By chance or by design? How clerkship and course directors navigate academic medicine

Abstract

Academic medical centers (AMCs) are complex, bureaucratic organizations with multiple, interconnected missions and constituencies (Brater, 2010). What happens in the classroom affects the operating room and lab. As the responsibilities to treat patients, discover new medical knowledge, and train future physicians become more complex, it is critical to define and situate the pathways to and roles of medical education leaders within the system, so that institutions can fully benefit from their contributions. This study uses an organizational communication lens to develop a theoretical understanding of the relationship between faculty members who are clerkship and course directors (CDs) and AMCs in the U.S. Clinical faculty who become CDs often do so because they are gifted educators. They are responsible for developing faculty, as well as managing curriculum and assessment. These complex roles often lack clear position descriptions and expectations. Though CDs value education, they may face economic pressures to spend more time in clinical duties at the expense of their education responsibilities (Cooke et al., 2006). This can create conflicts in organizational identity and values, as well as an unclear path to tenure, promotion, and rewards (DeAngelis, 2004). This study uses in-depth interviews to explain how CDs manage the multiple (sometimes competing) values and priorities of their roles. Semi-structured interviews were conducted with eight CDs, from institutions of similar size and type, to investigate three interrelated concepts: how faculty become CDs; how they make sense of their roles and values in relationship to those of the institution; and how the structure of AMCs shapes the roles and values of CDs. A qualitative approach, as applied in this study, is useful to understand behavior in complex organizational contexts (Castillo-Page et al., 2012). Interview findings were aggregated into significant narratives and organized by theme, including: pathways to the role; a conflict in values; inconsistent funding; and structural challenges. A grounded theory was developed to explain the process by which CDs manage their complex roles. Findings from this study indicate that CDs are critical to the education mission and can be powerful in shaping the institution, though they face significant challenges. They can feel isolated, because each institution might only have a few individuals that serve these functions. Diverse responsibilities of CDs might also mean that their paths to promotion are unclear or tenuous. Further research is necessary to understand the process of socialization and impact of the reward structure for CDs. Clerkship and course directors do seem to value their sense of organizational identification within multiple contexts, including the medical school, discipline, and the hospital system. In the same vein, it would be helpful to have a better understanding of the connections among their multiple identifications. Additionally, exploring the identification of university faculty in multiple settings may serve to expose subtle differences for identification management used in different contexts for faculty with different roles. Results of the study can be used to shape policies and faculty development efforts for CDs, leading to a clearer sense of purpose and reward system. A deeper understanding of the experiences of CDs benefits both faculty and institutions. Faculty receive more role clarity and individual agency, and AMCs receive information on how to better meet the needs of this population, thus improving the efficacy of medical education.