric medicine, occupational medicine, and research.[2] Students may have had these experiences before their clerkship in Emergency Medicine.

Graduate Medical Education Each EM residency is required to have one core faculty for every three residents. The Emergency Medicine program requirements state, “A core faculty member is one who provides clinical service and teaching, devotes the majority of his or her professional efforts to the program, and has sufficient time protected from direct service responsibilities to meet the educational requirements of the program.” The EM Residency Review Committee states that core faculty should not be working more than 28 clinical hours per week.[5] Other responsibilities of core faculty may vary a great deal between institutions and even from individual to individual. These responsibilities may include research or other scholarly activity, administrative jobs such as program director or medical student education director, ultrasound education director, director of simulation education, and many other job descriptions.

The foundation of an Emergency Medicine teaching career is in resident contact and is focused on directed learning, 18


Historically, there have been many shortcomings in the area of educational research. Quality medical education research often requires money and there has been a relative paucity of external funding for this type of research. This leaves it to be largely a local, institutional activity. In addition, few IRBs understand educational research. There are concerns about mandating informed consent for “routine” educational activities, consideration of learners as a vulnerable population, and the struggle with the ethics of “withholding” an educational benefit in a control group. These problems have led to inadequacies in the quality of educational research including weak study designs, lack of programmatic development (“convenience” studies and fragmentation/isolation), and an overall neglect of literature production.[9] However, there have been some advances in participation of medical educational research in recent years. A growing number of training programs and fellowships in medical education research have been developed. Expanded attention has been given to graduate medical education and internationalization of medical education research. There have been advances in quality with methodological diversity and heightened standards for reviewing educational research. More and more promotion/tenure committees are recognizing education and education research.[9]

EM academicians have a responsibility to provide career advice and mentorship in addition to providing teaching to residents. Many residents need career counseling as they approach the end of their training program. They may be considering academics, community practice, or any of the EM subspecialties (emergency medical services, toxicology, sports medicine, etc…). Residents benefit from insight into the personal attributes that allow a good fit with a particular career path and value discussions to enlighten them on the general job descriptions of the paths they are considering. As academic educators, this is an opportunity to encourage residents and insure that they consider academics, fellowship training, and research careers in their list of options. A career as a residency program director is a rewarding option for academic physicians. It is the responsibility of the program director to organize, oversee, and guide the residency program to meet these requirements and develop unique characteristics for that program. The general curriculum for each residency program is derived from a document containing the entire breadth of the specialty. Initially known as The Core Content of Emergency Medicine, it is now called, The Model of the Clinical Practice of Emergency Medicine.[6, 7] This document was published as a consensus policy developed by academic leaders from ABEM, ACEP, CORD, EM-RRC, EMRA, and SAEM and provides a template of educational topics for graduate Emergency Medicine educators. While the curriculum outline is provided by this document, the program director(s) decides how this curriculum will be implemented and shapes the residency program with each detail. The road to becoming a successful program director is outlined in some detail in Chapter 9 of this Academic Career Guide, “Pursuing the Residency Director Career Pathway.” In addition to an Emergency Medicine residency program director, academic emergency physicians who have focused their careers on a subspecialty may consider a career as a fellowship director (Toxicology, EMS, Ultrasound, etc…). Many of the same considerations and characteristics are vital to this role with varying differences depending on the subspecialty and fellowship structure.

A great deal of opportunity for educational research in Emergency Medicine exists. EM provides a unique educational environment with a wide range of urgent presentations, diverse interactions, and an emphasis on decision making. Development of decision making skills, understanding of the ED in the context of the healthcare system, and educational benefits of simulation technology represent just a few examples of opportunities to design unique educational experiences and document educational outcomes.[9] Emergency Medicine is fertile ground for anyone interested in conducting quality educational research.

Finding the Right Mission Many universities are recognizing the need for excellent clinical educators and are developing promotion tracks with this in mind. However, one must be mindful of the written and unwritten value systems established at the proposed workplace. Variables such as educator expectations, contract details, promotion opportunities, and the overall mission of the learning environment must be examined. Boyer’s concept of “expanded scholarship,” in which educators are responsible for dissemination of newly discovered original research, may be the backbone of a teaching career. But in reality, advancement within an academic institution is much more complex.[10] Many universities have differing opinions of the role of the clinical educator in academic Emergency Medicine. Achieving tenure at most institutions may be a complex model of objective and subjective requirements. The best reference is usually the department chair of EM and/or mentors to determine the specific variables of advancement through the ranks.

Educational Research In addition to exemplary teaching skills, many institutions have standards for scholarly productivity for success in an academic career (even if teaching is the focus). Many job descriptions will include expectations of peer-reviewed publications, textbook chapters, and/or grant funding. Beyond the requirements of the institution, educational research should be of great importance to those focusing your academic careers around education. You will be expected to design effective educational programs for residents, students, nurses, EMS personnel, or patients. Educational research allows for the advancement of medical education with the discovery of new ideas, validation of the product, and dissemination to the education community through peer-reviewed publication.[8] 19


Perhaps the most critical step in finding the ideal environment to establish a career in EM education is the evaluation of the overall mission of the proposed institution. The importance of finding a faculty and institution that values clinical teaching, with promotional tracks that reflect this belief, may be foremost in your job search. Careful planning by the proposed faculty member with the chair of the department determines if his or her skill set matches the academic reality of the institution.[2] Make sure that the tenure track does not include requirements in grant writing, clinical research, and peer-reviewed publications if your future practice scope does not include such aspirations.[2] Finally, closely examine the clinical-educator track to determine whether or not it ends in tenure at that institution.

This makes it difficult for faculty to define academic roles and identify mentors. However, graduates of a faculty-development program for medical educators identified “having a mentor” to be the most positive influence on their career development. They stated that the lack of a mentor was felt to be the factor with the greatest negative impact on their careers.[13] The positive news is that when promotion criteria was assessed at several U.S. and Canadian medical schools, clinician-educators’ roles were valued by those institutions.[14] But in 2003, Jackson et al. once again identified the lack of a mentor as one of the most important negative factors hindering career progress in academic medicine.[15] Junior faculty who wish to succeed and be promoted as clinician-educators should actively seek out mentorship.

Faculty Development Opportunities – Becoming an Accomplished Teacher

Farrell et al. provide an outline of how to embark on a mentoring relationship as a clinician-educator.[16] The authors state that: 1) Potential protégés must first perform a critical self-assessment. You should reflect on your educational skills and define your career goals while becoming familiar with expectations and promotion requirements that apply to the path you have chosen. 2) Once you have reflected on your current strengths, you must identify which academic role needs developing and select a content area on which to focus. These decisions may be influenced by how your institution assesses the educational scholarship of academicians with teaching as a focus.[14] 3) Once the academic role and content area of focus has been determined, you must identify potential mentors. Potential mentors in medical education should be recognized teachers who have established commitment to mentoring activities. Finding the right mentor may involve active networking within and outside your department and institution. 4) When potential mentors have been identified, you must approach them demonstrating seriousness about your career aspirations. When inquiring for advice, you should start with concrete, practical tasks and questions. A rewarding mentoring relationship may indeed be the most important factor in developing a successful career as a clinician-educator.

Once you have decided to commence upon a career in academics with teaching as the focus, you should first define your long-term career goals and aspirations. This should include a vision of an ideal faculty position and consideration of specifics such as what percentage of time to devote to various aspects of the job (i.e., direct patient care, medical student or resident education, administrative tasks, research, writing, committee work).[11] The answers to these questions will help determine the best approach to becoming a more accomplished teacher. Resources available include short courses and workshops to advanced degree programs and fellowships. There are many national and local programs available to develop teaching skills. Many universities offer programs in medical education for their own faculty and it is important to take advantage of these local opportunities. Faculty development courses are also offered during regional and national meetings of the Emergency Medicine organizations (SAEM, CORD, AAEM, and ACEP). Some more in depth venues to develop teaching skills are available in courses and fellowships lasting multiple days to weeks to years. While many skills to be an exemplary teacher can be learned on the job and with attendance of the courses above, an advanced degree is a way to develop proficiency rapidly. In addition, a graduate student develops contacts with graduate faculty and other students that can lead to new ideas, collaborations, and other opportunities. And finally, an advanced degree may serve as an additional credential, providing credibility in a competitive academic world. Conners discusses advantages and possibilities of advanced degrees for academic emergency physicians.[12] He considers public health, administration, and education in some detail and provides links to sites with lists of available programs and rankings.

Promotion and Tenure Clinical Track vs. Tenure Track Many institutions offer duel tracks of employment as faculty physicians (clinical track and tenure track), while others only maintain the tenure track. Institutions with the clinical track and the tenure track typically have different expectations/ requirements depending on the track chosen. Those focusing on teaching in the “clinical track” will be required to demonstrate excellence in teaching to achieve promotion but will have significantly lesser requirements in research and service than those on the tenure track. In addition, some institutions consider the clinical track less of a “high stakes game” than the tenure track. Dismissal can occur if promotion and tenure is not achieved at the expected time. Remember that objective criteria for success as a teacher (clinical or tenure track) have not been universally defined or applied by promotions committees. Each

Mentoring Relationships for the Clinician/ Educator Objective criteria for success as a clinician-educator have not been universally defined or applied by promotions committees. 20


academic institution is different in its criteria for advancement as compared to other institutions and differences likely apply even within the institution depending on the clinical and tenure tracks.

References 1.

Russi, C. and G. Hamilton, A Case for Emergency Medicine in the Undergraduate Medical School Curriculum. Academic Emergency Medicine, 2005; 12(10): 994-998.

Local Values

2.

Hobgood, C. and Y. Calderon, Teaching as the Foundation of an Academic Career, in Academic Career Guide. 2000, SAEM and EMRA.

3.

Hayden, S., Developing a Career in the Scholarship of Teaching as a Clinician-Educator, in Faculty Development: SAEM/AACEM Faculty Development Handbook, Society for Academic Emergency Medicine.

4.

Cydulka, R.K., C.L. Emerman, and N.J. Jouriles, Evaluation of resident performance and intensive bedside teaching during direct observation. Academic Emergency Medicine. 1996; 3(4):345-51.

5.

Education, A.C.f.G.M., Emergency Medicine Guidelines, in Residency Review Committee. 2005.

6.

Allison, E.J., Jr., et al., Core content for emergency medicine. Task Force on the Core Content for Emergency Medicine Revision. Annals of Emergency Medicine. 1997; 29(6):792-811.

7.

Force, E.M.R.T., et al., The Model of the Clinical Practice of Emergency Medicine: A Two - Year Update. Academic Emergency Medicine, 2005; 12(6):543-558.

8.

Coates, W.C. and G.J. Kuhn. Educational Research in Emergency Medicine. in Society for Academic Emergency Medicine Annual Meeting. 2004. Orlando, Florida.

9.

Gruppen, L. The Current State of Medical Education Research. in Society for Academic Emergency Medicine Annual Meeting. 2004. Orlando, Florida.

A thorough understanding of published institutional requirements for promotion and tenure and an appreciation of any unwritten local “value systems” is necessary when considering an appointment. Quality of teaching, evaluation methods, numbers and types of publications that are needed for advancement should be understood .[17] It is often helpful to look at what others have done to achieve promotion with teaching as their area of excellence (review successful dossiers, etc…). For those who choose a position at a university without a clinical track for clinician-educators, traditional promotion standards apply.

Documentation Criteria for promotion and value assigned to specific activities vary among medical schools. Promotion committees often value some activities over others. In descending order of importance: teaching skills, clinical skills, mentoring, academic administration, developing educational programs, nonresearch scholarship, clinical research, service coordination, and educational research.[14] It is difficult to measure diverse clinical, teaching, and scholarly activities. For example, the four most important methods of teaching evaluation cited in the same survey were awards, peer evaluation, learner evaluation, and the teaching portfolio.[14] It is vital to keep up with everything: all education endeavors, teaching evaluations, any and all awards, and evidence of quality advising (publications with students or other outcomes of learners such as national boards, career choices, etc…). Promotion and Tenure Committees are interested in evidence that an area of special interest/expertise has been developed. Evidence of this comes with participation in committees, presentations at local, state, and national conferences, and invited lectureships. Such committees value course development or course enhancement locally and in leadership roles with professional associations.

10. Boyer, E., Scholarship Reconsidered: Priorities of the Professoriate. The Carnegie Foundation for the Advancement of Teaching. 1990, San Francisco: JosseyBass. 11. Stern, S., Fellowship training: a necessity in today’s academic world. Academic Emergency Medicine. 2002; 9(7):713-6.

The promotion and tenure process can be very complicated and it is incumbent upon individual faculty members to identify mentors to guide you through the academic promotion and faculty development scheme. It is unlikely that one individual can provide all the advice needed in all areas (teaching, research, etc…). The department chair provides ongoing support as an advisor and advocate while monitoring academic progress but cannot alone guide each faculty through this entire process while guiding the department as a whole.[17]

12. Conners, G., Advanced Degrees for Academic Emergency Physicians, in Faculty Development: SAEM/AACEM Faculty Development Handbook, SAEM, Editor. 13. Marks, M.B., Academic careers in medical education: perceptions of the effects of a faculty development program. Academic Medicine. 1999; 74(10 Suppl):S72-4. 14. Beasley, B.W., et al., Promotion criteria for clinicianeducators in the United States and Canada. A survey of promotion committee chairpersons.[see comment]. JAMA. 1997; 278(9):723-8.

Conclusion An organized and methodical approach has been presented to help guide the interested reader through the obstacles facing a clinical teacher. These obstacles can be navigated successfully resulting in the realization of a successful and productive career.

15. Jackson, V.A., et al., “Having the right chemistry”: a qualitative study of mentoring in academic medicine. Academic Medicine. 2003; 78(3):328-34. 21


16. Farrell, S.E., et al., Mentoring for clinician-educators. [Review] [28 refs]. Academic Emergency Medicine. 2004; 11(12):1346-50. 17. Coates, W.C., et al., Faculty development: academic opportunities for emergency medicine faculty on education career tracks. Academic Emergency Medicine. 2003; 10(10):1113-7. Other Resources Web Pages The Society for Academic Emergency Medicine: www.SAEM.org, specifically the Faculty Development and Resident Sections The American College of Emergency Physicians: www.ACEP.org, Education/Graduate Medical Education The Emergency Medicine Residents’ Association: www.EMRA.org The American Academy of Emergency Medicine: www.AAEM.org, Rules of the Road for Emergency Medicine Residents and Graduates

22


CHAPTER 8

PURSUING THE MEDICAL STUDENT EDUCATOR CAREER PATHWAY By Gillian Schmitz, MD, Resident Physician, and Cherri Hobgood, MD, Assistant Professor, Associate Dean for Curriculum & Educational Development, University of North Carolina School of Medicine, Chapel Hill, NC First Year Curriculum:

Emergency Medicine educators have a unique opportunity to teach and enrich the educational experience of medical students. When individuals focus their academic career on undergraduate medical teaching, they can contribute to the educational curriculum of the medical school, become a mentor and role model, and help guide the career of future physicians. Emergency Physicians can impact medical education through didactics, procedural training, assessment of undifferentiated patients, development of critical thinking, and application of basic and advanced life support. They can also participate in educational experiences outside of the classroom to promote the growth and development of medical students and young physicians.

First aid should be the focus of Emergency Medicine education in the first year of medical school. This should include first aid for simple problems that do not require a great deal of background knowledge for initial management, as well as training in cardiopulmonary resuscitation and choking. This can be done via standard courses such as, Basic Life Support and Basic Trauma Life Support, or with independent learning modules. If an independent course is developed, its goal should be to teach the emergency management skills that every physician is expected to know. First year students may also be introduced to the systems of care delivery used to provide care to more than 11 million patients annually.[5] EMS systems, triage principles, and basics of disaster management may be explored by workshops, didactics or observation. Because these systems are organizational in nature, the lack of extensive medical knowledge is not a barrier to learning the basics of these systems.

Undergraduate Medical Education Background The Macy Foundation published, “The Role of Emergency Medicine in the Future of American Medical Care,” in 1995.[1] This report illustrated the surprisingly poor training US medical students receive in the fundamentals of emergency care and life support. At that time, less than 20% of US medical schools had required courses in Emergency Medicine in their curricula. To correct this deficiency, the report recommended all applicants for medical licensure have specific training in emergency care during medical school. Further, the report recommended that competency in emergency care should be assessed during the United States Medical Licensing Examination (USLME). Although faculty members from many different medical specialties could contribute to basic instruction in emergency medical care, physicians certified in Emergency Medicine were recommended by the Macy Foundation report as best qualified to be teachers of Emergency Medicine.[2]

The first year is also a time to introduce the fundamentals of the patient interview and physical examination. This may be accomplished with standardized patients or through observation of real patient interactions in the Emergency Department. In addition, many medical schools have focused courses on medical ethics and medicine and society. Courses such as these are excellent opportunities for emergency physicians to teach the ethics of emergency care and the responsibility Emergency Departments bear as a “safety net” for individuals who have no other source of medical care. Second Year Curriculum: During the second year, when most medical school curricula emphasize pathology, pathophysiology, and pharmacology, there is ample opportunity for emergency medical educators. Emergency physicians are well suited to deliver didactic lectures on many of these topics, and they provide excellent opportunities to introduce concepts unique to Emergency Medicine into the curriculum. Shock and environmental emergency cases can become teaching modules for the principles of oxygen transport and acid-base metabolism. Case studies related to alcohol, tobacco, drug abuse, violence, and injury control and prevention can be integrated into pharmacology, pathology, pathophysiology, and introduction to clinical medicine.

Currently, 35% of medical schools require an Emergency Medicine clerkship. In 2003, six major Emergency Medicine organizations collaborated to develop a standardized curriculum in EM. The Emergency Medicine Student Curriculum (EMSCG) was published in 2006.[3] The purpose of the new EMSCG is to combine and update earlier curricula into a singular uniform curriculum. The new curriculum incorporates the most current LCME requirements and discusses additional aspects of the educational model such as feedback, evaluation, and implementation.[4] Using a nationally developed and accepted curriculum as a template for undergraduate teaching activities gives Emergency Medicine educators an integrated and validated plan to present to their individual institutions. Emergency Medicine can be incorporated into all four years of medical school in a well-directed and standard manner. Faculty who desire to focus on Emergency Medicine education for medical students can find many opportunities in all facets of this curriculum description.

The second year is also a time when most schools begin a formal Introduction to Clinical Medicine course. Emergency physicians who tutor these small groups can have a dramatic impact. These tutors often become identified as lifelong role models for students and can provide important insights into Emergency Medicine as both a specialty and a career choice. 23


objectives will be met. Clerkship orientation on the first day helps organize the goals and expectations of the student. This should include job descriptions, attendance requirements, grading policies, procedural logbooks, required reading, didactic schedule, tour of the ED, and overview of the clerkship. The orientation meeting is also an opportunity to make introductions, develop rapport, answer questions, and provide an overview of the institution for visiting students.

At the end of the second year, students are eager to learn basic procedural skills such as phlebotomy, intravenous catheterization and basic airway management. Learning modules and skills laboratories focused on these techniques are well received by students as a transitional course, which smoothes the way into the third year clinical clerkships. Observational rotations based in the Emergency Department can also serve to emphasize clinical concepts previously introduced in lecture format. During this experience, the student should be exposed to prehospital care and triage.[6] Exposures such as these will develop in the student an understanding of the importance of ancillary personnel, their roles in the delivery of health care, and the importance of teamwork.

There are many different approaches to the didactic component of the fourth year elective. Student directed lectures can be taught by faculty, residents, or other students with appropriate supervision. This gives learners of all levels an opportunity to teach and improve their presentation skills and knowledge base. Adult learners are a special subset of students. Educators should strive to develop a firm foundation in adult educational theory to optimize learning. The core content should focus on common chief complaints and life threatening emergencies that students may encounter during a rotation. Educational topics can be covered in lecture format, case presentations, question and answer sessions, mock clinical cases, and problem based learning. Procedures taught in skill labs and simulator courses enhance a “hands-on” approach to learning. A variety of educational tools such as web-based radiology studies, EKG modules, and clinical pictures reinforce visual learning. A varied approach incorporating all of these methods allows the educator to tailor the learning needs of individual students. As student specific teaching has been an effective means of imparting medical knowledge,[9, 10] separate time should be set aside for their conferences. Medical students should also attend weekly conference within the department, which enables them to have contact with residents and faculty, and exposes them to other forms of didactics including review of M&M cases and mock oral boards. Independent learning and assigned reading of text chapters and review articles supplement and reinforce knowledge.

Third Year Curriculum: There are many opportunities to teach during the third and fourth years. Ideally, there should be a dedicated four to eightweek core rotation in Emergency Medicine. However, most institutions still offer Emergency Medicine only as a fourth year elective. Working within the context of your institution, clerkship requirements in Emergency Medicine can be developed in a variety of ways. Rotations in the Emergency Department, as a part of basic clerkships in general surgery, internal medicine and/or family medicine can be developed. Emergency Department shifts can be assigned to complement clinical time in other outpatient-based rotations. An independent mini-course focused on the core competencies of the directed history and physical examination, as well as basic clinical procedures such as phlebotomy, intravenous catheterization, simple suturing, and more advanced airway management could also be developed.[7] Whatever the clerkship structure, Emergency Medicine educators should take the opportunity to directly supervise student clinical activity when rotating through the Emergency Department. Fourth Year Curriculum: During the fourth year, a four-week clinical rotation in Emergency Medicine should be integrated into every medical school curriculum.[8] A complementary didactic program, emphasizing problem-oriented case management for a wide range of chief complaints, should be designed to supplement the student’s bedside learning. Advanced airway skills and cardiac resuscitation, as well as screening exams for domestic violence, alcohol abuse and injury risks should be taught. Fourth-year students are ready to evaluate undifferentiated patients in the Emergency Department where they can improve bedside clinical skills, including recognition of life-threatening conditions and treatment of a broad range of common acute problems.

Students maximize their learning by applying their knowledge at the bedside where the academician can teach the unique physiology of Emergency Medicine as only an emergency physician can. The skilled clinician demonstrates the process of decision making, illustrates the hands-on tools of the trade and the excellent communication skills that make us capable of rapidly developing the trust of patients and families. These skills are unique, separate and distinct from the classroom skills that we also seek to cultivate. In the academic Emergency Department, the interface between the classroom and the real world, academic educators teach physicians learners to become real physicians. The high acuteness of care delivered in the Emergency Department provides an unparalleled educational experience and a rich environment for clinical teaching. Yet turning each clinical case into a learning experience requires great innovation and presence of mind. Students must be under the supervision of faculty at all times, and most patients are seen and evaluated by a faculty member

Defining specific content areas for instruction and a frank assessment of the learner’s understanding of the specific topic and their educational priorities can help insure a receptive audience for the delivery of educational concepts. This definition substantially increases the likelihood that educational 24


independently of the student. This “precepting” allows the student to formulate independent thought and gives the faculty member the opportunity to provide quality assurance and focused teaching for each case. Thus, on a case-by-case basis, the student’s fund of knowledge and management skills are evaluated. This ongoing assessment of patient management competency is one of the primary responsibilities of clinical educators. There are many ways to assess competency and, in most educational systems, the evaluation method exerts a major influence on the performance of students and instructors.[11] The primary means by which most faculty members evaluate clinical competence is actually based on indirect measures, i.e. verbal presentation skills, perceived interest in learning, and the accuracy of patient assessments.[12]

The fourth year also provides an opportunity for more specialized electives such as: toxicology, occupational medicine, sports medicine hyperbaric medicine, aeromedical services and emergency medical services. If a dedicated Pediatric Emergency Department is available, an elective in Pediatric Emergency Medicine should be developed. In institutions active in Emergency Medicine research, elective research programs should be offered.[6]

Maximizing Your Student Contact Several other opportunities to interact with medical students are available during their medical school career. Maximizing your academic influence on medical students does not end in the classroom; other extracurricular activities can be developed to extend your sphere of influence. What follows is an incomplete list; not meant to be all-inclusive but to stimulate individual educators to identify these and other opportunities for involvement within in the context of their home institution.

Many opportunities for learning are available with the variety of cases and acuity, diversity of patients, complexity of chief complaints, and number of social issues that arise in the ED. Faculty must balance student autonomy and independent learning with patient safety and efficient flow within the department. Educators adapt their teaching methods based on time, degree of crowding and acuity in the department, and capability of the individual student. Faculty may observe the student perform a history and physical to assess their skills, thought process, and bedside manner. Students may improve these skills by observing the attending re-evaluate the patient.[13] Depth of knowledge, organization, and clinical judgment can be assessed through patient presentations, differential diagnoses, and formulation of assessment and plan. Students should be encouraged to develop their thought process as educators provide timely and useful feedback. Medical students can improve their procedural skills through observation and participation in resuscitations and codes with direct observation of faculty supervision. Faculty can optimize learning opportunities by selecting interesting teaching cases, pointing out interesting physical exam findings, reviewing imaging studies with the student, and encouraging literature review and background reading based on clinical cases in the department.

Career Advisor The process of selecting a career specialty can start at any point in medical school. Most medical schools assign advisors to students upon matriculation. These advisors are oriented toward the global academic development of the student.[14] Their emphasis is on the student’s interface with the general academic program and the clinical environment in the first three years. Emergency Medicine faculty should seek to become general academic advisors to students. This role is important to raise the awareness of Emergency Medicine as a career choice and contributing to the general welfare of students. It also places Emergency Medicine faculty in a position of counselor and mentor for students early in their career, a role model who few students ever forget. Most schools also offer a specialty-specific career advisor listing of faculty who are willing to mentor students. Students who develop an interest in Emergency Medicine are frequently assigned a non-Emergency Medicine general advisor. During the third and fourth year, most of these students consult their schools career advisor listing seeking faculty for specialtyspecific advice and mentoring. It is critically important that Emergency Medicine educators be available for these students seeking specialty career advice. In a study by Blumstein et al, [15] 38% of Emergency Medicine residency applicants surveyed reported receiving information only in an informal manner from an emergency physician. In addition, up to 57% of students reported receiving negative information about Emergency Medicine from non-Emergency Medicine advisors. These factors have been postulated to adversely affect entry in the field of Emergency Medicine.[16]

Emergency Medicine Subinternship Emergency Medicine Acting Internships should also be available in the fourth year. These should be designed for those students interested in Emergency Medicine residency training. The basic principles and experiences for an acting internship would be similar to those outlined for a required fourth-year rotation. However, students would be expected to perform with a higher level of clinical skill, especially if they have already completed an Emergency Medicine rotation. Students that possess a good working knowledge base can apply these skills to learn the management of critically ill patients. Educators can present scenarios, mock cases, and human simulation to recreate time pressure and sense of urgency. Students can continue to develop critical thinking, rapid diagnosis and management, and procedural skills.

Career guidance should include preparation for an EM rotation, assistance with location and number of EM rotations, and advice on ways to make positive impressions. Students from institutions without an EM residency in particular will likely 25


Medicine educators. The students are interested and eager to learn more about the specialty. Your tutelage can provide broad exposure to the many areas of Emergency Medicine practice and help students expand the focus of the established Emergency Medicine curriculum. Interest groups can develop skills labs, lecture series, community outreach projects, and career days to further the goals of a broad based Emergency Medicine education within the medical school. Giving basic introductory lectures and practice labs that students can enjoy without the pressures of exams or grades is a great opportunity for all involved to learn more about Emergency Medicine in a relaxed and collegial atmosphere. Clinical skills such as suturing, splinting, and BLS can be taught in little time and at low cost and can be geared towards medical students with varying training levels and fields of interest.[23] Support is available for interest groups through SAEM’s Emergency Medicine Medical Student Interest Group Educational Grants. These grants are offered yearly to support educational activities or projects related to undergraduate education in Emergency Medicine. EMRA also provides two local action grants per year, available to Emergency Medicine Interest Groups that wish to perform community outreach projects. In addition, EMRA provides resources to help faculty and students start and maintain an interest group. Ideas for activities and links to all established Emergency Medicine Interest Groups can be found on their web page. Resources such as these can help faculty guide the development of an active and stimulating interest group, which becomes an opportunity for institutional networking and provides a relaxed educational venue.

need advice on obtaining helpful letters of recommendation, the residency interview process, and the match. A realistic assessment of the student’s capabilities and interests should be discussed to determine the number and types of programs an applicant should consider. The career counselor should also create an honest depiction of the benefits and frustrations or our chosen field so that the student can make an informed decision when considering Emergency Medicine as a specialty.[17] Faculty career advisors have a wealth of resources available to help them facilitate student decision-making. Faculty can make themselves available to students through established mentoring programs or informally through the dean’s office or EM interest group. For students who need additional career advice or do not have access to an EM advisor at their school, the SAEM Virtual Advisor Program can be an additional resource. Virtual advisors are experienced individuals who provide information electronically on frequently asked questions, clerkships and careers in EM, and personalized advice on the application process.[18] Mentoring Mentoring is an ancient concept that has undergone recent revitalization. It has recently been defined as “an intentional process of interaction between two individuals that includes nurturing to promote growth and development of the protégé”.[19] A mentor is more than just a role model; he or she has an active role in the future and career development of a student. A number of studies have consistently demonstrated that individuals with supportive mentors have greater job satisfaction and greater productivity.[20] A mentor can, in fact, be the primary influence on career selection. This is especially true for women and underrepresented minorities in academic medicine, although there is a paucity of available mentors.[21] Although our field attracts more women and minority faculty than other competitive specialties, there are currently fewer of them with high-ranking academic positions. Many major EM organizations are now targeting underrepresented minority medical students through early clinical exposure to Emergency Medicine and mentorship for career development. As the number of female and minority applicants grow, more experienced academicians will be needed for mentorship and career guidance.

Clinical Research Clinical research provides an opportunity to teach students the fundamentals of research methodology while addressing issues of clinical importance to Emergency Medicine. Faculty members can offer summer programs, research electives and extracurricular projects to students interested in developing this skill set. There is a well-documented need to develop educational processes that teach the fundamentals of research.[24] Top training priorities, which have been identified, are: study planning, problem identification, hypothesis development, and proposal writing. There is an educational need to provide broad research training which addresses improved proposal-writing skills and the initiation and planning phase of a study. During the research experience, the student should be exposed to additional principles of research including: data collection, basic statistical analysis, and manuscript preparation. Incorporating the student into a proposed or ongoing research study may accomplish this training. Student research projects should be well organized and designed to allow the novice researcher to achieve progress throughout the project. This requires that the experience and the project be tailored to a realistic expectation of both the student and faculty member’s time allocation. Small or pilot projects should be developed which can easily be completed in the time available.

The investment of time and energy in mentorship of medical students is rewarding and will shape the future leaders of our field. The mentorship relationship can evolve throughout an individual’s career to define personal and professional goals and provide continuous feedback and support. Ideally all physicians, regardless of experience and stature, should be part of this mutually fulfilling relationship with lifelong benefits of education and personal development.[22] Interest Group Advisor Becoming an advisor to an Emergency Medicine Interest Group can be an excellent opportunity for Emergency 26


Journal Clubs

determine if their skills are improved; if not, perhaps you should reevaluate your teaching techniques. Above all, be open and receptive to continuous improvement of your skills as an educator. If you do, lifelong personal learning, as well as the satisfaction that comes from contributing to the knowledge of your students, will reward you.

Providing an excellent journal club experience is a low-stress method for teaching important clinical concepts, reviewing the literature and even teaching students evidenced based techniques. In a small controlled trial, Emergency Medicine residents were taught critical evidence-based literature appraisal skills during a journal club experience.[25] Although evaluation of these skills did not demonstrate a significant improvement over a control group, the trend was toward enhanced evidence-based decision-making and literature evaluation. No matter how you structure your journal club, the open dialogue and relaxed approach to problem solving is a fun and easy way to teach important clinical concepts.

Conclusion Many opportunities exist to help you build an academic career focused on teaching medical students. The rewards of an academic career are numerous. You will enjoy the benefits of lifelong personal learning and develop a successful personal career. If you truly love to teach and seek the daily challenge of creating an environment where education is of paramount importance, then a career in Academic Emergency Medicine is for you. You will contribute to the betterment of your students, the institution, and the specialty.

Web-Based Learning Web-based learning is becoming a way of life in almost all academic institutions. Educational projects ranging from lectures and independent study programs to a broad range of assessment activities are now web based. The World Wide Web has provided an ideal medium for the continuous updating of educational materials and curricula allowing these documents to become truly dynamic and an excellent resource for educators.[26] As the speed of Internet access increases other media applications including sound files, video streaming images and 3-D graphics will become better integrated into teaching modules allowing improved platforms for teaching. The use of search engines to query the Emergency Medicine literature has made evidence-based teaching at the bedside a reality and revolutionized clinical teaching. These innovations have not replaced the excellent clinical teacher, but they have significantly augmented the arsenal of tools we have in our armamentarium of teaching techniques. The development of our own search skills, as well as teaching these critical skills to our residents and students, is an important educational activity that will help ensure the use of evidence based techniques in our graduates.

References:

Becoming a Better Educator As with all things “practice makes perfect.” Becoming an excellent educator is no exception. If you plan to make education a primary focus of your career, you should practice your skills as a teacher and work to develop yourself along those lines. You must read educational texts and go to courses that teach educational skills. Good examples of these courses are the ACEP Teaching Fellowship, the CORD Faculty Development Conference, and the educational track at the SAEM Annual Meeting. The American Association of Medical Colleges also offers courses designed to improve your professional skills. In addition, you must actively seek feedback on your lectures and your bedside teaching skills. When you get this feedback, take it seriously and work to improve your ability to transmit information in a clear and meaningful way. Identify someone who gives excellent lectures or emulates qualities you value in education and ask them to mentor you, or to come and hear you teach and provide a critique. Evaluate your students and

1.

Bowles LT, Sirica CM (eds). The Role of Emergency Medicine in the Future of American Medical Care. New York: Josiah Macy Jr. Foundation, 1995.

2.

Ibid.

3.

Manthey, D et.al, Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide. Report of the Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide. Ann Emerg Med. 2006; 47(3):e1-e7.

4.

Ibid.

5.

LF McCaig and CW Burt. National Hospital Ambulatory Medical Care Survey: 1999 Emergency Department Summary, National Center for Health Statistics, Hyattsville, MD (2001).

6.

Lawrence LL, Counselman FL, Gluckman W, Guidelines for Undergraduate Education in Emergency Medicine. ACEP Online www.ACEP.org

7.

Ibid.

8.

Burdick W, Jouriles N, D’Onofrio G, et al. Emergency Medicine in undergraduate Education. Acad Emerg Med. 1998; 5 (11)1105-1109.

9.

Binder L, Scragg W, Chappell J, Gelula M. Augmenting the critical care data base of junior medical students with an emergency medicine lecture curriculum; a controlled study. J Emerg Med. 1990; 8: 211-4.

10. DeBehnke DJ, Shepard D, Ma OJ. A case-based emergency medicine curriculum for senior medical students. Acad Emerg Med. 1995; 2:915-22. 11. Langsley DG. Medical Competence and Performance Assessment. JAMA. 1991; 266: 977-80. 27


Books

12. Cydulka RK, Emerman CL, Jouriles NJ. Evaluation of resident performance and Intensive Bedside Teaching during Direct Observation. Acad Emerg Med. 1996; 6(4): 345-351.

Rx for Medical Faculty Development Series. A softbound book series dealing with topics pertinent to the medical educator. For list of topics contact: Dr. Neal Whitman, University of Utah School of Medicine, Department of Family and Preventive Medicine, 50 North Medical Drive, Salt Lake City, Utah, 84132.

13. Kelly AM. Getting more out of clinical experience in the emergency department. Emerg Med. 2002; 14:127-30. 14. Binder LS, DeBehnke DJ. The Importance of Being Earnest----and Student-centered. Acad Emerg Med. 1998:5 (1)103.

The Springer Series on Medical Education. A hardbound series covering a wide range of topics on medical education including bedside teaching, lecturing, and creative teaching. Published by the Springer Publishing Company, 536 Broadway, New York, New York.

15. Blumstein HA, Cone DC Medical student career advice related to emergency medicine. Acad Emerg Med. 1988; 5(1): 69-72. 16. Ibid. 17.

Garmel GM. Mentoring medical students in academic emergency medicine. Acad Emerg Med. 2004; 11:13511357.

18. Society for Academic Emergency Medicine, Virtual Advisor Home Page, medical Student Advisor Program. Available at http://saem.org 19. Garmel GM. Mentoring medical students in academic emergency medicine. Acad Emerg Med. 2004; 11:13511357.l 20. Paice E, Hears S, Moss F. How important are role models in making good doctors? BMJ. 2002; 325:707-710. 21. Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T. Having the right chemistry: a qualitative study of mentoring in academic medicine. Acad Med. 2003; 78:32834. 22. Garmel GM. Mentoring medical students in academic emergency medicine. Acad Emerg Med 2004; 11:13511357. 23. Pitre CJ. The unique educational value of emergency medicine student interest groups. Journal of Emerg Med 2002, 22: 427-428. 24. Supino PG, Richardson LD. Assessing Research Methodology Training Needs in Emergency Medicine. Acad Emerg Med.1988; 5(1): 69-72. 25. Basarian JJ, Davis CO, Spillane LL et al. Teaching Emergency Medicine Residents evidence based critical appraisal skills: a controlled trial. Ann Emerg Med. 1999; 34(2): 148-54. 26. Savitt DL. Implementation of a hypertext based curriculum for emergency medicine on the world wide web. Acad Emerg Med. 1997; 4 (12): 1159-1162.

28


CHAPTER 9

PURSUING THE RESIDENCY DIRECTOR CAREER PATHWAY By Carey Chisholm, MD and Kevin Rodgers, MD, Indiana University School of Medicine, Indianapolis, IN

A career as an Emergency Medicine (EM) Program Director (PD) is a very demanding one involving a potentially overwhelming number of tasks and responsibilities. It can also be a very gratifying career choice considering the positive impact you exert on the next generation of emergency physicians. Unfortunately, there are no well-developed, formal training programs or fellowships in EM for those considering this career pathway. Currently, most PDs receive their initial “training” via mentorship while serving as a Chief Resident or Assistant PD. In an attempt to bridge this “training gap,” the Council of Residency Directors for Emergency Medicine (CORDEM) developed the PD’s Monograph and the New Program Director’s Workshop. While both of these resources provide training in a variety of PD skill sets, neither is comprehensive. This lack of formal training is not unique to EM. Only the American Academy of Family Practice has attempted to provide more formal training through their own National Institute for Program Director Development, which provides a nine month fellowship (on and off site) for aspiring PDs.

will also provide a template for “informal” training through mentorship and conferences. PDs must assure that their program is designed to meet and is in compliance with all Accreditation Council for Graduate Medical Education (ACGME) and institutional guidelines. Key to maintaining accreditation is familiarization with the mechanism of a RRC (Residency Review Committee) survey and its associated Program Information Form (PIF). Developing and maintaining a method for documentation is also essential to this process. Other administrative tasks include: creating a system for resident evaluation and feedback, resident scheduling, annual budget development and management, and insuring optimal resource utilization within the department and institution alike. PDs are also people managers and mentors. They provide guidance not only for their own residents but for their program coordinators, their faculty, and their institutional GME program as well. Excellent communication and leadership skills are essential to successful management of a program. PDs must develop a concise, comprehensive residency manual each year that delineates the expectations and rules of the program. When residents fail to comply with these requirements, PDs may be forced to mediate conflict resolution, perform an impairment assessment, or design a remediation program. Knowledge of the legal ramifications of each of these processes is crucial as well. Fundamental to maintaining a successful program is the annual interviewing, recruitment, and selection of medical students for future residency classes.

Does this lack of formal training impact the quality of program leadership and job satisfaction? Although the quality assessment is difficult to answer, an indirect assessment of job satisfaction may be crucial to PD longevity. Several papers from multiple specialties document excessive stress, inadequate training, and rapid turnover of PDs. In a recent informal survey of EM PDs, 69/83 PDs had been in the job less than 3.5 years and had spent less than 2.5 years as an assistant PD prior to assuming the PD job. Based on this incredibly high turnover rate and the lack of formalized training for PDs, it is critical that anyone selecting this career pathway have a well-developed plan for acquiring the necessary skill sets.

On an educational level, the PD must create and implement a clinical and didactic curriculum. The Model of the Clinical Practice of EM (available at www.saem.org) serves as template for curriculum development. Essential to maintaining a dynamic educational program is designing a process within the residency that continually assesses both clinical (rotation) and didactic (lecture, small group, laboratory, reading) quality as well as searching for new opportunities to enhance training. To insure comprehensive training in all facets of emergency care, PDs must establish a database that tracks all resident educational endeavors. This documentation is important for the RRC review, state medical licensing, ABEM certification and medical staff credentialing.

Prior to entering the PD pathway, one must first make the successful transition to an academic career as these same skill sets (clinical teaching, research, academic writing, evidencebased medicine, presentation and communication skills) are invaluable to the PD. Residents and faculty considering a career as a PD should first explore the requirements of an academic career by reading Chapter 3 (Choosing Academics, and How to Plan Your Residency), Chapter 5 (The “Academic Skill Set”), Chapter 6 (Creating a Healthy Career- Time Management, Wellness, and Mentoring), and Chapter 7 (Teaching and Education- Academics as a Clinical Educator).

The Job

PDs must also maintain their own professional development and often oversee the faculty development within their academic department. This includes being involved in scholarly activities such as research, academic writing, national didactic presentations, or serving as editors or manuscript reviewers for EM journals. PDs must actively contribute to the

The first step of job exploration is to understand the components of the PD’s job. PDs perform a combination of educational, administrative, personnel management, and professional development tasks on a daily basis. Because of the lack of standardized training, recognizing these components 29


development of their specialty via their active participation in EM organizations. These endeavors also provide an excellent opportunity to network with other PDs and leaders in EM. On a personal level, development of their computer, time management, and wellness skills will undoubtedly contribute to their longevity.

director remains on average under five years in duration, reflecting the innate stressors associated with the position. There is a recipe for success that involves three distinct components: superstructure, infrastructure, and time management skills. Program directors lacking one of these are unlikely to find career success or longevity.

Finally, PDs must be forward thinkers. Maintaining a program that meets the expectations of its residents requires not only assessment of the current components but strategic planning for the future as well.

Infrastructure Conceptually, this involves the Chair and milieu of the medical school/sponsoring institution. Without strength in these roles, critical resources are often missing. This places the PD in a position of sacrificing educational possibilities, and limits the potential for innovation and development. The key elements of infrastructure include finances, access to local development resources, and local expertise to assist in the management of inevitable and predictable individual resident needs. Another key component is the Chair’s role in interdepartmental conflict resolution surrounding curricular and educational issues. Without strength in this position, the PD is likely to be forced to compromise service needs at the expense of educational opportunities. Distribution of access to invasive procedures, and attendance of EM didactic sessions during off-service rotations are examples. In addition, it is absolutely critical that the Chair reflect and support the residency program’s needs regarding faculty responsibilities.

Job Preparation for Residents and Faculty Residents exploring a career as a PD should access every academic opportunity their residency program has to offer. This will not only help them decide whether an academic career is a good fit but will provide an excellent foundation as well. Several residencies now offer academic electives (see Resources for an Academic Elective, SAEM GME Committee, SAEM website) in order to expose residents to the nuances of an academic career (i.e. Promotion and Tenure). Obviously, the optimal experience for a resident exploring the career as a PD is that of Chief Resident (CR). CRs are exposed on a daily basis to the internal workings of their residency and commonly begin to develop the administrative and personnel management skill sets required of a PD. Serious candidates should develop a formalized mentor relationship with their PD so that a concrete plan can be developed that provides exposure to most of the aforementioned components of the PD’s job. Involvement with national EM organizations (specifically SAEM and CORD) and attendance at their scientific meetings provides an opportunity to network with like-minded individuals and enhance their academic foundation as well. Of special interest is the spring CORD meeting. This meeting is a combination of Navigating the Academic Waters (for aspiring academic faculty), New Program Director’s Workshop, and Best Practices (for PDs). This is as close as EM comes to formal training for PDs.

Obviously, inadequate financial resources will adversely affect the PD’s ability to maximize the developmental atmosphere for the residency. Without the institutional and departmental commitment, the infrastructure cannot be maintained. Obvious components include the size of the faculty, ability to finance resident scholarly activities, and to send residents and the program leadership to regional and national meetings. However, many “amenities” that allow a program to transform from an impersonal workplace to a focused team rely on this financial commitment. Examples include uniform and meal allowances, parking, benefit packages, recruitment assistance, text and computer resources, and social gatherings. Cash-strapped PD’s will struggle to keep ahead of the national trends in EM education, and possess less collateral to sooth the inevitable annoyances residents encounter in their day-to-day workplace.

Faculty considering a career pathway to program directorship should seek an Assistant PD job in a program with an established PD who is willing to mentor. This provides the best opportunity for mentorship. In addition to the annual CORD meeting, they should take advantage of any training offered by their own institutional GME office as well as national ACGME conferences. Additional resources for training include the annual American College of Emergency Physicians/Emergency Medicine Foundation Teaching Fellowship as well as universitybased degrees in education. In addition to EM journals, Academic Medicine is the primary journal for publication of educational research in the US.

Institutional resources are also critical for assistance in resident remediation, impairment assessment, database access, faculty development skills, and opportunities for general resident education such as professionalism, teaching skills, and “merit-badge” courses. Without these, the program leadership shoulders the burden alone. A single “problem resident” can consume the focus of a program director for weeks when lacking institutional assistance. Access to expensive new technologies (e.g. ultrasound machines and simulation labs) depends upon institutional support.

Career Longevity Items: Recipe for Success

Finally, access to space is important. Office space, conference rooms, resident offices/lounge and proper work environment for the administrative staff are all crucial to a well-run program.

The job responsibilities associated with the program director position are seemingly endless. The tenure of an EM residency 30


Superstructure

notably preparation for a successful RRC-EM site visit. Once accomplished, the assistant has the option of a career move to program director at another institution (or succession), or can become an associate PD at one’s own institution. At such a point, the leadership dynamics can change to more of a team effort. While the RRC mandates a single “director” in such a setting, the leadership is completely interchangeable, each capable of independently operating the program. This assures a consistency and smoother operation during temporary transitions such as maternity leave or temporary leadership commitments in EM organizations.

This encompasses the actual program leadership team and administrative support. A key role is the residency coordinator (RC). Simply stated, this individual makes or breaks the program director. Responsibilities include the day to day administrative components (including all of the program, institutional, ACGME and other reporting forms), as well as correspondence. Oftentimes, this individual serves as a de-facto resident counselor, particularly during the transition period between medical school and the end of the first postgraduate year. The RC may be best positioned to recognize early warning signs of pathologic stress or impairment in a resident. There are often local as well as national resources available for RC development.

Personal Organization Skills In a job without boundaries, one either sets them or becomes consumed by the position. While problems in infrastructure or superstructure certainly account for many PD transitions, much PD burn-out likely resides here. Formal time management skills training is mandatory for those who wish to pursue a lengthy career as a PD.

The second critical component is secretarial resources. The volume of paperwork associated with a residency program has grown tremendously over the last decade, reflecting local and national requirements. The number of forms and letters associated with the credentialing process of a graduate serves as one example. Maintenance of resident files (electronic or paper) is another key responsibility and continues to grow in complexity.

The RRC-EM recognizes the importance of protected time from clinical activities, and has placed a maximum number of acceptable hours. While this may allow a program with strong infra- and superstructure to meet basic operational requirements, PDs scheduled at the RRC maximum will invariably lack the time for innovation and development of the program, and will unlikely continue in the position for many years. Twenty hours per week is doable, 16 hours adequate and 12 hours is ideal. PD’s also must learn to incorporate protected time blocks into their schedule, such as the day following an overnight shift. Offset office hours, so that a portion falls before or after regular hours, allows uninterrupted work time (this favors the early risers, as one is seldom missed at home at those times). Finally, “workfree” days and vacations are critical for career longevity.

The third component of the superstructure is the faculty. Without dedication to the residency mission, the program is doomed to poor clinical teaching and even worse formative and summative feedback for resident growth and evaluation. The faculty not only serves as the backbone for clinical teaching, but provides critical mentorship, counsel, and didactic curriculum support. They are critical in assisting with individual resident remediation programs. Their role must be codified by the Chair who assures accountability and documentation to assist promotion efforts. Failure to do so sets the entire faculty towards a “regression to the mean” in which there are no rewards for commitment, and no penalties for non-participation. Providing shift evaluation, attending didactic sessions, or high quality curriculum efforts serve as examples.

A key skill is the ability to translate the annual cyclic program calendar into an action plan permitting fewer peaks and troughs of mandated activity. This permits realistic scheduling of didactic, scholarly and personal time. Predictable events are listed in Table 1. The most critical is the interview season, which serves as an emotional and time drain that only PDs fully appreciate. However, mid and end-of-year formal evaluations can also create significant time sinks. Planning a scholarly activity, travels or other commitments during these times requires careful planning. Buffers must accompany deadlines in order to accommodate invariable unforeseen circumstances. The art of “retrograde planning” is valuable (starting with a firm deadline, breaking a task into component parts, and then planning each into one’s schedule).

The fourth component is the program leadership. This structure will vary according to the size of the residency, but at bare minimum must consist of a director and an assistant. Due to the high turn-over, both roles are often filled with relatively junior faculty. In such settings, it is mandatory that the Chair and institution provide mentoring support and adequate time to assimilate the many required tasks. By default, the program director’s responsibilities include the development of the assistant program director(s). In a setting with multiple training sites, the assistant PD may simply function as a glorified site coordinator. This leaves the program vulnerable to turbulence in the event of PD turnover. It is our belief that the PD should work to develop the assistant PD toward the goal of being capable of independently leading a residency. This is a 4-5 year process, and is not complete until the assistant can perform all of the required components of residency management, most

Delegation of tasks is a learned skill, and is particularly problematic for more junior PDs. The desire to micro-manage the process doesn’t easily diminish, but is critical to learn. Chief residents, the Residency Coordinator, and faculty fulfill important curricular and administrative roles maximized by 31


Table 1: The EM Residency Director’s Annual Calendar

effective delegation. For success, the PD must provide the resources, conceptual boundaries and authority, then step aside. The process should undergo monitoring without interference and incorporate timely feedback.

July: Orientation, end of year evaluations August: End of year evaluations

The “Big Picture”

September: Preparation for interview season

A PD with firm infra-and superstructure, and organizational skills must explore opportunities for innovation and change. Medicine and EM in particular, are dynamic and ever-changing. A program gravitating towards the status quo soon stagnates, as does its leadership. Changes must develop through a predictable process, and be grounded on the program’s mission and values (we have been impressed how few programs actually clearly articulate a statement of mission and values). Our program has practiced a mantra: “How can we do this better?” and “What opportunities are here that we are not fully taking advantage of?” Obviously, change involves risk, and philosophically the program must be comfortable that “mistakes” will occasionally occur. A premeditated process of change creates an evolutionary process resulting in a dynamic residency that never loses its youthful enthusiasm.

October: Open ERAS, screen applicants, and prepare invitations November 1: Medical Student Performance Evaluation letters arrive November - January: Applicant screening, invitations and interviews February: Rank list preparation, ABEM Intraining, Mid-year evaluations March: CORD, Chief Resident selection, curriculum assessment, match results April: Curriculum assessment, Block Rotation diagram

One component that proves troublesome to many PDs is the repetitive nature of the annual cycle (with interview season being the most problematic). This cyclic nature can actually prove to be a benefit, as time requirements and work load are predictable. Creative planning permits these events to be enjoyable, or rewards interwoven with more onerous tasks. For instance, our leadership takes a five day trip in mid-January in order to address the stress of interview season. Done properly, every June becomes a mixture of painful goodbyes juxtaposed with excited hellos. After all, a new crop needs to be sown, and the harvest lies 3-4 years later. The foundation of longevity in the PD role stems from the intimate participation in the transformation process of student to specialist. Our reward is the experience of watching the change from an anxious, inexperienced new resident into an accomplished EM trained physician with whom we trust the care of our own family.

May: SAEM, finalize annual didactic schedule June: Exit interviews & letters, graduation, welcome new residents

Final Thoughts Successful PDs who remain in the position for many years likely share an undying and intense interest in the medical education process and relish the interaction with learners. Their ongoing “raison d’etre” is the preparation of the next generation of EM specialists in an environment better than experienced by those who came before. Decisions are always framed from the perspective of what is in the best interest of the education of the resident… a position that periodically may place one at odds with colleagues or the administration. Conflict resolution skills, honesty, the ability to step back and examine criticism without defensiveness and the ability to admit and learn from mistakes go far in assisting long-term job satisfaction. For those who have found it, it becomes the best career pathway in all of medicine.

32


CHAPTER 10

PURSUING THE INVESTIGATIVE SCIENTIST CAREER PATHWAY: HOW TO WRITE AND BE SUCCESSFUL IN THE GRANT APPLICATION PROCESS By Thomas Fisher, Jr., MD, MPH, Instructor and Terry VandenHoek, MD, Associate Professor, Section of Emergency Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL how to resuscitate ischemic tissue at the molecular and cellular level. At the bottom line, there is a gold mine of good research questions in Emergency Medicine for those willing to ask them. These questions are keys that can open many doors at academic institutions to investigators in other fields doing related work. Get appropriate research consultation. Emergency physicians are used to working and consulting with other healthcare providers to create a diverse team of people tailored to meet the needs of any given patient. For example, it is not unusual to have discussions with cardiology, neurology, and orthopedics regarding a patient with atrial fibrillation, new focal weakness, and a hip fracture after falling at home. These same people-skills can be used to request a “research consult” about an interesting research question. For example, it would not be unusual to bring together a team of neurologists, engineers, paramedics, and emergency physicians to ask whether paramedics could induce focal brain hypothermia in stroke patients, and perhaps extend the window of opportunity for treatment with thrombolytics. If we wanted to model such a system in cellular and animal models, veterinarians and cellular biologists might also become involved. If the question relates to effects of nightshift work, there are many world-class sleep physiologists and patient safety experts who are waiting to receive a phone call or visit from an emergency physician willing to ask “how can we better adapt to night shift work?” If the question relates to how to improve screening and referral for substance abuse, then a team of social workers, sociologists, and psychiatrists/psychologists might become involved. In addition, some of the same colleagues we interact with in the Emergency Department during patient care could become important partners in research. Don’t be afraid to ask these other scientists for input on your research. Be ready to give a short presentation about your work and your research question; this will be tremendously helpful in refining your questions. It’s also fun to hear a completely different perspective on your work. One of the best experiences junior faculty will have in giving lectures about their ideas and areas of interest is the feedback received from interested students and professors from other disciplines.

“Publish or perish” is a common mantra for success in academic medicine; “Funded or farewell” may be more accurate. A long term, successful career in academic Emergency Medicine is nourished by independent, preferably extramural, grant funding of an individual’s career development and subsequent research projects. These resources provide protected time, salary, equipment, supplies, and administrative support, along with prestige. We will explore finding a good research question and follow with a discussion on grant funding in general and more specifically how and where to find such funding. Not intended to be exhaustive, this should provide an overview reference with enough detail to begin the process.

Finding a Good Research Question How do you induce a promising research career? Your area of research emphasis is an important and perhaps the most fundamental decision to make in your research career. It may determine your level of passion when you are staying up late at night to get a grant proposal finished; if it is well-honed, it will help create boundaries which will keep you focused on what is most unique about your work; and it may also determine how well you fit into the overall mission of your section, department, institution, and field. Like all important decisions, it is well worth the time and investigation you put into it. Take advantage of the unique questions Emergency Medicine faces. Emergency physicians are in a position to contribute to world-class research. We have an inherent advantage no amount of postdoctoral or PhD training can ever give--exposure to a challenging clinical practice, which is filled with individual research questions that can best be answered by our specialty. Since the Emergency Department provides medical oversight to Emergency Medical Services in the community and is open to all who seek care, these questions span many issues of health service and public health not faced by many of our colleagues. Such research may investigate how to: break down barriers to healthcare access, effectively screen and refer patients affected by domestic violence, care for the homeless or substance abuse patient, improve physician-patient communication, monitor and decrease Emergency Department overcrowding, prevent medical errors, improve resource utilization for emergency medical transport services, and improve readiness for natural and man-made disasters. Also quite unique to our field are questions of how nightshift work may affect productivity, physician wellness and health, and patient safety. There are a multitude of questions regarding rapid diagnostic and treatment strategies for medical conditions that span all other specialties within medicine. These questions may range from better diagnostic algorithms for pulmonary embolism to learning

Find the right question. There are enormous opportunities for finding out what the cutting-edge questions are in any given research area. Do you wonder why particular types of patients in the Emergency Department do better and others do worse? Despite the hectic pace and stress of the Emergency Department, it is often a rewarding question to ask such questions about even one patient. If you can, find out what your clinical consultants know and don’t know. Perhaps they are interested in the same group of patients, and are doing research to answer some of the same questions you have. Find out what the literature 33


Who Provides Grant Funding?

knows and what it doesn’t, and who in the world is focusing on the problem. Important websites that may be helpful include PubMed (http://www4.ncbi.nlm.nih.gov/PubMed). There are thousands of abstracts of reviews performed by the Cochrane group which can be searched at http://www.update-software. com/Cochrane. Other helpful links may include general search engines such as http://www.google.com or http://vivisimo.com. Ask your colleagues about search strategies they use.

The Federal government is the largest source of research funding. Grants are given through agencies such as the National Institutes of Health (NIH), the Agency for Healthcare Research, and the Department of Health and Human Services and various governmental departments and agencies that may have resources specifically relevant to Emergency Medicine like the Department of Defense or the Center for Disease Control and Prevention. Some state government agencies, such as state emergency medical services agencies, provide funding for related projects.

It’s helpful to make a list of the resources you find most helpful in knowing what is happening in your research area of interest. Key resources include journals (look at them as scientific catalogues of research possibilities--most academic institutions have a number of e-journals available, and it is helpful to bookmark the access site to those journals and try to read each month what is being published in your areas of interest), seminar series (these are usually posted at academic institutions weekly or monthly, physically or electronically) and academic interest groups (usually monthly or quarterly) relevant to your interest can also become important sources of new insights. Look around the campus so that you don’t miss a visiting professor lecture series- often an opportunity that may include internationally renowned speakers talking to groups of less than 30 people—a great opportunity to talk to some of the world’s brightest scientists. Be aware that most clinical and laboratory research groups conduct frequent meetings about research in progress—ask if you can attend some of these if the work being done is of interest to you. Being interested in someone else’s research is usually considered a great compliment. Find out what excites you, what feels important to you, and ask a lot of questions. If there are any chances to present your research interest, do it. It will help you refine your thinking about what your research focus is, and allow others to give feedback. These presentations may include anything from grand rounds for residents/faculty, to a more informal overhead presentation for a laboratory research group, or a very brief presentation on a laptop to a fellow researcher on campus.

Private foundations, such as the Robert Wood Johnson Foundation, The Ford Foundation, The W. K. Kellogg Foundation, the Commonwealth Fund and the Pew Memorial Trust, also provide many opportunities for both career development and project funds. Most foundations have a specific focus and therefore fund projects relevant to their mission. Professional organizations, like the American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Foundation, and American Heart Association have several different grant programs and are important sources of funding for Emergency Medicine research. These organizations often offer small grants for beginning investigators, and larger grants as well for specific projects. Pharmaceutical manufacturers, medical equipment manufacturers, and other private for profit businesses often fund projects related to their products by providing money, drugs or compounds, or medical devices. Of the grants available, the most prestigious and difficult to harvest are those of the NIH. NIH grants for physicians are offered via the 25 disease specific institutes. There is no “National Institute of Emergency Medicine.” One must craft a project that connects their ambition to one of the standing institutes. For example, work on HIV in the ED would be amenable to the National Institute of Allergy and Infectious Diseases. Or a study searching for better methods to stratify syncope could be sent to the National Heart, Lung, and Blood Institute.

Learning the science environment may mean talking to other faculty within your department or section to find out what research focuses exists at your particular institution. If you have a few areas of research in which you have equal interest, think seriously about pursuing the area which can best “ride the wave” of departmental and institutional momentum. To find out what funded research is happening at your own institution, a helpful website is the Computerized Retrieval of Information on Scientific Projects (CRISP) NIH database, located under “grant topics” on the NIH Office of Extramural Research homepage: http://grants.nih.gov/grants/oer.htm. You can query this site by multiple search criteria, including new and old grants funded at your institution, the name of the Principal Investigator for each grant, and the abstract of the research funded. This is a good place to look for opportunities to focus existing successful research at your institution in new creative ways on an Emergency Medicine problem. Say hello and tell them your question.

What Types of Grants are Available? The NIH provides grants for the full trajectory of an academic career: Beginning with the pre doctoral period, progressing to career development, concluding with career transition, or the founding of centers for study. F-Series-Individual Fellowships F31-Predoctoral F32-Postdoctoral F33-Experienced Fellow The F series grants provide funds for the education and training of pre- and post-doctoral training. F31 funds go to 34


support the education of individual who, if in medical school, must pursue a PhD. Post doctoral grants come in two types: F32 grants which offer an opportunity for fellows/residents with two years of training to enhance their understanding of the health-related sciences and extend their potential for a productive research career. F33 experienced scientists who wish to make major changes in the direction of their research careers or who wish to broaden their scientific background by acquiring new research capabilities. These awards enable individuals with at least seven years of research experience beyond the doctorate, and who have progressed to the stage of independent investigator, to take time from regular professional responsibilities for the purpose of receiving training to increase their scientific capabilities

T-Series-Training Grants T32-Institutional Research Training Grant T35-Short Term Institutional Research Grant Awards for institutions include the P and T series grants. P series grants fund program projects or projects closely related to a central theme that can be conducted more effectively and efficiently through a coordinated collaborative or multidisciplinary approach that utilizes common resources, facilities, and instruments. T series grants fund institutions to develop or enhance research training opportunities for individuals, selected by the institution, who are training for careers in specified areas of biomedical, behavioral, and clinical research. Private foundations and for-profit organizations frequently have specific areas of interest they are willing to fund. Various organizations offer funds that mirror the NIH in scope and scale. Refer to the individual groups for specifics.

K series-Career Development Grants K23-Patient-Oriented Clinical Research K08-Basic Scientist Development Award K02-Research Scientist Award

How Do You Write a Grant?

Career development is the second category of funding available. This series of funds awards provide resources for specialized study for individuals with a professional doctoral degree who are committed to a career in research. The goal is to cultivate the research ability of candidates such that they have the potential to develop into independent investigators. The K awards supports a three, four, or five year period of supervised research experience that may integrate didactic studies with research. They are offered for those interested in patient oriented clinical research (K23), laboratory or field research (K08), and others for mid and advanced career academic physicians. These large grants typically provide 75% salary support and funds for didactics and research. Most importantly they allow clinicians protected time to pursue research endeavors.

The pursuit of grant funding is arduous and competitive. The absolute competitiveness varies based on the source of the funds sought. In general, successful grants proposals share certain qualities regardless of their target institution or the potential research project. These qualities are: • Hypothesis driven • Fill a gap in knowledge • Fueled by strong preliminary data • Have clear attainable objectives • Highlight your strengths • Make clear potential pitfalls/alternatives

R series-Research Project Grants-Single project R01-Traditional Research Projects R03-Small Grants R13-Conference R25-Education Projects

Communicating these qualities requires the completion of the grant application in a timely, meticulous manner. The format will vary by source; government grants are usually constrained by the NIH PHS-398 form. This multi-sectioned application begins with a Face Page, which asks for demographic information such as the applicant’s name, institution, address, collaborators etc.

The crown jewel of NIH grants is the R series of single project grants. Typically the largest grants, they provide complete support for a project including salary, benefits, equipment, supplies, renovations, publications, administrative funds, consultants, travel and indirect funds for institutional facilities and administrative costs. The size and prestige of these awards allow their recipients independence intellectually, financially and institutionally.

The Abstract follows; it is a one-page summary of the entire project. The majority of the reviewers read just the abstract, with only a small subset of the reviewers assigned to read and evaluate the entire grant application. A clear, complete yet concise, tightly written abstract is essential. It is easiest to write the abstract after the remainder of the application has been written.

P series-Center Grants P01-Program project Grants P30-Center Core Grants P50-Specialized Center Grants

The body of the grant application involves describing the research plan in detail. In general, this section begins with Specific Aims. This segment is used to provide a short overview of what you aim to accomplish. A commonly implemented 35


approach begins with a paragraph providing an overview of why this project is important and continues with a statement containing the hypothesis and how it will be tested.

as secretaries and technicians available, etc.). The indirect costs are calculated as a percentage of the direct costs. Many institutions have personnel dedicated to grant writing and coordination. This office will assist in budget creation and may indicate the institutional norms for direct costs.

The Background and Significance section is used to contextualize the project within the published literature on the subject. This piece should provide a synthesis and evaluation of the current literature, leading to a discussion of the gaps in knowledge. The first paragraph in the section should be a broad view of the problem. The subsequent paragraphs often include pertinent literature leading up to why your work is important and how it will add to the field. Throughout it should be noted how and why the project will answer specific issues. To conclude, restate overall objectives.

The application concludes with Bio-Sketches or brief information on the backgrounds of key members of the research team. Along with information frequently found on a Curriculum Vita, this section should provide a listing of all the currently funded grants and pending grant applications for each investigator. Demonstrate that the investigators have sufficient time left over after already funded projects to perform this project, and show that a project similar to the grant proposal is not already being funded by another agency.

The Design and Methods section is the place to elucidate the structure of the research project. This section should provide a rationale for your approach, each specific aim and how it will be addressed. This section should be relatively detailed and make clear to the reviewer your ability to execute a plan in order to answer the questions. Pilot data is often provided in this section to convince the reviewer of the potential success of project given already completed research. The research methods are central and specific to this section. For clinical research, information on what types of patients are to be included, how they will be identified and enrolled, what will be done, and a tentative timetable for carrying out the study should be included. This section should include a statistical discussion that incorporates a statistical power analysis and a description of how the data will be analyzed.

Final Tips/Thoughts. Projects are evaluated by various criteria that at times seem to be at the whim the evaluator. When the grant is complete it should specify the following: 1. Significance and originality of the proposal 2. Adequacy of methodology 3. Qualifications of PI 4. Availability of resources 5. Reasonableness of time/budget 6. Relevance to mission of funding agency The grant is not complete until these points are described in a clear and elegant manner. Review and revision are central to the grant writing process. Have colleagues, mentors and chairs critique your proposal.

A strong application should include a realistic Limitations section. Recognize each approach will have some potential problems both in its technical execution and in the confines of how the data can be interpreted. The limitations section should address these and provide alternative approaches and conclusions.

To make your proposal easy to navigate, include only one major idea in each paragraph. Make the first sentence the topic sentence. Use headers to divide sections and introduce ideas. Let the text breathe by adding diagrams, pictures and graphs. Ample space makes the text readable and helps the reader get through an idea dense proposal.

The section on Budget outlines all the costs of performing the study, including salaries, consultant costs, equipment, supplies, travel, patient care costs, etc. Do not under budget in an attempt to make your research look like a bargain, nor is it wise to pad your budget to get the maximum amount of funding available. Agencies are looking for a well-conceived realistic budget, likely to result in successful completion of the project. Budget forms can appear complex. NIH has recently attempted to simplify budgets through its modular grant application, whereby applicants request funding in $25,000 increments, rather than preparing detailed budget forms.

Pitfalls to avoid:

Budget costs are generally divided into direct costs, or the actual costs of performing the research, and indirect costs, or the administrative costs to your institution of doing research (e.g. running an Institutional Review Board and Human Subjects Committees, having facilities and employees such

1.

Lack of new, original ideas

2.

Hypothesis or objectives are not clear or not feasible

3.

Preliminary data are poorly interpreted or does not support hypothesis

4.

Diffuse, superficial, unfocused aims

5.

Poor grantsmanship: Due to the competitive nature of funding allocation, one cannot afford to have grammatical/ spelling errors

For Corporate/for profit grants NEVER:

36

1.

Agree to an exclusionary review by the company

2.

Agree to allow the company to suppress negative data


3.

Offer quid pro quo

4.

Fail to disclose any proprietary interest in corporate research with the company in publication

Grantsmanship in Academic Emergency Medicine Kelly D. Young, MD, Harbor-UCLA Medical Center Roger J. Lewis, MD, PhD, Harbor-UCLA Medical Center http://www.saem.org/publicat/chap11.htm

It is important to appreciate that the majority of grants are not funded on the first submission. Do not despair, this is an opportunity to further hone ideas and prioritize aims. Garnering funding is central to a successful research career. Start early, stay organized, seek help, write daily, and be persistent.

Applying for a Research Grant-Administrative Overview (A Power Point Presentation, 2006) Lauren Zajac Department of Medicine, University of Chicago RO1 and R21 Proposals (A Power Point Presentation, 2006) M. Eileen Dolan, PhD Department of Medicine, University of Chicago

Other Useful Information- Federal Grants NIH applications currently are submitted in paper format, and utilize the PHS 398 forms and instructions. http://grants2.nih.gov/grants/funding/phs398/phs398.html Starting with the June 1, 2006 R21 and February 1, 2007 R01 deadline, grants will be submitted electronically using the Grants.Gov system. The NIH Office of Extramural Research website lists all available “Requests for Applications” (RFAs) and “Requests for Proposals” (RFPs) at: http://grants1.nih.gov/grants/guide/ index.html.

Further Information on federal government grants: http://grants1.nih.gov/training/careerdevelopmentawards.htm (This is the “K Kiosk”- a very helpful NIH informational site to get you started) http://grants.nih.gov/grants/funding/funding_program.htm http://www.gpoaccess.gov/fr/index.html http://www.fbodaily.com/ http://crisp.cit.nih.gov/

Information on Non-Federal grants Community of Science: Funding Opportunities Service http://www.cos.com/ GrantsNet http://www.grantsnet.org/ The Foundation Center (by subscription only; please contact Office of Foundation Relations) http://www.fdncenter.org/ The Robert Wood Johnson Foundation http://rwjf.org/applications/index.jsp

References (This chapter reflects updates and /or adaptations of the following material): Developing a Career in the Scholarship of Discovery Terry VandenHoek, MD http://www.saem.org/facdev/fac_dev_handbook/2-5_ scholarship_of_discovery1.htm 37


C H A P T E R 11

CLINICAL DIRECTOR- RUNNING AN ACADEMIC EMERGENCY DEPARTMENT By Ellen J. Weber, MD, Professor of Clinical Medicine, Division of Emergency Medicine, Medical Director, Emergency Department, Moffitt-Long Hospital, UCSF Medical Center, San Francisco, CA

Why be a Clinical Director?

Who should do it?

To be frank, being a Clinical Director does not come with a great deal of prestige. In academics, it doesn’t count for tenure-track promotions which are largely based on research productivity and teaching, and only moderately for clinicalscholar tracks. So why do it? I have only one answer: to try to make things run the way you would like them to, both within your department and outside it. Not that you are given carte blanche to do what you want, but by being the Clinical Director, you will have the opportunity (or be able to create the opportunity) to effect change within your ED and to directly lobby for changes in the hospital that will improve conditions for your staff.

You can probably guess from what we’ve already said, that if you are interested in full-time research, in running a residency program, or if you really just want to do your shifts and forget about the ED at other times, being a Clinical Director is not the right position for you. But if you are the type of person who likes to have some control over the environment they work in, enjoy a challenge, and most importantly have a vision and a passion for running an ED that delivers the safest, highest quality, and most efficient patient care, then this is the job for you.

The Job How much responsibility and for what will probably depend on the structure of the department. In most institutions, there is a nurse manager who is responsible for hiring nurses, setting nursing policy for the ED and adhering to hospital-wide nursing policy, auditing nursing charts, and making sure the facility is clean and equipped. The nurse manager may also be responsible for the clerical staff and various patient care assistants (“techs,” EMTs). The Clinical Director usually is considered responsible for managing the physician end of clinical operations – staffing, charting, protocols or standards for patient care, interactions with referring physicians, and consultants and physicians from ancillary services (e.g. radiology, lab). Handling patient complaints and overseeing the QA (quality assurance) process is also included. There is usually a great deal of overlap and joint decision making with nursing administration regarding patient flow, patient safety, handling complaints and QA issues, interactions with admitting and consulting services, and so forth. Additionally, the Clinical Director will undoubtedly be involved in any Performance Improvement initiatives coming from the hospital and inspections by the Joint Commission on Hospital Accreditation (JCAHO), and any other investigations of the department. Organizing your emergency physicians is a big part of the job. The Clinical Director often does the schedule, but a better way may be to set the rules and then farm this headache out to someone who enjoys it and has more time. It is also a good idea to have two sets of eyes on the final schedule to make sure there are no errors. Quality assurance is also a pretty big job, and you may wish to appoint a QA director just for this purpose. If you have midlevel practitioners in the ED, you will probably need physician oversight of this group. This could be the Clinical Director’s job or you can appoint someone else; don’t feel bad about delegating. Ultimately, it is still your responsibility to oversee the people you select to do these jobs, and you will have plenty else to do.

In both academic and community settings, there usually is some financial bonus to serving in this position, and it may also (or instead) result in doing fewer clinical shifts or fewer painful shifts. Since being a Clinical Director often requires you to be available for meetings during the day, the Clinical Director may do fewer overnights, for example. It also makes you far more visible to the other physicians and administrators in the hospital, so if one of your career goals is being the Chief Medical Officer, or moving into some other aspect of administration, this is definitely a good track to be on.

When should you do it? Although many academic programs give this position to a junior faculty member, I would advise against taking the position then. Although it’s flattering to know that your Chief or Chair thinks that you are doing a good job and are trusted by your fellow clinicians, this position will undoubtedly slow you down in your research and teaching productivity. If you are working in an academic institution, having some publications, a teaching award or a CV that includes university service, will increase the respect you receive from fellow faculty and with hospital administrators. If you have colleagues in other institutions that recognize your accomplishments and leadership, it is always useful in swinging your weight just a bit within your own institution. Even if you are not considering research–even if you are not in academics at all–being a Clinical Director in any hospital will bring you into interactions and negotiations with senior leadership. You will want to have had at least several years clinical experience at that hospital, have served on a hospital or medical school committee or two, and gotten some education in the politics and finances of the institution before venturing into this arena. Most importantly, because so much of the job involves asking people to accept your suggestions, and trying to get buy-in and compromise, you will want to have had some experience, and perhaps training, in working in multidisciplinary teams or committees, running meetings, and even persuasive speaking and writing.

Your next level of responsibility is in running the department. How much involvement you have in this aspect varies. The 38


Clinical Director may only wish to have input on how the nurses work with physicians at the bedside, while others take a more expansive view and will want to become involved in registration, triage, information technology, issues, designing of charts and order sheets, set up of rooms and location of equipment, the role of the clerical staff, types of medications kept in the department and so forth. Here is where you will also be doing a lot of interfacing with other members of the ED staff – nurses, techs, clerks, registration, and housekeeping. This may include fielding complaints (in both directions), attending nursing meetings (a very good idea), and attending collaborative practice meetings. You play a dual role in these interactions as a director and to some extent as the liaison from the physicians to the rest of the staff.

The most rewarding part of the job, and the most difficult, is innovating. Your experience with all of the tasks above will put you in the right position to recognize the need for change. The difficulty will be in convincing others of the need. Once you have done that, you may either mastermind the changes or appoint others to do so (keeping a close eye and gentle hand on their deliberations and final recommendation). Once a change is agreed on, you will need to create buy-in among your physician colleagues and help do the same with other members of the staff affected. You will need to supervise the change closely when it goes into effect, and do everything in your power to prevent backsliding until the change “sticks” or you all decide it wasn’t a good idea.

Qualifications

Since this discussion focuses on the Clinical Director in academic department, you will also need to interface with the Residency Program Director and the resident staff. The resident staff will be an important contributor to the manpower used to staff the department but accreditation rules govern everything from how many attending supervisors must be present to how they are supervised. The resident work rules are strictly adhered to; the Program Director will assist in coordinating the resident schedule with the attending schedule.

In addition to the enthusiasm for challenges, hard work, and making improvements, some basic skills will be helpful in this job. First, you should have worked in the department at least 35 years, and already had some administrative experience within your own department that has required you to run meetings, interact with satisfied and dissatisfied customers (even if they are your own colleagues), and work with colleagues outside of the department. It is imperative that you learn how to prepare for and run meetings well, as this is the most obvious place where your leadership skills will be recognized. Books abound on this subject and often include useful information on leadership and management strategies. Take at least one class or read books on how to get your message across. If you are not a great writer or speller, try to work on this, or at minimum have someone proofread memos and e-mails going to senior leadership. It is helpful, but not essential, that you know how to read a spreadsheet and understand things like RVU’s and CPTs, but these are things you can learn on the job.

The Clinical Director will also collect and organize data. If your department doesn’t already have to collect and track data, you need to figure out a way to track how you are doing. At minimum, length of stay (LOS), left without being seen (LWBS) rates, admission rates, and diversion times need to be followed. You will need to review these at least monthly and look for long-term trends. These will be important for assessing how good your flow is and where to make changes, as well convincing others of the needs for change and for resources. You should have a good familiarity with Excel and at least one database program.

Tips on serving as an effective Clinical Director

Finances may also be a part of your role. In most academic hospitals, physicians are on salary and there is a physician budget that entails salaries, benefits, academic accounts, and so forth. If you are on a professional fee system, you will probably need to be tracking how well your coders are coding, and how quickly and completely the bills are paid. It may also include some input into the departmental budget (usually under nursing). A large part of being a Clinical Director is interfacing with other services. This will include forwarding complaints from staff to the lab or radiology, forwarding new procedures to and from your department, or actively working on performance improvement projects such as door-to-balloon times for MI patients. Additionally, you should be involved in hospital-wide committees that look at patient flow and satisfaction, quality of care, transfers, and other matters that will impact the Emergency Department. 39

1.

Round in the department regularly (even if just for a few minutes) to allow face to face feedback from all staff.

2.

Answer e-mails and calls promptly so people know you are responsive, even if it’s to say you will think about it (see next three tips).

3.

Avoid harsh e-mails to anyone or any service when you receive a complaint. There are always two sides to the story.

4.

Don’t put anything in writing you couldn’t say to someone face to face.

5.

Don’t put anything in an e-mail that you don’t want forwarded or might be misconstrued.

6.

Use the phone more than you like.

7.

Keep the patient as the focus for any discussions, not what’s best for the doctors or the nurses.

8.

Be a nurse ally whenever possible. You will get farther in any changes you wish to make.


9.

Insinuate yourself in nursing issues frequently. Nursing is far more regimented, and they may be asked to do things that don’t really apply in the ED.

10. Keep the needs of your department visible by getting yourself or another ED physician on as many hospital operations committees as possible. 11. Show up at hospital social events.

A few recommended readings (all available in paperback): Hardball for Women. Pat Heim with Susan Golant. (Plume/ Penguin) Although this book is written for women, men can learn an awful lot about making their way to leadership. Highly recommended. How to Make Meetings Work. Doyle and Straus, 1986 (Jove) I’ve read several of these and this is so far the best I’ve come across. One Minute Manager – Blanchard and Johnson, 1983 (Berkley Trade) A classic and quick read. In its 10th printing. Good to Great. Jim Collins, 2001 (HarperBusiness) The original was written for businesses, but there is a new monograph on applying the principles to the Social Sector. Very useful.

40


CHAPTER 12

ASSISTANT PROFESSOR LAYING THE FOUNDATION FOR AN ACADEMIC CAREER, THE EARLY ATTENDING YEARS By Jedd Roe, MD, MBA, CPE, Chair, Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI

need to revisit your long-term vision periodically to see if it is still compatible and synchronized with your other life goals.

Congratulations! You’ve become a junior faculty member in Emergency Medicine. “OK”, you say to yourself. “Now, what?”

“Work on interpersonal skills – communication style, confrontation skills – no matter how sharp your clinical acumen; if you cannot relate to others, you will be your own worst obstacle for career advancement.” -John T. Finnell, MD

Many of us began this phase of our careers with exactly this sentiment. In fact, as your career progresses, you’ll still feel that way. It is often hard as you begin, with the competing demands of clinical work, department administrative activities, and your own academic projects, to find time or the inclination to actually think about where you are heading professionally. Yet, it is in that planning where the foundation for your career is born.

A mentor can be exceptionally valuable for you as you develop your career, particularly in the early stages. Mentor–mentee relationships don’t happen overnight. You must actively seek out and nurture this relationship. The insights, wisdom, and advice you receive from a senior colleague are useful not just for career development, but also for navigating the relationships and power structures that exist within your department and institution. While one must be sensitive to the fact that we, as mentees, are adding to the many time commitments of our senior colleagues, most mentors find developing and maintaining such relationships to be among the most rewarding things they have done in their career. It is one of the rich traditions of medicine that each person that rises up one rung of the career ladder gives back to those following behind, and as a result, you will find many colleagues in your department willing to help you.

Felix Ankel, MD compiled some “tips for junior faculty” from senior faculty and distributed them on the CORD listserv. Some of my favorites are interspersed in this chapter as appropriate. For instance, “Don’t ever be reluctant to trade or work extra shifts; you want all your colleagues to be sure they want you around.” -- Peter Rosen, MD As you join an academic Emergency Department, you are usually assigned to a certain area of concentration and in Emergency Medicine, these are often comprised of education (EM residency program, medical student activities), department administration, local EMS agencies and systems, and research.

Involve your Chair early in your career planning process. Faculty development and retention may be the most important Chair function, and there is not likely to be an individual at your institution that will know the “rules” and how to succeed better. Understanding your Chair’s expectations of you helps you appreciate what it will take to advance within your department, and usually you can align your own career development goals with these expectations.

It may seem that once an area of interest is identified that it might be difficult to change the course of one’s career development. As one who has been involved with four out of the five activities on the list above, I can tell you it can be done, though I am not necessarily advocating that as an initial plan. If you find yourself with an initial area of interest that works for you, stay with it! You will likely be able to develop specific expertise and recognition within Emergency Medicine faster than otherwise.

“Don’t be defensive with the residents; they may not treat you with the same respect as senior faculty; or actually they may but you don’t see it; remember they are feeling defensive about their roles, and you should remember better than senior faculty how you felt at that stage of life.” -Peter Rosen, MD

“Pick a topic and focus on it; e.g. become knowledgeable about reperfusion, or splinting, or an area emergency physicians are typically weak in such as neurology” –Peter Rosen, MD

You will need to learn the Promotion and Tenure (P/T) guidelines at your institution. While most universities have similarly defined positions such as Instructor, Assistant Professor, Associate Professor, and Professor, the exact criteria as to what defines each often varies considerably. As defined in “Chapter 5: The ‘Academic Skill Set’ ”, you will have to achieve a varying amount in each of the components of your current position, clinical care, teaching/education, administration, and research.

The place to begin you planning process is with the vision of a path to your ultimate ambition or goal for your career. Do you aspire to be a Chair? A Program Director? Director of Research? Professor? If you can, begin thinking of these longterm destinations where you might end up five, ten, or fifteen years down the road. Remember, this is a fluid process. Your needs and desires often change as life progresses, and you will 41


“Look at what the faculty a few years above you have done for advancement.” -J. Stephan Stapczynski, MD Many experienced faculty recommend developing and maintaining an “academic portfolio” of your work. This is more than maintaining your CV, which you should do as well. In a sense, you are keeping a scorecard of your achievements in each of the previously mentioned categories that will be judged when you are considered for promotion. Tracking your departmental activities and academic work will not only be useful in preparing for your promotion, odds are, such data will be very helpful for you and your Chair in justifying your advancement at your annual evaluations. “Building up a portfolio of educational stuff is great, but while education is given lip service everywhere, publications remain the true currency of academia. If junior staff can find an area of research they enjoy (which could include research on education), they will do well.” -Wyatt Decker, MD Now that you have some general thoughts, it’s time to think about creating a strategic plan for going forward. While many strategic plans are created around a five-year time window, it’s equally helpful to have a specific plan for the coming year. The structure of the plan is up to you. You might plan based on time (e.g. by September, I will have created two new didactic presentations), or you might design achievable objectives based on the general headings (e.g. clinical care, teaching/education, administration, and research) on which your future promotion will be based. “Keeping the ‘fun’ in emergency medicine is in my opinion the key to advancing a career, and excelling in an area that one loves is fun.” - Charlene B. Irvin, MD

42


CHAPTER 13

ASSOCIATE PROFESSOR - TAKING THE NEXT STEP By Susan Dufel MD, Residency Director, Integrated Residency in Emergency Medicine, Associate Professor, Department of Traumatology and Emergency Medicine, University of Connecticut Health Center, Hartford, CT The advancement from Assistant to Associate professor within the medical school is a leap much greater than you can probably anticipate. If this is your goal as an academic emergency physician, you must start the process now. Most departments will assign you an initial rank of Clinical Instructor or Assistant Professor. After this, the promotion/tenure (P/T) process is individual to each institution. This variability should encourage each faculty member to become familiar with their institution’s by-laws, learn about the promotion process, and understand what constitutes scholarly activity within their academic environment. Our training rarely or incompletely prepares us for the specifics of career advancement in the academic arena. As the complexities and variability of our jobs increase, even the most talented among us need guidance and careful attention to career development. We are all unique in our interests and will require a well-thought-out career plan. The process should have measurable goals, frequent re-assessment, and effective mentoring. Discipline will be a key predictor for success as our time is limited and demands are constantly increasing. The objectives for this chapter will be to:

will have different names or titles for these specific categories. They may be defined as medical educator, investigator, clinician investigator, clinician scholar etc. or they may be simply defined as a clinical track or a traditional track. Make sure you know in which category you’re applying. As an example, a ResearchEducator track is intended for individuals who may have a doctoral rank in both basic science and clinical departments with a major career commitment to basic science or clinical research that is likely to result in funding by peer-review granting agencies. Such individuals are provided with protected time to pursue their research interest and to participate in teaching and service activities. The second track, identified as the ClinicianEducator track, is intended primarily for clinical faculty and represents a scholarly academic track of equal stature/status as the Research-Educator track. Both research and service activities are required. This track emphasizes and recognizes the unique role of the clinician-educator at the forefront of faculty within the School/College of Medicine. Most academic medical centers have goals that require mastery in three areas: patient care, education and research. This “triple threat” was obtainable in the past but has been increasing difficult for individual faculty to contribute to all three. Faculty members may need to focus their efforts in one or two of these academic arenas. For the most part, most faculty focus on patient care and research or patient care and education. One of the issues facing faculty who wish to be promoted is that the Promotion and Tenure Committees tend to value patient care and research over the latter.[1-4] A report from Johns Hopkins found that the chances of having a higher academic rank were 85% lower for academic clinicians and 69% lower for teacherclinicians than for research faculty.[1] Faculty who spend more than 50% of their time caring for patients were more likely to be on a non-tenured track and showed slower career progression than those who spent less than 50% of their time caring for patients.[2] In addition, time to promotion was significantly shorter for those who spent 80% of their time in research than those whom spent 30% or less. It has been reported that rates of promotion were slower, even with defined criteria and tracks within the clinician-educator faculty. This delayed promotion may be related to longer periods of time required for identification and development of expertise in either clinical or educational areas.[4] Some institutions have yet to define standards for early advancement for faculty in the above track. Another study found that faculty who spent a majority of their time involved in clinical activities had less time for protected activities such as research and mentoring and often this time was lost in a busy clinical work week. The actual time spent on scholarly activity was less than designated as “protected.”[5]

• Define in general terms, the requirements of an institution’s Promotion and Tenure Committee • Become knowledgeable about what documentation you will need • Identify areas of interest you have and will need to develop • Organize a portfolio for achievements, letters, evaluations, contacts, etc. that can be used for supporting documentation • Define a networking system with other faculty who have advanced to the Associate Professor level • Recognize the importance of volunteering and becoming involved in both regional and national organizations that represent our specialty

Promotion and Tenure Committee of the Medical School (P/T Committee) The P/T committee is made up of faculty members who have already achieved promotion and may be tenured. These individuals are charged by the institution with the task of insuring that all faculty who are promoted have achieved expertise in an academic area, demonstrated their effectiveness in teaching, fulfilled clinical service requirements, and contributed in a meaningful way to the mission of the institution. To get started, you will first need a letter from the sponsoring Department Chair which clearly identifies the promotion to Associate Professor and professional category. Each institution 43


Information and Documentation you will need for the Promotion and Tenure Committee

Mentoring and advising Mentoring can include medical student advising and mentoring junior faculty and senior residents. Get involved with your school’s Emergency Medicine interest group. Many medical students, interested in Emergency Medicine, are looking for faculty knowledgeable about the application process and other Emergency Medicine programs. Most medical school Deans hold a lot of stock in educating and advising medical students and your participation becomes noticed. Being a member of the medical school admissions committee will help you become acquainted with other faculty within the medical school including both those in the basic sciences as well as clinical faculty. Building these bridges and developing relationships with others not only in Emergency Medicine will ultimately be a bonus.

Documentation Required documentation for the Promotions and Tenure Committee will include, but may not be limited to, the following: 1.

Detailed and comprehensive letter of recommendation from the Department Chairperson. The letter should include a qualitative and quantitative assessment of your clinical, teaching, research and administrative contributions to the School of Medicine, its affiliated institutions and any other local, state, national or international activities.

2.

Curricula Vitae, including Bibliography (the bibliography must include complete title, bibliographic citation, and date). Manuscripts in preparation are not allowed.

3.

Summary of Teaching Responsibilities indicating evidence of teaching quality and teaching quantity.

4.

Summary of clinical responsibilities.

5.

List of at least six outside authorities of the same rank to which you are applying, four internal (your University faculty) authorities and usually eight students or residents that you have had contact with during your career.

6.

Copies of your most significant manuscripts (original research papers are most important to the Committee, book chapters less so). Manuscripts in press must have an editorial acceptance letter.

Administration Administration can be a large part of any core faculty’s time but may be important in contributions to the Department and relationships formed with other faculty within the University. Volunteering for medical school committees such as admissions (as mentioned above), graduate medical education, resident education, and residency leadership committees are all areas where your leadership skills can be developed. Assistant, Associate or Program Director positions can aid your advancement within the administrative arena. Scholarly activity Appropriate scholarship has traditionally been evidenced by publications of original research in peer reviewed journals. Large-scale blinded randomized controlled prospective clinical trials are often most revered in clinical research and by the promotions committee. Research focus in a particular area is highly desirable and increases the potential for external grant support and promotion. Many institutions will only award tenure to those who can demonstrate ability to obtain funding through outside grants. Recently, the definition of scholarship has expanded to include articles that are not based solely on the discovery of new scientific knowledge to be used when attempting to demonstrate productivity and excellence in scholarship. Examples include published curricula, syllabi, web based publications and other multimedia materials that have been used for teaching. Peer-reviewed publications, case reports, book chapters, and case-review articles all contribute to scholarly productivity. Participation in editorial services for specialty journals in Emergency Medicine is always of value.

Keeping track of all scholarly and administrative activity will be invaluable. Develop a portfolio and keep every lecture, all teaching/lecture evaluations, awards, CME certificates, special training, Press-Ganey reports, medical student and resident evaluations, and all publications and on-going projects. In light of the ACGME Core Competencies, many faculty have developed innovative ways to evaluate and measure these six competencies. Make sure you keep track of residents and current or former faculty that can attest to both your teaching excellence and academic success. These residents and faculty should span your entire time at the institution and include several “senior” faculty (faculty with academic rank of Associate Professor or Professor). Teaching Keeping track of everything you do as a faculty member will be a key to your successful rise up the promotion ladder. Finding an area of interest and developing that venue will be important but documentations of your contributions in all areas will be important for promotion consideration. Areas involving teaching can include lectures, CME, bedside teaching evaluations, curricula development, awards and new innovations in teaching. These become even more important as we begin to measure outcomes in the general competencies.

In conclusion, the faculty member who wishes promotion to the Associate level needs to develop a plan generally formulated in conjunction with his/her Chair, to determine what will be expected prior to being recommended for promotion to the Associate Professor level. As mentioned, this plan may involve a specific window of time. This is especially true in institutions whose by-laws demand that all faculty members be tenured. This clock is usually set for between seven to nine 44


years. This means that the faculty member must complete all of the requirements for promotion within that time period or leave the faculty. To avoid this concern, academically oriented emergency physicians should understand the consequence of accepting a tenure track appointment. The advantage of this system is that pressure is placed on the department to ensure promotion and the department chair not only becomes expert in helping faculty accomplish the tasks that are necessary, but also is closely involved in monitoring progress. The faculty member may feel a great deal of pressure to engage in research, obtain grants, and publish in peer-reviewed journals. Many faculty members, with the support of their chair, choose the non-tenure track position. Non-tenure track positions don’t usually dictate specific time frames for promotion. However, the chair may not monitor or encourage faculty performance leading to promotion as carefully as s/he would monitor tenure track faculty. Additionally, the faculty member may not feel the same amount of pressure to be promoted and so may not work as hard in the scholarly arena. Attaining promotion to the level of Associate Professor requires careful and thoughtful planning the moment you take a position and engage in an academic career track. Participating in activity that allows a faculty member to demonstrate teaching excellence and a focus of scholarly activity is essential. Clinical excellence is a requirement unless one is solely in the Research Track and has no clinical requirements. Documentation of accomplishments that demonstrate to the institution the faculty’s value and their scholarly achievements are mandatory. The rewards of achievement are well worth the effort for they attest to recognition by the academic community that a faculty member has been successful in adding to the value of that community and helping fulfill the institution’s mission of teaching, research, and service.

References 1.

Thomas, PA, Diener-West M, Canto MI, Martin DR, Post WS, Shrieff MB “Results of an academic promotion and career survey of faculty at the Johns Hopkins University School of Medicine” Acad Med 2004;79258-264.

2.

Buckley LM, Sanders K, Shih M, Hampton CL, “Attitudes of clinical faculty about career progress, career success and recognition and commitment to academic medicine: results of a survey” Arch Int Medicine 2000; 160:2625-2629.

3.

Levinson W, Rubenstein A. “Mission critical-integrating clinician-educators into academic medical centers” N Eng J Med 1999; 341:840-843.

4.

Kelly WN, Stross JK, “Faculty tracks and Academic success” Ann Int Med 1992; 116:654-659.

5.

Sheffield JV, Wipf JE, Buchwald D, “Work activities of clinician-educators” J Gen Intern Med 1998;13;406-9.

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CHAPTER 14

BECOMING A FULL PROFESSOR- TOP OF THE LADDER? By David S. Howes MD, Program Director, University of Chicago Emergency Medicine Residency, Professor of Medicine (Emergency Medicine), University of Chicago Pritzker School of Medicine, Chicago, IL First of all, I acknowledge and thank Joseph P. Ornato, MD, Professor and Chair, Department of Emergency Medicine, Virginia Commonwealth University, for his (own) superb review of this topic. I refer you to his wonderfully written monograph entitled “The Rank of Professor: How to Get There” which may be found in the SAEM/AACEM Faculty Development Handbook at the Society for Academic Emergency medicine website (www.saem.org). I have borrowed very liberally from his work and hope that this tribute will beset his perfect right to accuse me of outright plagiarism.

for their expertise in a given content area. For example, the newly minted Professor in a classic academic track will have a long track record of extramural funding for their research, will have averaged approximately four peer-reviewed publications per year over an extended time period with approximately 40-50 peer-reviewed publications and double that number in total publications (including book chapters, abstracts, review articles, case reports, articles credited to a committee, etc.), will have served on local, regional, and national (and international) committees in their field, and been involved at a leadership level with one or more national organizations. The attainment of the rank of Professor represents recognition of substantial, sustained academic achievement.

I have had the privilege over the last twenty-plus years to council hundreds of senior residents and interview a like number of physicians who are seeking an “academic career.” Most state that they want to work in an environment in which they can teach residents and students. My rejoinder is always the same; although teaching is an important element of an academic career, in order to ascend the academic ladder, a faculty member must demonstrate expertise and accomplishment in multiple areas in addition to teaching. The successful career academic faculty member actively contributes to the development of a specialty or discipline and does so with breadth and depth. It is a given that a faculty member is a competent clinician and will give adequate instruction and guidance to residents and medical students in the clinical setting. However, in order to qualify for promotion, one must go far beyond the day-to-day, onthe-job “apprentice” teaching and make substantial scholarly contributions to their specialty.

The length of time required to achieve this rank depends upon the productivity of the individual and the philosophy and customs of each institution. In general, productive individuals spend 1-2 years at the Instructor level, 3-7 years at the Assistant Professor level, and 5-15 years at the Associate Professor level before attaining the rank of Professor. Exceptionally productive individuals may ascend to the rank of Professor in their early to mid 40s; typically a reflection of an especially gifted and hard-working academician who has been successful in obtaining much extramural funding and has assiduously completed and (after multiple revisions from tough editors) published numerous scientific papers that reflect an area of expertise and significant accomplishment. These Professors have no “clinical” modifiers attached to their academic title, and they enjoy national and often international prominence in their particular specialty area.

Academic Rank: What does the term Professor mean? The typical academic rank at most colleges and universities, in ascending order are Instructor, Assistant Professor, Associate Professor, and Professor. You are assigned to a rank within (in medical disciplines) either an “academic” or traditional track, or a “clinical” track. Academic tracks are reserved for fulltime departmental faculty pursuing a more scholarly career and classically involve a great deal of research and publication. The clinical track is appropriate for individuals who function mainly as clinician educators, providing direct patient care, bedside and classroom teaching, but who have modest expectations to accomplish research or other scholarly activity beyond the scholarship associated with teaching. In addition, faculty members in clinical tracks will often also serve in important administrative capacities, particularly as their length of service increases in the university setting.

As mentioned earlier, one may also aspire to the academic rank of Professor in a “clinical” track; this individual is a clinician educator providing patient care and bedside/didactic teaching with modest expectations of scholarship beyond that associated with teaching, and who often serve in important administrative capacities in the hospital/university setting. However, this “clinician-educator” must still achieve prominence at a national level in order to be promoted to Professor, thus these faculty members have often published widely regarding their clinical observations and investigations, have authored multiple chapters, monographs, reviews and other works related to committee work, and have served on numerous local, regional and national committees and served in a leadership role at the national level. Of interest, there has been a recent trend in some universities to drop the “clinical” modifier to titles of full time academic faculty who are in such clinician-educator tracks; this is recognition of and is an attempt to attach greater importance to the role that these individuals serve in the academic university setting.

As one might discern from the number of levels one must attain in order to reach the rank of Professor, these individuals are senior academic faculty members. This longevity is required in order to have attained national (and often international) prominence 46


How to get there: The importance of selfmotivation and plain hard work!

hours until such time as you can “buy down” your time with external funding (or internal funding for significant teaching or administrative functions for the university). In the past, many individuals started out with protected time and lost it if it was not used productively, however, it is more common presently for new faculty to begin with a larger amount of clinical time, which they subsequently pare down in return for demonstration of academic productivity.

The majority of individuals who have attained the rank of Professor have managed to stay (alive and) productive for a long enough time period in an academic environment that eventually they created a niche area of expertise that was personally rewarding, fun, and of value to the larger medical community. Over time, opportunities come their way, and they put in the time and effort required to accomplish each assigned task. Before long, the individual amasses accomplishments and is offered (punished with?) even more opportunities to contribute in a meaningful manner at the regional and national (and eventually international) levels. Becoming a full professor is not about brilliance; it is rather the embodiment of Thomas Edison’s remark that “there is no substitute for hard work.” If one reviews the SAEM website listing of the approximately 270 current full professors in Emergency Medicine, if you have been around any length of time in our specialty, you will recognize virtually every name. These are individuals who have worked hard over many years, representing our specialty in any number of venues that reflect much accomplishment in scholarship, research, educational and administrative/leadership.

It is important that the developing academician narrow their focus to a limited area of specialization with the goal of becoming a leading authority in a specific content area. The choice of content area often occurs serendipitously based on an individual’s prior life experiences or talents. The most important thing is to find an area that is “fun,” read everything you can about the subject, and attend meetings and conferences related to the topic. Ask questions of the experts and those presenting papers at educational meetings. Find someone to mentor you who is knowledgeable in this area and has attained a track record of success, preferably within your own academic institution. However, they do not have to be in Emergency Medicine. Some of the most successful academic emergency physicians have collaborated with educators and scientists from other departments/fields from their own and often other universities. You must eventually identify a research topic in which you can answer an important question that is relevant to the field. Join interest groups relating to the subject and make every effort to have your name considered when regional, national, or international committee positions become available. Look for opportunities to give talks or presentations regarding your developing area of expertise. Get yourself out there. You have to be known in order to be promoted up the academic ladder.

More often than not, the academician who is successful enough to achieve the rank of Professor will possess many (not necessary to have all- nobody is perfect) of these features: 1.

Initiative, self-motivation

2.

Strong work ethic (more coming on this)

3.

Reliability

4.

Punctuality in meeting deadlines

5.

Team spirit

6.

Organized, efficient

7.

Technologically competent

8.

Stays at the cutting edge

9.

Appreciation for any opportunities that are provided by others

Lastly, the need to network and collaborate with others is vital to your success in the academic environment. It is difficult and one will fail if they operate in an academic vacuum. The extent to which an individual can network and collaborate will dictate their success. Multidisciplinary collaboration within the same or outside one’s own institution is the hallmark of the modern scientist, educator and others who contribute to the creation and dispersal of new knowledge. For those in traditional academics, collaboration will usually make it easier to obtain research grant support. And of course, when it comes time for promotion and tenure review, collaborators make perfect external departmental candidates to sit on one’s Promotion and Tenure Review Committee. External collaborators from other national and international medical centers can provide letters of recommendation that will support the contention that the professorial candidate is, in fact, nationally (and internationally) well known.

10. Willingness to collaborate 11. Willingness to help and mentor others It is a common misconception that one can be successful in an academic environment working a 40-hour week as long as there is sufficient “protected time.” This is a myth. Most academicians who have attained the rank of Associate Professor or higher average 60 or more hours per week over their entire academic career. You’ve got to love this job, and the environment in which you work, as you will work longer hours for far less money than your colleagues in the community setting. Significant “protected time” for academic endeavors is important to have if an individual is to be successful in an academic career, but you will have to earn it, which means working significant clinical

“Playing smart” in the promotion process Faculty members are responsible for tracking their academic progress and must develop and maintain an academic and 47


teaching portfolio. This document contains supporting evidence for information contained in the individual’s Curriculum Vitae. A well-constructed portfolio should contain tangible proof of one’s accomplishments, including copies of important publications, chapters, and monographs, evaluations from students, residents, fellows, peers, and course participants, letters of invitation and appreciation for important professional meetings, committee work and leadership roles, and similar materials that substantiate that you are a hard-working, valuable, and productive academic citizen. Such information will prove invaluable to the faculty member when the Promotion and Tenure Committee requests evidence that can confirm the candidate’s lifetime accomplishments.

Summary Please take a moment to visit the SAEM website and review the listing of the current full professors in Emergency Medicine. These are individuals who have worked hard over many years, representing our specialty in any number of venues that reflect much accomplishment in scholarship, research, educational and administrative/leadership. For the most part, they did not start their academic careers thinking that they would be full professors some day. They just showed up, worked hard, did what was asked of them, and found an area of interest that was fun and eventually others appreciated what they had done and promoted them. They in turn now take the opportunity to help the next generation of academic emergency physicians do the same. I hope that you will join us!

48


CHAPTER 15

THE MEDICAL SCHOOL- BECOMING A DEAN AND BEYOND By John E. Prescott, MD, Professor and Dean, West Virginia University School of Medicine, Morgantown, WV

No one enters Emergency Medicine with the goal of being a dean. Yet over the past ten years, more and more academic emergency physicians are being presented with the opportunity of contributing to academic medicine through this unique pathway. Who ends up being a dean? What’s it like? When does one have to make this career choice? How does one become a dean? And finally, why would an emergency physician choose this career pathway? This chapter will answer these questions and offer some additional insight into the “life of a dean.”

I have always enjoyed leading and have looked for opportunities to serve others. EM was still in its infancy when I completed my residency training, and there was a great push for graduates to assume leadership in EDs and to develop academic departments. Just as others have unique clinical, educational, and research abilities, I knew that I had a skill set that enabled me to organize individuals and develop strategies to move our Emergency Department forward. Most often, individuals who want to serve as a dean are seeking a way of contributing more to their institution. Sometimes, they have been asked to fill an open position as an interim dean and have found the experience challenging and fulfilling. And for others, it is a natural next step in their career progression within a given mission. Many individuals serve their school as an assistant/associate dean for many years and both the school and dean are content with this arrangement. For others, the position is one that will eventually lead to even greater responsibility within the institution. Still others, once they have tried the administrative aspects of academic medicine, are certain they want to return to their prior careers.

The Academic Dean: The organizational structure of most medical schools is dependent on the leadership provided by departmental chairs, center directors and deans (assistant and associate). Chairs lead discreet departments that correlate with specific academic disciplines. Center directors often lead multi-disciplinary or interdisciplinary functional units. Academic deans usually coordinate and lead traditional mission-based activities such as research, education, and clinical service. I have found it useful to describe the governance of medical schools by drawing parallels to the leadership that exists at state and federal levels. The role of the chair parallels that of governors, each has operational responsibility for a defined organizational unit. Center directors are like cabinet secretaries and often have direct influence over large entities with a specific focus. Assistant/associate deans closely parallel senators in that they have little direct operational control of an organization, yet they possess great power in influencing and directing actions across the country/school.

If you want to serve as a dean, you must carefully assess your desire, motivation and strengths. You must know your “comfort zone” – what is it that you like to do? What are your strengths? Your weaknesses? Will your ego get in the way? Do you have the required skill set? Will you enjoy having one foot in the dean’s office and one in your department? If you are seeking control and power by becoming a dean, choose another career path. Deans have more influence than direct control and chairs and university presidents quickly discern which deans serve the institution and which deans serve themselves.

As of February 2006, there were four emergency physicians leading medical schools as dean. In this capacity, they serve as the chief academic officer for their institutions and are responsible for ensuring the success of a large, highly complex, and constantly evolving academic enterprise. Most school deans have previously served as chairs of academic departments and/or served as associate deans.

Seek mentorship and advice from those who currently hold the position within your academic institution and from the outside. Find out what it is that keeps them going and what it is that has allowed them to succeed. Also, speak with those who have decided not to become a dean. There are many chairs in EM who have consciously made the decision not to move into the dean’s office – why is that so? A good friend of mine once reminded me that just because I could do a particular job didn’t mean that that job was right for me.

Should I serve as a dean? All of us wrestle with questions about our career paths, and I truly believe we often end up in our roles through a combination of motivation, opportunity, fate, preparation, and perseverance. Never in my wildest dreams as a medical student did I see myself as a leader in academic medicine. The thought of serving as associate dean had never crossed my mind as I was preparing to become chair. Now as dean I am trying to figure out what surprises the next ten years of my life will hold.

Understand what your family wants to do and is prepared to do – pursuing a deanship is truly a family decision and will affect each and every member. If moving is out of the question – that factor must enter into all of your decision-making. You become a very public figure not only within the university setting but within your state and even nationally. 49


The Dean’s Job

As dean, you must get comfortable with the fact that your work is never done and the demands of the position can have serious consequences on your family. The “shift” never ends and if left unchecked, your schedule will consume you and all of your personal time. Time off and away from the office and university/school events must be rigorously enforced to ensure your long-term survival and happiness with the position. Being dean is like being in a marathon – so think in terms of running a marathon that never ends instead of a sprint. All emergency physicians have “burned the candle at both ends” for a short time, when you’ve had to assist others due to unexpected staffing shortages or a family emergency. However for the dean, this practice will lead to marked inefficiency and lessened effectiveness. Long-term success as dean depends on maintaining your health despite an overloaded schedule full of unhealthy breakfasts, lunches, dinners, and social functions.

Serving as dean has truly been one of the most challenging yet fulfilling jobs I’ve ever had. Like the practice of EM, being a dean is a constant challenge with new twists and turns everyday. No matter how much others and I plan a day or a week, there are always unexpected challenges and opportunities that keep the job “fresh” and invigorating. As is the ED, there are rules and systems to assist and help you be more effective and efficient but sometimes they are simply overwhelmed by circumstances. Being dean is not for the faint-hearted – it is no gentle canoe trip across a calm lake. Rather, it is white-water rafting at its most challenging – even with the best skills you are going to get wet. The key is to stay safe, remain in the boat, and enjoy the ride. As dean, you are expected to set the vision for the school, be a good steward of resources – facilities, personnel, and money, and you have to recruit, retain, and develop the very best talent that you can. Everything you do as dean falls into these categories. Consistent, sincere, and clear communication throughout the institution is key to your success. The most important skills for the dean include the ability to listen, make fair and objective decisions with incomplete information, set high expectations for performance and to be available for guidance and mentoring – not at all unlike the skills of your average emergency physician.

How to become a dean First, there must be a strong personal desire, and that desire must be built around an understanding of the job – the prerequisites, the commitment, the challenges; and the expectations. Others must believe in you and you must have the confidence that you can do the job. Get experience at leading – most deans have been department chairs and this experience has given them knowledge of personnel issues, operations, academic issues like promotion and tenure, faculty development, and departmental/school finances.

By default, by the time issues rise to your attention as dean, they have been unsuccessfully addressed at other levels. Simple “black and white” questions give way to many “gray” concerns and a strong set of personal and institutional values is needed to center you and your decisions. These values also assist you in working with all of the big egos that present to your office, often seeking resources that benefit only a few individuals or a particular section/department. As dean, you must keep reminding individuals of their mission to work within the school and for the betterment of the institution. Your perspective must cross disciplines and missions and you must have the vision and willpower to know when and how to get the best out of individuals and how to give them someone and something to believe in.

If you are particularly strong in one of the three traditional missions – maintain that strength but seek ways to enhance your knowledge of the other missions. My own experience is that I had a great deal of knowledge of our clinical mission and certainly knew the finances of the school. I had to plot out how to get additional information regarding research and education. My formal preparation began while being chair and really took off as an associate dean and CEO of the faculty practice plan. But my life experiences in college, medical school, the Army, and as a new faculty member presented me with a host of leadership opportunities. I have been fortunate in that I have a pretty good means of learning from past mistakes. I also have a reputation for listening, approaching difficult issues with an open mind, and for achieving clarity in assigning responsibility.

To be successful, you must be good at delegating and you must have good people surrounding you that you can trust. Like the physician in charge during a mass casualty incident, the dean loses effectiveness if he/she is providing direct care. The dean must be the one leading, directing and inspiring others.

Once you’ve chosen this career path, learn everything you can about it and become known in your field. Prospective deans need to make their name outside of EM, and they have to be able to demonstrate an appreciation of all the missions of the school or academic enterprise.

Personnel issues take up more time than I could ever have imagined, and I have learned repeatedly that physicians are not usually adept at dealing with them. Most of us have received little formal training in evaluating, mentoring and counseling individuals, but it is absolutely essential that you possess these skills as dean. You must be able to draw out the best in individuals as well as how to hold them accountable for their actions and decisions.

Seek additional responsibilities by speaking with your chair and dean. Letting them know of your interest can pay off in a major way when a new opening occurs or a new opportunity 50


develops. They can also assist you in identifying programs that will help enhance your skills.

Can I still recognize a sick patient from across the room? Absolutely. Do I hesitate to act when I see a patient in an emergent situation? Never. But if I’m honest with myself and ask if should I be mentoring and guiding the rising generations of EM residents in the ED, the answer is clearly no - my skill set has changed. This does bother me to a degree but times have changed, and I have accepted that as dean, I simply can’t do everything. I still like to teach in the ED but to do this properly I need to supplement the attendings already working the shift and not replace them. I do remind myself that one new benefit is that I’m often given the opportunity to teach across all specialties and across generations of physicians.

Test the waters. The AAMC’s Council of Deans has a yearlong fellowship program for those interested in becoming dean. For women, the Executive Leadership in Academic Medicine (ELAM) program offers an outstanding curriculum. Update your CV and keep it current - opportunity has an uncanny ability to strike at unusual times. Attend non-EM focused academic meetings and head to the AAMC’s annual meeting to make national contacts and gain a broader perspective. Alternatively, become a representative from your school, SAEM, ACEP, or other group on a national committee. The exposure is good for you as an individual and for your department and school.

Finally, those shifts in the ED are good for me and there are some definite benefits to working in the ED. I find out first hand about key issues – problems with consultants, patient flow, and I learn about new treatments, etc. And when you are dean, there is nothing quite like calling a consultant and asking them to see a patient in the ED. Delays almost never occur and the EM residents and staff love to see that.

An individual once recommended to me that I expose myself to new concepts by expanding my reading beyond medical journals and a weekly newsmagazine. I subscribed to FORTUNE and the Harvard Business Review and soon found myself adopting innovative ways to address problems.

Closing thoughts: Occasionally I’m asked, “What’s next? What will you do after being a dean?” For me, the issue is not an urgent one, I’ve been dean for only 18 months but I have always found it useful to be thinking of my next career opportunity and thus I have and will continue to keep my options open. While I look forward to being dean for the foreseeable future, I understand that sometime I may be asked to assume even greater responsibility as the Vice President for a Health Sciences or as a leader of an academic institution. Certainly, there could be openings at the state or national level in medicine and healthcare. Private industry and/or consulting may be another option. And finally, I could find myself returning to the practice of academic Emergency Medicine (after a bit of a tune-up). I’m not worried about the specifics at this time and will work to keep my options open at every level.

How do you balance practicing EM and being a dean? The four emergency physicians who currently serve as deans of their medical schools have approached this question with different solutions. All face similar demands on their time and all have dramatically curtailed their clinical, teaching, and research activities due to the administrative demands of the job. But each has maintained some contact with their specialty – whether it be the occasional shift in the ED, teaching students or residents, or maintaining their scholarly activity. During the five years immediately preceding my becoming the dean, I served as clinical associate dean and as the President/CEO of our faculty practice plan. As I accepted my new responsibilities, I had simultaneously stepped down as chair and subsequently there was a gradual decline in my active participation within the academic department. This was difficult for me because I enjoyed my time in the ED with the residents, and as an Emergency Medicine faculty member, I took great pride in literally knowing the names of all of the housestaff in every specialty. But because of my new responsibilities, I had to cut back my clinical and educational tasks and soon had a difficult time knowing even the names of the EM residents. I remember asking myself, “Was I ready for this?” – and honestly my answer was “Yes and no.”

I also realize that someday I might be asked to step out of my role as dean rather unexpectedly. I have consistently counseled others not to define themselves by their job or its title but rather by those all-important individual characteristics that make us unique. I believe that I have the wherewithal and skills to accept that eventuality and move on to the next phase of my life. I absolutely believe that my decision to enter Emergency Medicine prepared me well for my role as dean, and I wouldn’t trade any of the experiences I have had in the 20+ years since I left my residency program. Nor would I trade the opportunity to serve as dean. It is a uniquely fulfilling experience for me, and I believe that in turn I have contributed to the success of our medical school and academic medicine as a whole. Thus, I look eagerly forward to other emergency physicians joining the ranks of the Council of Deans.

Well-meaning individuals often ask, “Do you miss being a doctor?” My answer is that I’m still a practicing physician but with a different set of patients and priorities. I’ll certainly never stop thinking like a physician and hope that I never stop thinking like an emergency physician. 51


CHAPTER 16

THE FUTURE OF ACADEMIC EMERGENCY MEDICINE By James Hoekstra, MD, FACEP, Professor and Chairman, Department of Emergency Medicine, Wake Forest University Health Sciences, Winston-Salem, NC, and President, Society for Academic Emergency Medicine relatively exclusive access to real-time, after-hours diagnostic and therapeutic technology, ED utilization will continue to grow. Academic Emergency Departments are usually on the cutting edge with diagnostic and therapeutic applications, and are therefore better equipped with diagnostic technology than their community counterparts, leading to a disproportionate share of the technology-driven growth of academic emergency services.

Academic Emergency Medicine continues to grow and mature, from it’s infancy in the 1970s to its present stature as an established force in academic medicine. This growth is evident in the number of training programs, the number of faculty, the number of academic departments, the quality of our residency recruits, and the growth of our clinical programs. In addition, the quality of research and scholarly productivity in academic EM is steadily improving. The future of Academic Emergency Medicine is bright, and optimism abounds. With the growth of any medical specialty, there are strengths, weaknesses, opportunities and threats to our continued success. How we navigate the academic and clinical minefields in the next few decades may well determine whether or not we meet our potential.

Finally, the continued specialization of medicine favors the growth of academic Emergency Medicine. Patients with specific complaints related to their specific illnesses, when given a choice, prefer access to specialists for their treatment. Patients with chest pain, for instance, would prefer going to an institution capable of performing cardiac catheterization center rather than an urgent care center if they are concerned about a heart attack. This preference for specialization favors the continued growth of Academic Emergency Departments, where access to specialists of all types is more possible.

Clinical Growth Trends in Emergency Medicine: The growth of academic Emergency Medicine is evident in the clinical, educational, and research arenas, but the clinical arena remains the main driver of Emergency Medicine’s success. The trends in access, demographics, specialization, and the utilization of technology predict continued growth of our specialty.

Teaching Programs and Scholarship: Since the first EM residency program was initiated in 1970, there has been steady growth in the number and quality of EM teaching programs. At present, there are over 130 EM residency programs, with over 1100 residency slots available each year through the match. Emergency Medicine remains one of the few specialties whose residency numbers are growing despite the 1997 Balanced Budget Act residency cap. At present, 8% of US graduating medical students are choosing Emergency Medicine as a career. The positions in the EM match are being filled by higher and higher quality candidates; there was a 98% fill rate in the 2005 NRMP match.

Clinically, the volume of patients accessing Emergency Departments throughout the country has continued to grow at an inexorable pace. According to the National Hospital Ambulatory Care Survey, ED volumes have increased nationally at about 1.5% per year, to a total of 114 million visits in 2003. That’s forty ED visits per 100 persons annually! Of these visits, approximately 81% take place in large cities, and 32% are in hospitals associated with medical schools. The latter statistic illustrates the crucial role of academic Emergency Departments in the provision of emergency care in the US.

As these high quality physicians fill our residencies in higher and higher numbers, the trickle down effect is being felt in academic medical centers and in academic medicine leadership. The number of Deans of medical schools who are emergency physicians has grown to four, and the number of Associate or Assistant Deans, especially in the educational and clinical areas continues to multiply. This leadership growth bodes well for the future of academic Emergency Medicine.

The demographic trends in the U.S. population predict continued growth in ED utilization over time as well. As the population ages, the need for ED utilization also grows. In the last decade, the percentage utilization of the ED by persons over 65 years old has increased 16%. Patients over 65 are more acutely ill, have more co-morbid conditions, and require the use of more technology and diagnostics which are only available in an ED. These factors result in a 40% ED admission rate for elderly patients.

In the scholarly arena, research in Emergency Medicine continues to flourish. In the 1980s, it was rare for an emergency physician to be federally funded through the NIH or CDC. Now, over thirty emergency physicians are principle investigators on NIH grants, and scores more are funded through the CDC or other federal agencies. Although the NIH does not recognize EM with its own study section, emergency physicians are obtaining grants in a wide variety of organ-specific or specialtyspecific sections such as NINDS, NHLBI, NIAAA, AHRQ,

The increasing utilization of technology in diagnostics is also tightly linked to increased ED utilization. The rapid accessibility of MRI, CT, nuclear imaging, etc, is only available in the ED setting. Of patients evaluated in the ED in 2003, 33% got a CBC and 43% received X-rays. Utilization of CT and MRI in the ED are up 103% in the last seven years. Only 9% of patients in the ED receive no diagnostic testing. As long as EDs retain the 52


etc. The special emphasis of the NIH on translational research, which brings bench discoveries to the bedside, and the array of funding for disaster preparedness all bode well for the continued growth of EM’s research endeavors.

patients, and orthopedic trauma enhance a given hospital’s referral base and enhance that hospital’s financial bottom line. Adding remotely based helicopters or critical care transport vehicles makes this access even more efficient.

Internal or foundation funding sources such as the SAEM Research Fund and EMF also provide training grants and mentorship opportunities for emergency physicians who are interested in developing their academic skills. These grants provide funding for career development of emergency physicians, regardless of disease state or topic-specific funding restrictions. Their success is well documented, and their funds should continue to grow.

The concept of access to the ED as a patient referral source goes beyond EMS systems. Many hospitals are now building free-standing EDs, often in affluent neighborhoods, to attract patients to their hospitals. Patients present to the free-standing ED for acute needs, and are subsequently either admitted or referred into the parent hospital system. The free-standing ED is essentially a remote front door, enhancing access to the hospital system. The marketing of access and availability is a strength that academic as well as community emergency physicians must take advantage of in order to grow and flourish.

Opportunities for the Future Emergency Medicine is a specialty built out of a clinical need. The patient who presents in the throws of acute illness, regardless of the nature of their disease or the time of day or day of the week is our patient. We are a time-based specialty, not a disease-state or organ-specific specialty. We are a diagnostic specialty as well, bringing diagnostic technologies and expertise to bear on our patients to help stabilize them and point them in the right direction for care. As such, opportunities for the growth of our specialty have presented themselves over the last few years. Our ability to seize those opportunities for growth is crucial to our success.

Marketing also extends to within the walls of a given ED. Dedicated chest pain centers, pediatric EDs, cardiovascular treatment centers, or fast-track/urgent care centers within a given ED essentially market the ability of the ED to provide after-hours access to urgent and emergent multi-specialty care. The ED which takes advantage of these marketing opportunities cannot only grow its own volume, but also grow its influence in the hospital and healthcare system. Academic Emergency Medicine is uniquely positioned to take advantage of some of these marketing and outreach trends in Emergency Medicine. Academic Emergency Medicine has the research, educational, and clinical expertise to allow subspecialization and marketing of areas of excellence in EM. We are also leaders in EMS provision as well. The future is bright for academic Emergency Medicine.

One such growth opportunity is observational medicine. The diagnostic technologies that are brought to bear on our patients often require an extended length of stay, beyond the traditional ED stay. Serial examinations, serial blood testing, MRIs, CTs, and nuclear medicine studies all add to the ED length of stay, making if difficult to balance the need for speed in ED throughput with the need to justify medical necessity for hospital admissions. Observation units, run by emergency physicians, with the ED as a gatekeeper, provide such a clinical service. Academic medical centers, where hospital admissions are often logistically difficult, are the home to many of the more successful observation units. Chest pain, asthma, CHF, syncope, TIAs, intoxications, abdominal pain, gastroenteritis, etc. can all be easily managed in a short stay, intensive diagnostic or therapeutic setting. These observation units have grown due to an identified clinical need, and emergency physicians are capitalizing on that clinical need to develop a niche specialty within the healthcare system.

Threats to Academic Emergency Medicine: In general, anything that threatens Emergency Medicine’s ability to provide care for patients in the ED is a threat to Academic Emergency Medicine. This includes both financial threats as well as direct competition from other specialties. The malpractice crisis, for instance, is a financial threat. Declining reimbursement is a financial threat. Managed care, with its retrospective denials of payment and increasing co-pays for emergency care is a threat. Competition for our patients by primary care centers, after hours urgent care centers, or other hospital systems is a threat. While these threats are real, they are also quite obvious to all participants, and probably don’t require much discussion. There are a few threats to Academic Emergency Medicine that are “sleepers” however, which we must guard against.

Another growth opportunity is the utilization of our “front door” for marketing and access purposes. The EMS system has long been Emergency Medicine’s partner in providing seamless care from the pre-hospital arena to the ED. We train and manage EMS systems, and we have long-standing relationships with EMS providers. The utilization of EMS systems to “market” hospital services and attract certain patient populations has been steadily growing. Critical care transport systems which are geared to enhance access to cardiology patients, stroke

First, we must maintain our focus on the provision of emergency care, any time, for any disease, regardless of our patient’s payor status or social acceptability. When we stray from these principles, we will stray from our most important duty, which is to our patients. Maintaining this high ground will forever give us credibility with our peers and our patients. 53


Academic medical centers and academic EDs provide the foremost examples of these principles in action. Second, we must continue to search for new opportunities for clinical expansion into new clinical niches. Many of these opportunities will be provided out of the clinical needs of our patients (such as observational medicine). Failure to seize new opportunities for filling clinical needs or our patients is a short-sighted strategy what will lead to unmet potential for our specialty. Third, in the research arena, we must search for collaborations with other specialties which can enhance our care. Emergency Medicine was not created in a specialty vacuum, but to enhance the care of patients in all specialties. Clinical research bears the same inter-specialty relationships. EM provides the clinical link for many research programs, with access to the subjects needed for clinical trials. Any therapy or intervention that is time dependent, where early intervention can lead to better outcomes, should be initiated and evaluated in the ED. Research involving these therapies should either involve or be initiated by academic EM physicians in academic EDs. Emergency Physicians should look for collaborative relationships with other specialties which are “win-win” for both specialties. Finally, we must take advantage of our educational strengths. We provide a unique educational opportunity for students and residents to treat acutely ill and undifferentiated patient populations. We also provide some of the best bedside teaching of any specialty, in a setting where the most diagnostic and therapeutic interventions can be utilized acutely. This educational niche cannot be under-estimated in its worth to academic medicine.

Conclusion It is difficult to find an area of Academic Emergency Medicine that is not growing. Clinical care, research, and education in Emergency Medicine continue to flourish. The clinical need continues to grow and re-define itself, the research on acute illness continues to mature, and the education of today’s brightest physicians predicts a bright future for our specialty. Academic emergency physicians with vision and leadership will continue to lead this growth, and define the future of our specialty.

References: National Hospital Ambulatory Care Survey: Available at http:// www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm National Residency Match Program: Available at http://www. nrmp.org/res_match/data_tables.html

54


NOTES


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Society for Academic Emergency Medicine 901 N. Washington Avenue Lansing, Michigan 48906-5137 Phone 517-485-5484 FAX 517-485-0801

Emergency Medicine: An Academic Career Guide  

SAEM Career Guide

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