Building Faculty Community: Fellowship in Graduate Medical Education Administration

Graduate Medical Education (GME) is undergoing dramatic changes. Successful program directors must demonstrate multiple areas of expertise that extend their duties beyond mentoring and curriculum oversight to include effective performance assessment, resource management, and employment-law adherence. Over the past decade, several factors have contributed to this change in roles. First, the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project has established that advancement in medical knowledge and patient-care skills is not a sufficient indicator of competently trained physicians. Other areas of required competency now include communication/interpersonal skills, practice-based learning and improvement, systems-based practice, and professionalism skills. The ACGME now demands that these skills be taught, documented, and assessed within the broad definitions of these 6 major areas of competency.

Second, as a result of the patient-safety movement and the recognition of diminished decision-making abilities in trainees due to fatigue, trainee work hours are now regulated.1,2 No longer is it acceptable to allow trainees to take part in 45 hours of continuous clinical responsibilities and/or 120-hour workweeks. Third, both the globalization of health care education and US security interests in the post-9/11 era have led to increasing complexity in trainee selection, employment, and documentation.3 Therefore, maintaining quality GME requires expertise in not only curriculum and instruction but now also in educational assessment and administration.

The medical education community has made great strides in promoting curriculum-design instruction, as evidenced by the growing number of teaching scholars programs in academic medical centers4–6 and the advanced National Board of Medical Examiners (NBME) assessment instruments. However, the training of faculty in educational leadership (formerly known as educational administration) is lagging behind training in teaching. There is little administrative guidance available for the novice, newly appointed program director.

Most GME leadership training is in the form of lectures, role modeling, and short-term workshops.7,8 Although not without value, these short-term experiences cannot fully capture the complexity of GME operations, the need for networking, the limitations and nuances of GME, and the spirit of stewardship needed for effective educational administration.9 The purpose of this manuscript is to describe the development of a program within the Department of Graduate Medical Education at Stanford Hospital and Clinics to teach and give program directors experience in the day-to-day working of the Department. The program provides the opportunity to observe, question, and practice essential high-level administrative skills under the direct supervision of Stanford's designated institutional official (DIO).

The Department of Graduate Medical Education at Stanford Hospital and Clinics recently performed an institution-wide needs assessment for the 77 fellowship and residency programs at the institution. This entailed conducting 69 semistructured interviews with acting program directors and associate program directors.

Findings from the needs assessment revealed that 41% of all program directors desired more educational and procedural information from the Department of Graduate Medical Education. Specifically, the program directors desired more information on program administration, including enrollment of foreign graduates, program expansion, completion of program information forms (accreditation documents), and efficient organization of the information needed for continued accreditation. Additionally, a significant number of program directors reported feeling isolated in their roles both from each other and from the Department of Graduate Medical Education. They requested greater communication of information, as well as opportunities to participate in an educational community.

As a result, the Department of Graduate Medical Education has developed an innovative professional-training experience for program directors: the Fellowship in Graduate Medical Education Administration. The goals of this one-year program include:

1. Producing a faculty cadre of knowledgeable and effective educational administrators who demonstrate greater understanding of complex administrative processes, such as visa requirements, recruitment practices, accreditation regulations regarding program expansion, and government- and hospital-based funding for trainees' salaries.

2. Completion of a curriculum which encourages active learning by the faculty fellow.

3. Creation of a collaborative partnership between program directors.

4. Promoting greater recognition among program directors and other key faculty of the unique challenge facing GME: balancing its key components of service and education.

The Fellowship entails a one-day-per-week commitment to the Department of Graduate Medical Education by the selected faculty fellow, during which time he or she must be relieved of all clinical responsibilities. The faculty fellow is responsible for completing two projects during the fellowship year: one service project and one individual educational project.

For the Fellowship's inaugural year, there was one applicant. However, beginning next year, individual fellows will be selected from a pool of faculty based on an application submitted to the Department, which includes a description of the applicant's past experiences and interest in GME and a formal proposal for an individual project during the fellowship period. A position as program director of an accredited specialty is required. Additional application requirements include a letter of recommendation and support from the respective departmental chairman and a copy of the applicant's curriculum vitae. Though we do not yet have a formal applicant-rating system, we include in the application process an analysis of the applicant's evaluations by students and the Department. Faculty evaluations at Stanford are roughly designed in core competency format and can provide a relative ranking. Special attention is given to teaching abilities, professionalism, and the applicant's ability to foster professional development among students. After interviewing with the DIO and other professional GME staff, the final selection is made by the DIO.

The faculty fellowship program provides an outlined curriculum to be covered in the year. Topics include:

• █ Requirements for ACGME-sponsored program expansion

• █ Importance of faculty diversity

• █ Managing the “failure to thrive” resident (approaches and resources)

• █ Fundamentals of employment law (hiring, firing, and accommodations)

• █ Service excellence and principles of patient-centered care

• █ Designing multirater and self-assessments for resident evaluation

• █ Essential details of Department of Homeland Security visa requirements

• █ Using program portfolios to identify “programs in trouble”

• █ Creating an e-portfolio for residents

The educational resources used for this curriculum include ACGME-generated materials, instructional materials from the hospital's legal counsel, and a standard text, Handbook of Research on Educational Administration.10 Topics are assigned by the DIO. Each month the faculty fellow reviews the associated educational materials and discusses them with the DIO. A luncheon program is then held for all program directors that is jointly directed by the DIO (or other GME administrative professional staff) and the faculty fellow.

The current faculty fellow will also help orient the next faculty fellow by meeting with him or her at the beginning of the fellowship year, serving as a mentor throughout the year, and helping guide the institutional goals for that year.

The goals of the service project assigned by the Department to this year's faculty fellow are to improve communication between the core pediatric graduate-training program and the 13 pediatric subspecialty fellowships; to assist the pediatric core and subspecialty programs in preparing for the upcoming ACGME-mandated internal reviews; and to counsel prospective program directors in submitting initial accreditation materials to ACGME. To improve communication, this year's faculty fellow is acting as a consultant to the pediatric programs, helping to standardize their assessment methods, and providing assistance to individual program directors in developing curriculum, mastering ACGME policies, writing assessment tools, and preparing for accreditation review. Currently, the faculty fellow is working with pediatric otolaryngology to develop the curriculum and other required program components to submit an ACGME application for initial accreditation.

Earlier this year, the department chairman of pediatrics asked for assistance in coordinating the 13 pediatric subspecialty fellowships and providing common language for accreditation. The faculty fellow developed an agenda for group meetings, reviewed the individual subspecialty program information forms with special attention to best practices, and developed a program information form that could be shared among the pediatric subspecialties. All these documents were reviewed with the fellow by the DIO and corrected as needed. The faculty fellow then presented the findings to the pediatric subspecialist program directors and coordinators. In addition to saving time and administrative expense, the project brought the 13 program directors together and led them to form an alliance to develop and share curriculum. Similar though smaller-scale leadership programs were formed in the Department of Urology and Physical Medicine and Rehabilitation to further develop GME expertise across departments and to increase opportunities for collaboration.

This year's faculty fellow has designed an individual project focusing on the use of high-fidelity patient simulation (HFPS) as an instructional and performance-assessment tool for high-acuity, low-incidence anesthetic management cases, such as diaphragmatic hernia. This template for HFPS instruction, along with information regarding necessary associated video techniques, can be built upon by other departments for their own case-specific, simulation-based instruction and assessment.

Financial support is supplied by the individual department in which the fellow is appointed and includes nonclinical salary support for 1 day per week (based on current salary) along with regularly scheduled nonclinical days. The Department of Graduate Medical Education provides a minimum of 1 hour per week of individual mentoring by a member of the GME staff, office space in the GME office, and administrative support (0.2 full time equivalent [FTE]). Additionally, members of the Stanford University School of Education faculty have agreed to act as consultants and provide appropriate directed reading.

The fellowship is expected to produce 2 major outcomes:

1. A minimum of 2 presentations based on either the individual or institutional service project assignment to any of the following: GME forum, departmental grand rounds or educational committee meetings, and national or international medical education meetings; and production of a manuscript suitable for publication in a peer-reviewed medical specialty or medical educational journal. To date, 1 national meeting workshop presentation and 4 internal meetings have been conducted by the faculty fellow dealing directly with the program as described or to promote the understanding of curricular items among other program directors.

2. Successful completion of individual project goals. Twelve of the thirteen pediatric subspecialty programs have successfully completed internal reviews. Additionally, the newly formed group of pediatric subspecialty program directors and their coordinators are holding quarterly meetings to discuss residency curriculum.

The first year of the program enjoyed successes and led to the identification of limitations. In the view of the current faculty fellow, the successes are as follows:

1. Scheduled nonclinical time has allowed the faculty fellow to spend uninterrupted time learning essential administrative policies and procedures.

2. Research expertise of the faculty fellow has enabled the Department of Graduate Medical Education to engage in scholarly research activities related to the advancement of GME.

One significant limitation is the lack of developed curricular materials and activities. At the end of this year, the Department of Graduate Medical Education will evaluate the strengths and weaknesses of the program to guide continued programmatic improvement.

Administering a residency program has become a complicated endeavor, the complexity of which is only likely to increase over time. Institutions must partner with faculty in order to develop the most-effective strategies for successful educational administration. This paper has delineated the goals, structure, and expected outcomes for a one-year Fellowship in Graduate Medical Education Administration program which actualizes and operationalizes this partnership.

The outcomes achieved during the initial fellowship year reinforce the practical utility of the program. The program was found to offer benefits concomitantly to the individual program directors as well as the Department of Graduate Medical Education in general. Given the goals and clearly defined structure of this innovative program, it is also easily generalizable to other institutions. Program directors will benefit from the opportunity to observe, operate, and interact with GME professional staff on a daily basis. Through learning the principles of educational administration, program directors are able to more effectively oversee their own programs. In addition, they will be able to transmit their new knowledge to other faculty and create a collaborative culture between faculty and the Department of Graduate Medical Education.

One significant limitation that was identified is the lack of developed curricular materials and activities. The opportunities and benefits that this program affords, given the outcomes reported, outweigh the limitations and minimal costs of the program. In addition to saving time and administrative expense, this program brought 13 pediatric program directors together to form a curriculum-sharing network which will yield benefits into the future. Moreover, 12 of the 13 programs have already successfully completed internal reviews. The Department of Graduate Medical Education will similarly benefit by gaining a better understanding of a program director's perspective while also drawing upon the research expertise of the faculty fellow to engage in scholarly research activity. In summation, this program builds a community of informed and effective educational administrators, helps eliminate academic silos, increases leadership skills in faculty, and provides a framework for additional research and testing of its effectiveness in other teaching hospitals and institutions.