Teaching Academies: Putting the School Back in Medical School

The first Glenda Garvey Scholar, Jonathan Barasch, Ph.D.'87/M.D.'88, and students in the Journal Club, part of the Science Basic to the Practice of Medicine course for first-year students. Photo by Charles Manley.

BY GINA SHAW
THE LEGACY OF A P&S EDUCATION REACHES BACK TO THE school's beginnings, when Samuel Bard and five other professors were named to the medical faculty of King's College, the original name of Columbia University. A P&S education is praised not only for being among the oldest in the nation Penn founded a medical faculty a few years before Columbia's but for being one of the most traditional medical educations around.
Each generation of medical students has had its teaching greats. Graduates from the 1940s and 1950s recall with almost missionary zeal the teaching talents of Dana Atchley, Robert Loeb, Dickinson Richards'23, and others. Students a half century later in the late 1990s singled out Andrew Wit, Jay Lefkowitch'76, Steve Miller'84, and Glenda Garvey'69 for their teaching contributions. Among those, Glenda Garvey's commitment to education, to patient care, and to passing along her ideals to students and residents has become the exemplar of a P&S education. So much so that before she died in 2004, P&S announced plans to create a Glenda Garvey teaching academy in response to a medical education environment defined by increasing work loads and decreasing rewards for teaching.
The challenge of maintaining quality teachers is not one unique to P&S, but P&S is joining a growing movement to address the challenge. The school is learning from the struggles of its peers. The University of California-San Francisco is a good example.
After Daniel Lowenstein was asked by his medical school dean at UCSF to lead the effort to rekindle the school's educational mission, he presided over six months of meetings but the group concluded what other top medical schools have found: "Deans need to value the education mission more and convey that message to faculty, particularly department heads."
"Like Columbia, Harvard, Duke, and other premier medical schools, UCSF has a very strong tradition in biomedical research and clinical care. And, like everywhere else, the education mission has become more and more marginalized," says Dr. Lowenstein, professor of neurology at UCSF.
But if UCSF, headed by a man Haile Debas so committed to the first mission of medical schools that his peers call him "the education dean," had not been able to make that mandate a reality, what medical school could?
It was then, Dr. Lowenstein says, that he realized something had to change. "It dawned on me that of course we can't change things with the way the current system is set up. Department chairs are hired to make their programs grow, and growing a program means investing in leading researchers and superb clinicians who can advance our knowledge and practice of medicine, bring in funding, and create an international reputation," he says. "Investing in a spectacular teacher, from a financial perspective, is a relatively terrible investment. It's the system that's flawed."
Education could not compete with a medical school's other missions within the department structure, Dr. Lowenstein decided; it needed to be literally its own distinct entity. This new "department without walls" would have the sole purpose of advancing the education mission, with no competing interests. Through a singular focus on education, it would not only reward teaching, but also create a forum for discussion on curricular innovation and bring together teaching faculty to think about advancing the teaching mission, first and foremost.
But what would the department chairs say about creating a new entity that would compete with all of them for resources? To Dr. Lowenstein's surprise, they said, essentially, "Go for it!" Using $5 million carved from the school's endowment, the Haile T. Debas Academy of Medical Educators was born and with it a national movement.

A Movement is Born
Actually, Dr. Lowenstein's 1999 brainstorm about a medical school teaching academy wasn't an altogether new idea. The first teaching academy in medical education was born at the Medical College of Wisconsin 15 years ago. MCW's Society of Teaching Scholars began with 12 founding members and had grown to 40 members approximately 4 percent of the teaching faculty by 2004.
But the concept really began to gain momentum at the turn of the 21st century, as first UCSF, then Harvard Medical School and Baylor College of Medicine inducted the first members of their academies within about a year of each other. Other institutions, like Mayo and the University of Chicago, launched academies earlier, but the new programs caught fire in a way that led other medical educators to take notice. To some extent, says Dr. Lowenstein, the reason for that success was financial. "Programs that have really grown are programs where the dean has committed substantial funding to the success of the academy," he says.
By late 2003, 22 teaching academies were in various stages of development at medical schools throughout the country, according to an article by Charlene Dewey, associate professor in general internal medicine at Baylor College of Medicine, in the April 2005 issue of Academic Medicine.
Soon, P&S will join that list; at the 2003 commencement, Executive Vice President and Dean Gerald Fischbach announced the formation of the Glenda Garvey Teaching Academy. It's still in its formative phases and the first "class" of Academy members has yet to be named, but P&S leaders hope the new academy will create the kind of hothouse environment for medical education at Columbia that has fueled success at UCSF, Harvard, and Baylor.

How a Teaching Academy Works
Each school's program is slightly different, but the programs share a few common, critical characteristics, as Dr. Lowenstein and co-authors David Irby, Molly Cooke, and Boyd Richards identified in an article in Academic Medicine in August 2004:
> a mission that advances and supports educators, provides faculty development, promotes curriculum improvement, advances educational scholarship, and offers protected faculty time for education
> a membership composed of distinguished educators who are selected through a rigorous peer review process that assesses contributions to teaching, mentoring, curriculum development and leadership, and educational scholarship
> a formal school-wide organizational structure with designated leadership
> dedicated resources that fund mission-related initiatives
For many of the academies, the first few years of growth have been about establishing their programs. At UCSF, the teaching academy now has 61 members, out of a total teaching faculty of 1,500. Harvard's Academy of Distinguished Medical Educators has inducted almost 150 members since its first "class" in 2003. Baylor's academy has 63 members and is expected to grow to a total between 100 and 150.
During these early years, Harvard has pulled together a number of disparate teaching awards into a much larger, more widely recognized schoolwide teaching award ceremony; sponsored a number of faculty development programs, including an annual education day run like a scientific meeting with poster sessions, workshops, and plenaries; and funded some 50 faculty initiatives in curricular innovation with small, $10,000 stipends. At UCSF, the lion's share of the academy's operating funds support a series of grants in educational innovation, available to both academy members and nonmembers; it also hosts seminars and offers a fellowship program in medical education. Baylor also provides mini-grants, hosts forums and a seminar series in medical education, and sponsors an annual faculty teaching recognition reception.
Now, says Dr. Molly Cooke, who is the Debas Academy's director, academies like UCSF's are turning their attention from "getting started" toward broader support of the teaching mission. "We have been active from the getgo in support of what I think of as our 'third mission,' promoting curricular innovation through an internal small grants program," she says. "That was a relatively easy program to get started, because all it took was money. Now, we're seriously looking at ways that we can be active beyond this, by moving the support of teachers and teaching out to the departments, where people really live."

Promotions: the Coin of the Realm
The real measure of the success of the academy movement, says Brownie Anderson, senior associate vice president for medical education at the Association of American Medical Colleges, will be when promotion and tenure decisions for faculty members are based as much on their contributions to teaching as their contributions to research and clinical service. "That's the coin of the realm that we have now, and that will be when we really know that this is being valued," she says.
At Baylor, the Academy of Distinguished Medical Educators seems to have had an effect on tenure and promotions. "Our P&T committee now actually recommends that for faculty members to be promoted on a clinician-educator track, they should have what we call our Fulbright & Jaworski faculty award for excellence in teaching," says Baylor's Dr. Dewey. (These awards are the primary way in which Baylor faculty members are named to the Academy.) Indeed, some might say that Dr. Dewey has been the prototype for clinician-educator promotion based on academy membership: A teacher in the ambulatory clinic and the inpatient setting as well as in faculty development, she has been promoted to associate professor.
"While there have been others who were promoted here at Baylor on a clinician-educator track, it wasn't many," she says. "At this point, I'm probably the one person currently in the trenches who was promoted this way, and I think it will set a trend. I think the academy has already made inroads here at Baylor for clinician-educators to be accepted and rewarded as a true faculty position."
Results have been even more pronounced at UCSF and Harvard. Within UCSF's carefully articulated promotion system, an advancement that occurs faster than the expected schedule is referred to as an "acceleration." These are usually quite rare: Less than 5 percent of a given year's personnel actions are accelerated, almost always as a result of outstanding grant-getting or clinical activity. "They're often retention moves," says Dr. Cooke. But since the academy was inaugurated, 14 percent of personnel actions for its members have been accelerated. "That's very striking, and it didn't use to happen for educators."
In the first two years of Harvard's academy, members were promoted at twice the rate of the faculty at large. "It wasn't a controlled experiment, and we certainly couldn't submit it to the New England Journal of Medicine, but the credential of membership in the academy plus our help in documenting credentials and serving as advocates clearly seems to have had an effect," says George Thibault, M.D., who directs Harvard's academy.
But that's only a beginning. "We do have notable examples of people who've gotten to be full professors based almost entirely on their teaching credentials, but those are still too rare," says Dr. Thibault, who also chairs a faculty committee on the promotion of clinician-teachers.

Growing Pains
Glenda Garvey with residents in the medical ICU in 1988
Glenda Garvey with residents in the medical ICU in 1988
At UCSF, Dr. Cooke has consulted with department chairs and service chiefs about their impressions of the academy. If a department has academy members, she asks about the impact of academy membership on the faculty members and the impact on faculty who care about teaching but are not members of the academy. The answers are revealing: "The chairs love the academy and think it's a wonderful thing that has increased the prominence of medical education on campus and rewarded outstanding teachers," says Dr. Cooke. "But when we ask them what it's done for teachers who are not academy members, every single chair pauses and says, 'I don't know.'"
That's a challenge that leaders in the academy movement agree will have to be addressed: making sure that medical education academies benefit not just their members, but all teaching faculty. "An organization that is cherished by its 61 members is not nearly as important as an organization perceived as influential by everyone who has a significant role in medical student education in the school," says Dr. Cooke.
"The primary goal of a teaching academy is not to serve the needs of its members but the teaching mission and the teaching faculty at large," agrees Dr. Lowenstein.
So academy leaders are seeking a fine balance between elitism and inclusion. "That's one of the tensions of creating an academy," says Harvard's Dr. Thibault. "We want it to be a little 'elitist' after all, it should be an honor, an important credential that people should aspire to. On the other hand, academy membership will always represent only a small percentage of the faculty who actually teach, and its existence should benefit everyone, not just academy members. We want it to improve the climate and the culture surrounding teaching at Harvard and provide real service to everyone."
One way in which UCSF is now striving to increase its academy's benefit to all teaching faculty is by using its members as liaisons to their departments, increasing departmental activities in support of teaching.
What else do medical educators want from these new academies? The top item on most faculty members' wish lists is protected time. "In a perfect world, we'd have the $100 million it would take to endow the thousands of hours that faculty spend teaching," says Dr. Cooke. "Right now, it's really impossible for a number of faculty to do the amount of teaching that they would really like to, because they can't put together their salaries if they teach that much."
Currently, there's no specific funding stream for teaching, nor will even the best-funded academy be able to create such a revenue base. But what they may offer is a more unified voice to help advocate for innovative solutions to help pay for teaching time. "I do think people will 'donate' their time to teaching if they think that it won't come back to bite them in the promotion process," says Dr. Cooke.
Other questions about the growth and role of academies for example, issues of how large they should become and how extensive members' responsibilities should be remain to be answered. "We're struggling with those issues now," says Dr. Thibault. "We want to make sure academy membership represents meaningful work, without being onerous. We don't want to become another burden for faculty members who already feel underpaid and unrewarded."
It's too soon to know if teaching academies will be effective in restoring the teaching mission from its second-class status in academic medicine. But early signs are promising. "We're in an absurd situation in medical education in the United States, where because of economic challenges in our system, the best faculty don't feel like they're being supported," says Dr. Lowenstein. "The reason you have such great faculty at a place like Columbia is because you have people who are gifted teachers, love the environment of a medical school, and are devoted to the needs of their students. We have to find ways to reward that."

The Glenda Garvey Academy
Columbia's nascent teaching academy, the Glenda Garvey Teaching Academy, expects to name its first "class" of physician-educators soon. More than $2 million has been raised in the multimillion dollar campaign to fund the academy, thanks in large part to two generous gifts. The academy's $1 million lead gift came from Stanley and Joy Ho, president and vice president, respectively, of their familyowned business, Allure Home Creations Co. The gift honors their long-time physician, Ron Drusin'66, professor of clinical medicine and associate dean for education. An additional $1 million has been raised by faculty, alumni, and students at Dr. Garvey's alma mater, the Brearley School.
In many ways, the Glenda Garvey Academy will resemble academies at Harvard, Baylor, and the University of California-San Francisco. An independent "department" of its own, with members chosen by peers for their excellence in teaching, it will be a community in which clinicianeducators can share ideas, find support, and explore innovations in health professions teaching. It also will promote curriculum innovation and reform and encourage funding and support for educational initiatives.
But in one significant way, Columbia's academy differs from other programs: It will encompass all schools at Columbia University Medical Center P&S, the School of Dental and Oral Surgery, the Mailman School of Public Health, the School of Nursing, and the graduate program. The academy will eventually have 48 members representing the four schools. The first 12 will represent the schools equally three each from the medical, dental, public health, and nursing schools. Criteria for membership include teaching excellence as identified by student and peer evaluations, teaching style and content, use of innovative approaches to teaching, and evidence of collaborative approaches across programs and schools.
Dr. Fischbach predicts that the new academy will have a "transformational" effect on health professions education at Columbia. "It will infuse and reinvigorate our educational mission with fresh vision and purpose, much as Dr. Garvey did during her lifetime."
Dr. Garvey, a 1969 P&S graduate who died in March 2004 at the age of 61 after a long battle with colon cancer, had come to symbolize medical education at Columbia. During her 25 years as a member of the faculty, Dr. Garvey trained more than 3,000 medical students, along with every intern and resident who passed through the Department of Medicine.
The Garvey Academy, an umbrella organization for all efforts to recognize, reward, and improve teaching, includes the Garvey Scholars program. The scholars program was created to recognize faculty active in teaching, particularly in the third-year clerkship in medicine, a special interest for Dr. Garvey, who directed the clerkship for 20 years. Contributions from her classmates at the Brearley School, an Upper East Side school for girls that Dr. Garvey attended before entering Wellesley College, were earmarked for the Glenda Garvey Scholars program.
Jonathan Barasch, a Columbia Ph.D. and M.D. graduate (1987 Ph.D. and 1988 M.D. ) who is a tenured associate professor of medicine and of anatomy and cell biology, was recently named the first Glenda Garvey Scholar. Dr. Barasch, who is considered an enormously talented teacher, was a preceptor for many years in Dr. Garvey's third-year clerkship in medicine. Dr. Garvey personally selected Dr. Barasch for this honor.

To inquire about supporting the Glenda Garvey Teaching Academy, contact Development at 212-304-7200.

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