Intervention and Context

The Clinician Educator Distinction (CED) was launched within the Yale internal medicine residency programs in 2016 as 1 of 4 “Distinction” pathways. The distinctions are optional, 2-year programs aimed to provide augmented training in medical education (Clinician Educator), research (Investigation), global health (Global Health and Equity), or health care systems (Physician Leadership and Quality Improvement). All distinctions include a core curriculum, experiential activities, scholarly projects, and faculty mentorship. Residents are invited to apply to join one distinction at the beginning of their postgraduate year (PGY)-2. Those who fulfill respective completion requirements receive a certificate of distinction at graduation.

The objective of the CED is to develop residents' skills across educator competencies to facilitate future careers as CEs. To graduate with the CED certificate, residents must meet a minimum of 85 activity credits spread across 4 domains: (1) education theory; (2) observed teaching with feedback; (3) medical education scholarship; and (4) leadership/administration (Table 1). Residents are not provided protected time but can use elective or research blocks to complete distinction requirements. Details regarding the CED curriculum, including funding and faculty support, can be found in the online supplementary data.

Table 1 Credit Requirements to Graduate With the Yale Clinician Educator Distinction

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Data Collection

We conducted a qualitative study of the first 2 cohorts of Yale CED participants who completed internal medicine residency training in 2018 or 2019.

Eligible participants included graduates from all 3 internal medicine residency programs at Yale: the traditional internal medicine (T), primary care (PC), and internal medicine-pediatrics (MP) residency programs. Graduates who had enrolled in the CED but did not complete certification requirements were also eligible. Invitations were sent by email and informed consent obtained prior to each interview.

Two authors (Y.Y., K.G.) conducted in-depth, semi-structured, one-on-one interviews between July 2019 and January 2020. Interviews followed an open-ended interview guide (provided as online supplementary data) that was informed by the literature, study aims, SCCT framework, and was reviewed by faculty leaders of the CED. Questions explored perceived benefits, efficacy of instructional methods, challenges to CED completion, motivations and expectations regarding CE careers, and experiences within the context of the educator community. Questions from the interview guide were iteratively adjusted with consensus between the authors as new concepts arose during data collection. Interviews were conducted in batches to allow for concurrent data analysis until no new concepts emerged. Interviews were audio recorded, professionally transcribed, and de-identified.

Additional data reported in this study regarding career paths and teaching and scholarly output were routinely collected via MedHub as part of distinction activity requirement tracking.

Data Analysis

We performed thematic analysis of de-identified transcripts using an inductive, constant comparative, constructionist approach via Dedoose. Each of the first 6 interview transcripts were coded independently by an initial team of 2 authors (Y.Y., K.G.) via open coding to generate a preliminary list of codes. Subsequent interviews were reviewed in batches by only one member of the coding team (either Y.Y. or K.G.), assigned such that the coder was not the same individual as the interviewer.

Once interviews were complete, a third author (C.S.) who had not participated in the interviewing process was included in the final coding team to ensure appropriate application of codes to transcripts and to review developing themes. The final coding team held regular meetings to iteratively modify the coding structure, reach consensus on transcript codes, and develop initial themes from coding memos. Coded texts were compared to analyze concepts and construct a final code book and thematic structure. The final coding structure was used to recode all transcripts.

The interview guide, coding structure, and resultant conceptual model were externally reviewed in consultation with expert educators trained in qualitative research in the Teaching and Learning Center at Yale School of Medicine.

Member Checking

All participants received a draft of the results by email and were invited to provide feedback regarding the identified themes. Nine participants responded to member checking, which did not lead to changes in study results.

Reflexivity

The research team consisted of an internal medicine fellow (Y.Y.), who was a founding member and graduate of the CED during their residency, a core faculty member of Yale Primary Care Residency Program (K.G.), and an associate program director of the Yale Traditional Residency Program (C.S.). All 3 authors were faculty co-directors of the CED. Two authors (Y.Y., K.G.) completed a scoping review on CETs in GME concurrent to the completion of this study.²⁰

This study was deemed exempt from review by the Yale School of Medicine Institutional Review Board.

Motivation to Go Beyond the Expectations of Residency

Many participants had pre-existing intentions to engage in teaching activities and would have sought opportunities similar to those offered by the CED independent of the distinction. Most described a longstanding interest in medical education and a history of seeking opportunities to participate in teaching (eg, serving as a teacher's assistant in college or medical school). Participants also joined the CED to focus on skills that might have garnered less attention earlier in their training. The extra time needed to focus on these skills through the CED was considered worthwhile and feasible (Table 3).

Additionally, participants reported that receiving credit or being observed gave them a sense of motivation to expend additional effort:

“The CED gave me sort of more [impetus] because I wanted to fulfill as many of the requirements as I could. So, I may have still done it but it definitely gave me sort of that push to be like ‘Oh, you should continue with this.'” (MP4)

Some graduates participated in the CED from a perception that they might be “missing out.” Having the opportunity to distinguish themselves as early educators was an additional external motivator for participation.

Early Educator Development Outcomes From Distinction Participation

Graduates reflected that they developed tangible skills for CE careers through CED participation, such as teaching in a variety of formats, adjusting teaching to different levels of learners, providing feedback, learning to critically appraise the teaching of others, and developing and assessing education interventions. Many also attributed increased self-efficacy in their current post-graduation jobs to the techniques and concepts developed through the CED. Participants also discovered previously unrecognized gaps in their skills and identified resources for continued development (Table 3).

The CED helped participants develop a clearer understanding of the breadth of CE careers. For example, many initially applied to the CED with hopes of becoming CEs but were focused solely on clinical teaching skills development. Through the CED, participants learned that CEs are involved in more than clinical teaching:

“I didn't really know what I didn't know, so I didn't know what to ask or what to think about. But just that idea that a huge chunk of folks [say], ‘Oh yeah, I love teaching, I love teaching.' But that alone is not going to get you a job as an educator being paid to just sit around educating.” (PC1)

Many graduates reflected on gaining a better appreciation of medical education scholarship, the role of scholarship in CE advancement, and the logistics by which CEs gain “protected time” for education. Graduates were able to calibrate this deeper understanding of CE careers with their own personal and professional interests. For some, the CED nurtured an interest in incorporating scholarship into their professional identities, while others determined that they preferred pursuing careers focused on clinical teaching without scholarship pressures.

Graduates noted that the CED enhanced their post-residency fellowship applications or job searches. Some felt more competent in documenting their skills and having informed discussions about educator career goals. Graduates also felt the CED equipped them with a better understanding of how to navigate early careers as CEs. Several chose to pursue additional medical education scholarship training.

Finally, the CED introduced participants to a broader group of peers and faculty within the medical education community. Identification with this community allowed participants to interact with like-minded peers within a safe learning climate. Networking opportunities at the undergraduate medical education and GME levels facilitated further practice and improved their teaching. Additionally, participants found role models for career development and professional identity formation:

“I might have gone this way one way or another in terms of getting an academic position, but I do think [the CED] helps because education [has] not always been the most popular route to go. But seeing other people who are attending, who are successful, and who are enjoying what they're doing as role models, is a really helpful thing to see for your own career.” (T2)

Factors Enabling Curricular Efficacy

Participants reported the CED curricular structure helped them reach their personal goals. They remarked on the numerous teaching opportunities offered to CED participants, as well as the positive impact of direct observation and feedback on skill development. Other effective features included flexible credit requirements, assigned advisors to navigate the distinction and connect with mentors, and opportunities for active learning and application of skills. Several of these factors—notably experiential workshops and direct observation and feedback on teaching—were reported as effective even by those who did not complete the distinction. Those who did complete the CED said the time commitment was reasonable (Table 3).

Opportunities for Program Improvement

A commonly identified area of improvement was the need for flexibility of distinction workshop scheduling to accommodate resident schedules. Barriers included call schedules, sign-out times, childcare responsibilities, and wellness needs. Many of the suggestions to improve access to didactic sessions centered around varying the time of day of the didactics and recording them for asynchronous learning. The need to leverage technology, like Twitter, Zoom, and mobile devices, was also mentioned (Table 3).

As noted in the supplement, residents are assigned a CED faculty advisor who assists them in finding a scholarship mentor. Graduates raised several recommendations to improve interactions with faculty, including increasing the frequency of meetings and more defined mentorship expectations, especially surrounding scholarship. Specifically, graduates felt many mentors in the CED were excellent clinical teachers but did not have the necessary skills to support their scholarly projects.

Additional areas for improvement included communicating a clearer set of pathway requirements, incorporation of a more streamlined web interface for credit tracking, reduction of “busywork” when observing others teach, and increasing structured discussion and reflection with peers.

Balancing CED requirements and competing priorities was the main reason some participants did not complete the distinction. However, these participants appreciated the opportunity to engage in CED activities even though they were not formally part of the distinction:

“I didn't know from like a time standpoint if I was going to be able to fulfill all the requirements, and so I didn't want to necessarily be a burden on the leadership...So that's why I just figured it'd be better to not formally do it, but still pick and choose a few things that I enjoy and thought would be helpful to me.” (T9)