Faculty Development for Community Practitioners

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Faculty

Development

for

Community

Practitioners

Thomas G. DeWitt, MD

ABSTRACT. Developing the academic skills of the in-dividuals who will serve as educators and role models in the community is critical to pediatric resident education in community settings. The main focus of any faculty development program must be on teaching, although for a subset of individuals, the development of research

skills should also be a consideration. The three key

ele-ments that must be considered for an effective faculty development program include: (1) creating a culture of mutual respect between full-time and community

fac-ulty; (2) basing the program on sound principles of edu-cation theory, especially adult learning theory, using ap-propriately trained faculty; and (3) establishing ongoing institutional financial and philosophical support. Effec-tively addressing these elements should create a faculty development program that will help the community practitioner become an effective role model and practi-tioner-preceptor-educator. Pediatrics 1996;98:1273-1276;

f

acuity development, pediatric resident education.

Developing the academic skills of the individuals

who will serve as educators and role models in the

community is critical to pediatric resident education in community settings. The main focus of any faculty

development program must be on teaching,

al-though for a subset of individuals, the development of research skills should also be a consideration. Ultimately, the goal of an effective faculty

develop-ment program is to help the community educator

make the transition from the role of

practitioner-whether it be as clinician, social worker, school

teacher, or other professional-to that of a

practi-tioner-preceptor-educator who can actively help

res-idents learn the knowledge, skills, and attitudes nec-essary to pursue and to assess the practice of primary care medicine.1

The following elements must be an integral part of

any faculty development program, regardless of

size, if it is to achieve the goal of helping the com-munity practitioner become an effective practitioner-preceptor-educator:

1. The academic health center and the community

faculty must respect each other;

2. The program must be based on adult learning

theory and the needs of the community faculty

and the curriculum; and

3. The system must provide ongoing support for the

program and its continuing development.

From Children’s Hospital Medical Center, Cincinnati, Ohio.

Acad-emy of Pediatrics.

MUTUAL RESPECT

A major issue that has historically confronted

medical education in community settings, pediatric

or otherwise, has been the belief that medical educa-tion is best taught in the academic health center. This belief has its origins in the report by Flexner2 at the

beginning of this century. Abraham Flexner, a

non-physician educator, wrote in his treatise on medical education that the clinical professor should

“devel-op-preferably in close connection with the

hospi-tal-a consulting practice, assured thus that his time will not be sacrificed to trivial ailments.”2 The

cre-ation of an academic, elite faculty based in the

ada-demic health center began a trend that grew into the

well-known town-and-gown issues that have

oc-curred throughout this century, particularly with

re-gard to medical education. To be successful,

commu-nity-based pediatric resident education must create

an environment that engenders mutual respect

be-tween the community faculty and the academic

health center faculty and that minimizes

town-and-gown issues.

The first step in this process is recognition that

community faculty, with primary care pediatricians

being the major component, have knowledge, skills,

and attitudes that are critical in the education of

primary care physicians. These attributes are

corn-plementary and additive to the educational program

based at the academic health center, and they should

not be considered a replacement for it. Community

practitioners have extensive experience applying the

core educational components of a traditional,

hospi-tal-based resident educational program to the

prac-tice of primary care. The challenge is to enable them to convey that experience in an effective manner.

Particularly critical in validating community

fac-ulty as teachers are two factors: acknowledging the

inherent skill of community faculty as teachers and

noting that the process of teaching has important

parallels with clinical medicine.3 The practice of

pe-diatrics, especially clinical decision making and

counseling about issues of parenting, has many

ele-ments that reflect basic educational concepts. Most

skilled pediatric clinicians have the training to be

skilled teachers. As importantly, just as clinical med-icine is based on core scientific concepts, teaching is

based on core educational concepts. Thus, the

pro-cess of learning about and becoming a skilled teacher

can be as academically rigorous as the process of

becoming a skilled clinician. Recognizing and devel-oping these skills in community practitioners legiti-mizes their academic role in resident education.

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1274 SUPPLEMENT

importance of teaching as a core knowledge-based

discipline is including not only community

practi-tioners but also full-time faculty as participants in the

program. This highlights the need for all faculty to

formally develop their core teaching skills and

knowledge. It also allows full-time faculty to

experi-ence the skills and knowledge of their community

colleagues, with generally positive results. This

ap-proach can also be applied to development programs

focused on primary care or population-based

re-search, enhancing both the skill and the knowledge

of, as well as the collaboration between, town and

gown faculty.

Incorporating community faculty into the

ada-demic and administrative infrastructure of the

pedi-atric department is another important aspect of

en-couraging the necessary respectful culture. Creation of a division that recognizes the community faculty, whether it stands alone or is integrated with general

pediatrics, should be considered.4 Appropriate

fac-ulty appointments are critical, with those community

faculty who are academically productive having the

ability to be promoted or to be switched to tracks that

reflect that productivity. Community faculty should

be involved in departmental academic activities that

relate to general pediatric training, such as

curricu-lum development, resident selection, general ward

teaching, and primary care research seminars and

studies. A particularly important activity for

corn-munity practitioners is participation in the planning and ongoing assessment of any faculty development program in which they are involved.5 Consideration should also be given to providing not only

appropri-ate financial remuneration to qualified community

faculty but also faculty benefits, such as access to

libraries and other university services.

Public recognition is the final step in creating the

respect for community faculty that is key to a

suc-cessful community-based education program.

Ac-knowledgment by senior academic administration,

ie, department chairs and deans, of the importance of

community faculty through plaques or certificates

displayed both in offices and at the medical center

and through verbal recognition at dinners and other

institutional events is a common approach.

Partici-pation in grand rounds and other formal academic

presentations should also be considered.

Appoint-ment to significant administrative

positions-whether in the division, ie, director of community

pediatrics; the department, ie, associate chair for

community affairs; or the institution-is effective

and appropriate.

THE PROGRAM ITSELF

The following fundamentals need to be

incorpo-rated into the planning and implementation of

fac-ulty development programs for community

practi-tioners:

1. Adult learning theory, andragogy, should be the

major basis of the teaching strategies used in any

program, including those in community settings;

2. The curriculum should be based on the teaching

of core educational and, if applicable, research

concepts; and

3. Logistical issues that facilitate attendance and

on-going participation must be given careful

atten-tion.

All have been more extensively addressed in the

literature, and the following sections will touch on

only the highlights of each.

Andragogy

Andragogy, adult learning theory-in contrast to

pedagogy, child learning theory-is based on the

learner rather than the teacher as the dominant focus

of the educational experience. The basic tenets of

andragogy are to respect the learner, to build on the

learner’s experience, to make the learning relevant,

and to provide a timely opportunity to apply what

has been taught.6 Unlike pedagogy, andragogy

as-sumes that learners bring to the educational

encoun-ter significant experience that will influence both

what learners perceive as their educational needs

and how they will assimilate and incorporate the

knowledge, skills, and attitudes being presented. The

practical application of these tenets, which has been extensively described in the literature, includes such

considerations as limiting the amount of formal

di-dactic presentation and substituting more directed

discussions, using role playing to practice what is

taught, being flexible during the actual educational sessions to adjust for unanticipated needs of learners,

and actively involving community practitioners in

developing the program curriculum.1’3’7

Curriculum

Basic educational and research principles serve as

a foundation for any curriculum used in a faculty

development program. Emphasizing these basic

principles, which are not necessarily linked to any

particular clinical knowledge or skill, allows a

di-verse group of participants to start on common

ground. Thus, a faculty development program can

have a diverse array of participants, from full-time

faculty to community pediatricians to other

commu-nity professionals, who would potentially teach in a

community-based educational program.

In the area of teaching, basic educational principles include the educational planning process, evaluation and feedback, learning styles, and curriculum

devel-opment. With the exception of curriculum

develop-ment, these principles have important parallels with

the clinical practice of pediatrics. For example, the

following educational planning process: (1) setting

overall goals, (2) determining the learner’s needs, (3) establishing learning objectives for the particular

ed-ucational encounter, (4) using appropriate teaching

methods to achieve those objectives, and (5) then

evaluating whether the objectives have been

achieved and giving the learner feedback, can be

presented as an easy-to-remember mnemonic

gnome, which Roberts6 discusses in greater detail.

This process parallels clinical care, as demonstrated in the Table. Similarly, evaluation and feedback have

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TABLE. Relationship Between Educational Planning and Clinical Care

Educational Planning Process Clinical Care

Goals and needs assessment History, physical

examination, and diagnosis

Objectives and teaching Treatment

methods

Evaluation Follow-up

many analogies in the principles of parenting,

espe-cially concerning discipline. Learning styles and

con-cepts of temperament and child behavior also mirror

each other. The teaching of core educational concepts

to health professionals who deal with children

con-sists of building on, and redefining, inherent know!-edge and skills.

In the area of research, concepts of basic method-o!ogy, data collection and analysis, and the

practi-calities of community-based studies should be

ad-dressed. Unlike the educational concepts, these are

often new, or long-forgotten, concepts that require

more time and development. To be successful in this

dimension of faculty development, community

prac-titioners must have a significant com.mitment to

learn and to participate in the process. Often, a

sub-set of community practitioners who are interested in

research, but not in clinical teaching, may serve prin-cipally as role models for practice-based research.

Application of Educational Concepts

In considering the curricular focus of faculty

de-velopment with regard to teaching methods, one

must address the three main teaching strategies used

in community-based medical education-clinical precepting, brief interactive presentations, and struc-tured modeling9’10-that allow efficient integration of

education and patient care. Clinical precepting, the

interactive teaching that centers around the care of a

patient, is the most common method encountered,

and it is particularly complex, because the preceptor

must attempt to meet the needs of both the learner

and the patient.1 Constraints of a busy clinical prac-tice essentially preclude lengthy didactic presenta-tions, and brief, 5- to 15-minute, topic-centered dis-cussions predominate. The third strategy, structured

modeling, is used to facilitate direct patient care

while actively involving the learner in the process;

this is accomplished by identifying before and

dur-ing the clinical assessment particular dimensions of

the clinical interaction that the learner should be

observing. The most critical reason for addressing these teaching strategies is that they are readily

per-ceived by community practitioners as the methods

they need to learn to be effective teachers in their

practices. All three strategies are critical to being able to teach and still to maintain reasonable efficiency in the practice.

Logistic Issues

Logistics is the fourth fundamental that needs to

be addressed in faculty development programs,

es-pecially when busy primary care practitioners are

involved. The educational concepts noted above

re-quire a significant amount of time for assimilation,

incorporation, and practice. Therefore, workshop

sessions to teach these concepts need to be

sched-uled in reasonable blocks of time, a minimum of 3

hours with 1- to 2-day sessions being the ideal. To

build on and to reinforce the elements learned, as

well as to underscore the concept of continuous

learning, these sessions need to be scheduled for

an extended period, preferably with advanced

ses-sions scheduled on an annual basis.7 Although

academic schedules often have the flexibility to

adjust on short notice, community professionals

usually need a longer time frame to make

arrange-ments to attend faculty development sessions. To

accommodate for this consideration, sessions

should be scheduled several months in advance,

optimally with community input as to the day of

the week and time of day. Granting continuing

medical education credit for this activity also

a!-lows community practitioners to use professional

development time within the benefit structure of

the practice. Holding the sessions at sites that are

removed from the usual practice environment, ie,

out of town, helps reduce the tendency of the

participants to remain on call. Finally, underwrit-ing some or all of the cost of the sessions, directly

or indirectly, enhances participation and provides

one approach to financial compensation for

corn-munity faculty.

ONGOING SUPPORT AND DEVELOPMENT

The final element for achieving a successful,

sus-tamed faculty development program is a mechanism

to assure ongoing support and continued

develop-ment of the program. The recruitment and retention

of faculty to direct and teach in the program, the

establishment of committed institutional support,

and the meaningful incorporation of community

fac-ulty into the process are all components of this

ele-ment.

Faculty with expertise, either individually or

col-lectively, in the concepts of adult learning theory, basic educational theory, and teaching in clinical

set-tings-especially in the community-need to be

identified as leaders of the program. To achieve the

required expertise and to model the effectiveness of

such an approach, a team of individuals is often most effective. In particular, members of the team should

have had formal educational training, extensive

practical experience in outpatient clinical teaching,

preferably in the community, or both. To enhance the

skills and knowledge of the program’s faculty in

specific areas, consultants from within or outside the larger institution can be helpful.

Institutional support for the program, both

finan-cia! and philosophic, is critical. Although funding is available externally, including from federal,

founda-tion, and industry sources, long-term survival of the

program is dependent on its incorporation by the

institution, be it medical school, hospital, or depart-ment, as an integral part of the overall training pro-gram. Such incorporation provides institutional

corn-mitment to the concept of faculty development as an

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appropri-1276 SUPPLEMENT

ate allocation of resources. It also identifies

scholar-ship in this area as an academic activity to be

con-sidered in the promotion and salary support of the

faculty involved. The fiscal benefit of supporting

such a program, which has the ability to develop and

then to have as a resource a large cadre of

commu-nity faculty who often volunteer their services, can

make institutional support a financially sound

en-deavor.

The active involvement of community faculty in

all aspects of the faculty development program is the

final consideration in its ongoing support and

devel-opment. Through participation in its planning,

eval-uation, and ongoing development, community

fac-ulty ownership of the program can be encouraged.

As the program matures, community faculty

mem-bers become more skilled, and they can also be used

to teach in the training sessions. Ultimately, faculty

development for community practitioners could

be-come predominantly overseen and taught by the

community faculty themselves, the ultimate goal of

life-time self-learning.

REFERENCES

I. Roberts KB, DeWitt TG. Faculty development of pediatric practitioners:

Complexities in teaching clinical precepting. Pediatrics. 1996;97:389-393

2. Flexner A. Medical education in the United States and Canada. In:

Carnegie Bulletin No. 4. New York, NY: Carnegie Foundation; 1910

3. DeWitt TG, Goldberg RL, Roberts K. Developing community faculty:

principles, practice, and evaluation. Am JDis Child. 1993;147:49-53

4. Broffman G, Stapleton RI. Integration of community pediatricians into

an academic department. Pediatrics. 1995;95:85-88

5. Christiansen RG, Wark K, Levenstein JP. Attitudes of part-time

com-munity internal medicine faculty about their teaching. Acad Med. 1992;

67:863-864

6. Knowles M. The modern practice of adult education. In: Pedagogy to

Andragogy. New York, NY: Cambridge; 1980

7. Hitchcock MA, Stutter FT. Bland CJ. Faculty development in the health

professions: conclusions and recommendations. Med Teach. 1992;14:

295-309

8. Roberts KB. Educational principles of community-based education.

Pe-diatrics. 1996;98(suppl):1259-1263

9. Medio F, Wilkerson L, Lesky L, Borkan S. Integrating teaching and

patient care. In: Edwards JC, Marier RJ, eds. Clinical Teaching for Medical Residents. Roles, Techniques and Prograns. New York, NY: Springer; 1988:214-227

10. Schemer AP. Guidelines for medical school education in

community-based pediatric offices: American Academy of Pediatrics Education

Subcommittee on Medical School Curriculum. Pediatrics. 1994;93:

956-959

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1996;98;1273

Pediatrics

Thomas G. DeWitt