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Editorial |
1 From the Department of Radiology, Education Division, Indiana University Medical Center, 702 Barnhill Dr, RI 1053, Indianapolis, IN 46202-5200. Received April 24, 2001; revision requested June 28; revision received and accepted June 28. Address correspondence to R.B.G. (e-mail: rbgunder@iupui.edu).
Index terms: Education • Radiology and radiologists, departmental management
The ongoing investments of radiology departments in their faculty members’ capabilities as clinicians and researchers should be accompanied by ongoing investments in their capabilities as teachers. Part of the need for faculty development stems from the fact that most medical educators have received little or no formal instruction in how to teach. The curricula of our medical schools and residency programs frequently ignore teaching, and we tend to make the unwarranted assumption that anyone who has completed medical school and residency is a qualified educator (1). In fact, however, educational researchers have shed considerable light on what makes an effective teacher, and radiology programs can capitalize on these discoveries by instituting faculty development programs.
This article addresses three questions: First, why should radiology departments consider making investments in improving the quality of their teaching? Second, once the decision is made to proceed with a faculty development program, what theory and skills should it attempt to teach? Third, what methods show the most promise in helping faculty members to become better teachers?
Rationale
The quality of today’s health care bears the imprint of the medical educators who have taught medicine over the past few decades, and the way medicine is being taught today will influence the quality of health care for decades to come. If medicine is poorly taught, the quality of health care will suffer. If it is taught well, everyone involved in health care stands to benefit, including not only patients and physicians but also families, allied health professionals, employers, and health care payers. The same can be said for the quality of biomedical research. Producing top-notch biomedical researchers requires top-notch research training programs, which in turn require top-notch research faculties.
Many crucial educational decisions are powerfully influenced by medical school faculty, including who is admitted to medical school and residency, what gets taught there, and how learners are evaluated. In public education, teacher quality—as measured by means of education, experience, and test scores on licensing examinations—has been shown to have a greater effect on student achievement than does any other single factor (2). In short, the quality of medical practice hinges on the quality of the people teaching medicine, including teachers of radiology.
Despite the huge influence of medical education over the future of medicine, education has not fared well over the past decade or two (3). The rise of managed care has spurred academic health care centers to devote more and more attention to the generation of clinical revenue. Faced with declining levels of reimbursement for care provided in academic centers, many department chairs and deans have adopted policies that encourage their faculty to behave more like community physicians. Each hour that a medical school faculty member devotes to teaching represents an hour of lost clinical revenue, which some see as placing the academic health care center at a competitive disadvantage. Yet time spent in delivering more clinical care clearly generates more revenue. Research, too, offers opportunities to generate additional income through extramural funding and partnerships with industry. Devoting more time to education, however, usually generates no immediate income.
As a result, education begins to look to a health care administrator like a loss leader, a product for which merchants will tolerate a loss in hopes of attracting customers who will more than make up the difference with other purchases. Far from inspiring enthusiasm, medical education has become a business line in which many administrators feel less and less inclined to invest. If we regard the traditional structure of academic medicine as a tripod made up of legs of clinical care, research, and education, then education has become the short leg. In fact, the neglect of education has become so dire that the whole enterprise is in danger of toppling over (4).
In short, the future of medical education, and therefore that of the entire health care enterprise, is in jeopardy. To meet these challenges, it is vital that academic health care centers develop creative strategies for maintaining and strengthening their educational missions. Health care payers seeking cost reductions are unlikely to take up this fight on their own. Instead, department chairs and faculty members must demonstrate that high-quality medical education represents a good investment and develop innovative strategies for funding it. Central to any such efforts is reexamination of the core values of medical education, including those components of the educational enterprise in which new investments are most likely to pay off. If we want to raise the bar of medical education to a new level, where can we best invest our time and energy?
As a rule, physicians set high standards for themselves and become frustrated when they are not able to perform at a high level. While some individuals are naturally gifted and would do a good job in almost any situation, most of us tend to perform better when we understand what we are doing. By helping faculty members better understand effective teaching, we can improve their teaching performance and thereby enhance their sense of professional satisfaction. This is especially important at a time when many academic disciplines, including radiology, are having difficulty recruiting and retaining physicians in academic careers.
Another benefit is the positive effect of faculty development efforts on morale. Laboring under ever-greater pressure to sustain and augment clinical throughput, many faculty members have become discouraged about their academic missions. Some chose academic careers in part because they liked to teach, and as managed care has eroded institutional enthusiasm for education, more and more of them have left academic medicine entirely. If the tide of disenchantment and demoralization is to be turned, it is important for academic health care centers to begin demonstrating a renewed commitment to teaching excellence. By investing in faculty development programs, academic radiology departments can provide a much-needed demonstration of their commitment to education.
Curriculum
What topics should be included in a top-notch faculty development program for academic radiologists? One crucial topic is curriculum development. At the level of medical student teaching, what do medical students really need to learn about radiology? Should radiology courses for medical students aim to create neophyte radiologists and recruit medical students into radiology careers, or should radiology instruction serve primarily extraradiologic purposes, such as making radiologists better physicians regardless of which career path they pursue?
At many medical schools, students receive little or no formal instruction in radiology, which makes gaining a foothold in the medical school curriculum a key objective. Radiologic educators need to be able to articulate a vision for radiology’s role in medical education. For example, educators might stress radiology’s ability to illuminate living human anatomy and physiology, the great value of the radiology-pathology correlation in illustrating disease processes, and the clinically integrative role radiology plays as a consultant to virtually all clinical specialties.
In the residency sphere, faculty development efforts could help foster reexamination of the radiology curriculum. The promulgation by the Accreditation Commission for Graduate Medical Education of new competencies that residency programs must address, including competencies such as communication and professionalism, means that the time is ripe for radiology to articulate anew what its residents most need to learn (5). To what degree are lesion detection and differential diagnosis the core skills that residency programs should continue to stress, and to what degree should attention be shifted to newer skills, as represented in the American College of Radiology/Association of Program Directors in Radiology noninterpretive skills program (6)?
Is radiology residency mainly a matter of transmitting radiologic facts, or should a greater role be played by the cultivation of other core capabilities, such as critical thinking, interpersonal communication, and research methods? One of the greatest benefits of reexamining the curriculum of any educational enterprise is that it gets faculty members talking to one another again about the nature of their educational mission, including their different conceptions of what makes a good radiologist.
Aside from what should be taught, reexamination of the curriculum also spawns discussion of how it should be taught. Are didactic lectures the best way of teaching, should residents be expected to learn most of radiology on their own through independent study, and what role should be played by computer-assisted instruction? To a large degree, how to teach depends on what information one is trying to convey.
If a residency program determines that critical thinking is a skill to which it needs to devote more attention, using a pedagogic technique such as problem-based learning might warrant consideration. Problem-based learning has become popular in medical school curricula because it encourages students to learn through actively solving problems rather than passively receiving information (7). For example, instead of giving 1st-year residents a series of lectures on abdominal imaging modalities, a faculty member might present them with a case of a patient with right upper quadrant pain and ask them to assess the advantages and disadvantages of various imaging modalities in the workup. Many radiology faculty members may be unfamiliar with curricular innovations such as problem-based learning and therefore lack the opportunity to take advantage of them in their own teaching.
Another important topic for the curriculum of a faculty development course is learning theory. What is known about how young adults learn, and what steps can be taken to create a better fit between instructional approaches and the psychology of learning? While most radiologists know little about instructional psychology, each radiologic educator operates from an implicit notion of how learners learn. For example, it makes a huge difference in teaching whether one regards residents as empty vessels to be filled up with information or as active inquirers who need opportunities to explore the domain. By examining some of the most prominent learning theories, radiologic educators can develop a better understanding of learning, both their students’ and their own.
Another important lesson of learning theory is that not all learners are created equal. For example, different people tend to learn better in different formats. Some learn best in the context of group interaction; others, in independent study. Some learn best when they read information; others, when they hear it. The very best learners will succeed in almost any circumstance. In recognizing that such differences exist, however, educators can use diverse instructional strategies, thereby enhancing learner achievement.
Another key topic in a curriculum of faculty development is educational assessment. Students tend to learn what they expect to be evaluated on, which means that the choice of educational assessment strategies powerfully affects where their focus lies. For example, if residents believe that they will be evaluated primarily on the basis of their fund of radiologic knowledge, they will spend much of their time studying textbooks and review manuals. If they believe that their ability to detect lesions and offer differential diagnoses is the primary focus of testing, they will devote much of their energy to taking cases. On the other hand, if they believe that critical thinking, communication, and research skills won’t show up on any tests or evaluation forms, they will tend to neglect them.
There are major questions in educational assessment. For example, which is more important for assessment to focus on, teacher effectiveness or learner outcomes? Teacher effectiveness focuses on what the teacher is doing. An example of a teacher effectiveness measure would be peer review of teaching, which is uncommon in radiologic education. Another would be teacher evaluation forms filled out by students or residents. Because there is so little peer review of teaching, most teacher evaluation has become heavily dependent on assessments by learners, meaning that the only formal evaluations and rewards for teaching are based on learner assessments. Whether peer assessment of teaching would produce the same assessments is unknown, but there is a danger that educators may begin to behave as though they were trying to win a popularity contest (8). If the only teaching evaluation that faculty members receive is based on what students have to say, over time they may feel subtle pressure to give students better evaluations in hopes of getting better evaluations themselves.
Alternatively, teaching quality can also be assessed by focusing on learner outcomes. Have learners in fact mastered the knowledge and skills that the curriculum prescribes? Even more important, can they apply what they have learned to new problems? The design of tests to assess learner achievement is a complex subject, as anyone who has written questions for the American Board of Radiology examinations can attest, and it would be helpful for faculty members to better understand some of the issues involved. Deciding how to focus educational assessment can exert a major influence on how teachers and learners behave and can spawn a number of interesting questions for educational research. For example, do learners in fact learn the most from the teachers they rate as best?
Another important area of the faculty development curriculum is the use of instructional technology. New learning technologies, such as web-based educational materials, open up new possibilities for sharing curricula, developing interactive tutorials, tracking learner behavior, and assessing learner comprehension in ways that would have been proved nearly impossible in decades past. Many faculty members are unfamiliar with the capabilities of the new educational tools of the information age, and this lack of familiarity handicaps their ability to capitalize on them in their teaching. While there is a limit to how much attention can be devoted to instructional technology in the context of a larger faculty development program, it is important to make faculty members aware of the possibilities and provide guidance in how to obtain additional training.
One caveat, however: There is an inevitable tendency for new instructional technologies to so dominate the educational agenda of a specialty such as radiology that other crucial aspects of faculty development may be pushed aside. New educational media are only as good as the educators designing them. The quality of the educational product still depends primarily on what and how faculty members are trying to teach and depends less on the tools available to do so.
Two final foci of the curriculum of faculty development are organization and communication skills. Organization skills refer to how faculty put their teaching sessions together, including sequencing of material and use of visual aids and equipment such as laser pointers. Communication skills, in contrast, refer to the nature of the interaction that takes place between teacher and learners. For example, is there in fact a two-way interaction, or is information flowing in only one direction? Does the instructor make effective use of humor and anecdotes, and does the instructor respond to learner cues such as puzzled expressions or sagging eyelids? While organization skills are visible only in the classroom, communication skills apply both inside and outside the classroom, including informal teaching opportunities that arise during the work day. Aside from the content of what faculty members are attempting to teach, the quality of their organization and communication skills can powerfully influence what learners take away from educational interactions.
In designing a curriculum, faculty members should be encouraged to pay close attention to two additional points concerning the alignment of its elements. First, they should attempt to develop a clear and widely shared view of what learners most need to know. A review of the current curriculum often reveals that some of the material being taught is not terribly important. Other material is important and should be taught whenever time and circumstances permit. Still other material is absolutely critical and must be taught at all cost (9). By attempting to differentiate between these different levels of importance, educators can ensure that educational priorities and curricular structure are appropriately aligned.
A second crucial point concerns the types of curricula that exist in most learning environments. There are three curricula: (a) the curriculum that exists on paper; that is, the instructional objectives; (b) the test curriculum, as represented, for example, on the boards examinations; and (c) the imparted curriculum; that is, what actually gets taught (10). It is not infrequent that these three curricula turn out in practice to be very different. For example, a program may have a written curriculum for its residents, but when those stated objectives are compared with what actually gets taught at conferences, the degree of correspondence between the two may turn out to be surprisingly low. Many programs do not know exactly what their residents are being taught, because no one keeps track of it. Moreover, there is often a large gap between what programs say their residents should know and the manner in which they assess learner achievement. Educators should bear in mind that when such gaps exist, learners will usually follow the path prescribed by assessment standards, whether they represent the more important material or not.
Methods
What methods work best for faculty development? Given the time constraints in academic medicine, it is tempting to set aside an afternoon or a day for faculty development on the basis of the presumption that even a short amount of time is better than none at all. For example, an outside educational consultant with a background in faculty development might be brought in to give several lectures on how to teach more effectively. In fact, however, 1-day workshops at which people are simply told what they ought to be doing usually produce few enduring results. Ongoing sustained programs, in which faculty members have the opportunity to revisit teaching on multiple occasions, work best.
The instructors in a faculty development program must understand the knowledge set and practice domains of the faculty. If faculty members are to realize substantial improvements in their educational effectiveness, the faculty development curriculum must be grounded in the subject they are in fact teaching—in this case, radiology. While many of the principles may be similar, the program used by the local public school system is unlikely to work well for medical school faculty members. Case studies and illustrations should be grounded in the environments in which radiologists actually teach. Many faculty members will rapidly tune out an instructor they think doesn’t understand what they do.
A variety of faculty development formats might be used. For example, there is no question that traditional lectures have some role to play. When it comes to providing a basic background in such subjects as learning theory, communication skills, and educational assessment, good lecturers foster substantial learning in a relatively short time (11). Basing the entire program on lectures, however, is another matter and would rapidly prove counterproductive. The passive learning involved in merely listening to lectures often produces what has been called "inert knowledge," information that learners are unable to use in solving novel problems (12). Instead, occasional lectures might be interspersed throughout the program, with other more interactive formats in between. For example, after a lecture on learning theory, faculty members might participate in small-group exercises in which they attempt to identify their own preferred approaches to learning.
As noted earlier, another small-group technique that invites active participation is problem-based learning. Groups might read vignettes on different teaching styles and be asked to provide constructive critiques for improvement. Similarly, videotapes could be used, again asking participants to assess what teachers are doing well, what they are doing poorly, and what suggestions they would make for improvement. Participants could be invited to look at videotapes of their own teaching, as well, or critique each other’s teaching styles with the help of an educational "coach." The goal of such sessions is not only to get participants actively involved in the pursuit of better teaching but also to help them become more self critical. If people are to improve at anything, first they need to recognize that they could be doing a better job; second, they need to develop specific steps they could take to bring about improvement.
Critique is important, but so is praise. One of the greatest deficiencies in radiologic education is the lack of positive feedback for teaching. Department chairs and hospital administrators track clinical productivity and research productivity very closely, but teaching is tracked poorly, if at all. As a result, many faculty members simply don’t know how well they are doing as educators. Through ongoing faculty development programs, departments can begin to support and foster faculty teaching efforts by providing some praise and encouragement. Teaching awards can certainly play a useful role in this process, although those who don’t receive awards may soon suppose that they aren’t good teachers and become discouraged.
Another important method of faculty development is encouraging the faculty to become involved in research on teaching. Many aspects of radiologic education have never been subjected to close scrutiny, and we continue doing them not because we know they work, but because it never occurred to us that there might be a better way of doing things. Consider, for example, the possibility that the quality of radiologic education might be substantially improved by asking radiology residents to do some writing. At the end of each rotation, every resident might be asked to write a 1-page critique that focuses on some aspect of that educational experience that could be improved. Similarly, residents might be asked to write a several-page essay each quarter on topics such as "The Subspecialty of Radiology That Appeals Most to Me, and Why," or "The Greatest Threat to the Continued Existence of Radiology as a Distinct Discipline." Would residents who participated in such educational activities emerge from the 4 years of training better radiologists? Only through educational research will we ever know.
Faculty members should be encouraged to discuss the importance of teaching in the overall mission of the organization. Is excellence in education truly a mission for this group, and what resources is the organization prepared to commit to make it possible? Is teaching sufficiently important that it should play an even more prominent role in departmental decisions on such issues as tenure and promotion? The more teaching excellence represents an important factor in the overall equation of academic success, the more likely faculty members are to devote serious time and attention to the quality of their own teaching.
If the faculty agrees that the profile of teaching should be elevated, introduction of teaching inventories and teaching dossiers can be of great value (13). Inventories and dossiers encourage faculty members to keep a record of their instructional activities, teaching development programs they have participated in, and evidence of the quality of their teaching. Scores on standard evaluation forms are important, but so are anecdotal reports such as unsolicited letters from students and peers that reflect educational dedication and excellence.
As in other arts in life, learning to teach involves a substantial amount of emulation. Discussing theory and participating in group exercises can take faculty members only so far. Ultimately, there is no substitute for exposure to great teachers, and a good faculty development program will involve opportunities to see great teachers at work. In an age when new radiologic information is readily available through journals and the Internet, continuing to use opportunities to bring in outside speakers to merely disseminate information through such venues as visiting professorships makes less and less sense. Instead, some of these resources could be used to establish ongoing workshops in educational best practices, in which master teachers could be shared between institutions to improve educational quality for all. Likewise, other faculty development resources such as curricula and methods could be pooled. If radiology departments can collaborate to improve the quality of radiologic research, why shouldn’t education benefit from collaboration, as well?
Challenges
Radiology educators must be prepared to make the case that providing a first-rate education for medical students and residents is in the best interests of their departments and institutions. Rationales for this position would include utilitarian arguments that enhanced education can improve patient care outcomes and decrease health care costs, as well as professional arguments that teaching is a core activity of medicine and deserves to be done well. There is no point in undertaking a faculty development program if the institution lacks the resolve to do it right, including a serious commitment of time and money. Merely paying lip service to education can backfire, producing even greater disenchantment among educators.
It would be foolish for an academic health care institution to assume that itcould provide excellent clinical care or produce first-rate research without making substantial capital investments in equipment and supplies. It would be equally foolish for an institution to suppose that it could provide an excellent education without making substantial investments in the human capital of its educators. Improving the quality of education is one of the best investments any institution can make, the "spillover" benefits of which include improved reputation, morale, and ability, and can strengthen everything else the institution does. Moreover, teaching well is one of the most intrinsically rewarding aspects of being a good physician.
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