Expertise, needs and challenges of medical educators: Results of an international web survey

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2010; 32: 912918Expertise, needs and challenges of medicaleducators: Results of an international websurveySOREN HUWENDIEK1, STEWART MENNIN2, PETER DERN3, MIRIAM FRIEDMAN BEN-DAVID4,5y,CEES VAN DER VLEUTEN6, BURKHARD TONSHOFF7 & CHRISTOPH NIKENDEI81University Childrens Hospital Heidelberg, Germany, 2University of New Mexico School of Medicine, USA,3University Freiburg, Germany, 4Centre for Medical Education, UK, 5Tel Aviv University Sackler School of Medicine, Israel,6Maastricht University, The Netherlands, 7University Childrens Hospital Heidelberg, Germany, 8University of HeidelbergMedical Hospital, GermanyAbstractBackground: Little is known about how medical educators perceive their own expertise, needs and challenges in relation tomedical education.Aim: To survey an international community of medical educators with a focus on: (1) their expertise, (2) their need for trainingand (3) perceived challenges.Methods: A web-based survey comprising closed and open free-text questions was sent to 2200 persons on the mailing list of theAssociation for Medical Education in Europe.Results: Of the 2200 medical educators invited to participate, 860 (39%) from 76 different countries took part in the survey.In general, their reported areas of expertise mainly comprised principles of teaching, communication skills training, stimulationof students in self-directed learning and student assessment. Respondents most often indicated a need for training with respectto development in medical-education-research methodology, computer-based training, curriculum evaluation and curriculumdevelopment. In the qualitative analysis of 1836 free-text responses concerning the main challenges faced, respondents referredto a lack of academic recognition, funding, faculty development, time for medical education issues and institutional support.Conclusions: The results of this survey indicate that medical educators face several challenges, with a particular need for moreacademic recognition, funding and academic qualifications in medical education.IntroductionOver the last 20 years, academic medicine has entered aperiod of uncertainty and decline, which has given rise towidespread alarm (Clark 2005; Sheridan 2006). An interna-tional campaign to revitalize worldwide academic medicinewas launched by the British Medical Journal, the Lancet, theCanadian Medical Association Journal, the Dutch Journalof Medicine, the Medical Journal of Australia, the CroatianMedical Journal, the Academy of Medical Sciences and others(Tugwell 2004). Within this movement, the major role ofmedical education in fostering change in the quality of healthcare became apparent. In a report from the Institute ofMedicines Committee on the roles of academic health centresin the twenty-first century (Cox & Irby 2006), it was observedthat among all of the academic health centre roles, educationwill require the greatest changes in the coming decade. Thisawareness is mirrored by the increasing interest shownby leading medical journals in publishing special medical-education issues or running series on medical education(Tugwell 2004; Clark 2005; Golub 2005; Cox & Irby 2006).Astonishingly, while medical educators are aware of thePractice points. Little is known about how medical educators perceivetheir own expertise, needs and challenges in relation tomedical education.. In this international web-based survey, most medicaleducators reported a need for training with respect todevelopment in medical education research methodol-ogy and computer-based training.. Medical educators perceived a lack of academic recog-nition and funding as the main challenges to medicaleducation.Correspondence: S. Huwendiek, Department of General Paediatrics, University Childrens Hospital Heidelberg, Im Neuenheimer Feld 153, D-69120Heidelberg, Germany. Tel: 49 6221 5638368; fax: 49 6221 5633749; email: Soeren.Huwendiek@med.uni-heidelberg.deyThis article is dedicated to our deceased colleague Miriam Friedman Ben-David, whose heartiness and vision impressed and continues to inspireus up to this very day.912 ISSN 0142159X print/ISSN 1466187X online/10/1109127 2010 Informa UK Ltd.DOI: 10.3109/0142159X.2010.497822Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14For personal use only.current situation of medical education and they play a majorrole in changing and preparing medical education for thecoming decades, very little is known about their views on theirown situation, their needs or the challenges which they face.We therefore surveyed an international community ofmedical educators focusing on three aspects: (1) their exper-tise, (2) their need for training and (3) the challenges theyperceived.MethodsDevelopment of the survey instrument and testingThe questionnaire was developed based on five focus groupsof medical educators (46 participants each). Five cognitiveinterviews were conducted to test uniformity of comprehen-sion with respect to the questions included. We additionallyconducted a pre-test using the web-based questionnaire basedon a sample of 30 medical educators. The final web-basedquestionnaire (commercial survey tool) took approximately20min to complete and comprised two open questions and34 closed questions designed to elicit medical educators viewson their expertise, need for training and challenges.The first set of seven items was used to collect demo-graphical data: age, gender, country of residence, professionalbackground, professional status, academic title and number ofyears of employment in health professions. Two furtherquestions referred to medical education degree earned orplanned and the number of years of active involvementin medical education. Items concerning participants worksetting and the role played by medical education in their workspecifically related to the organizational unit of work; theproportion of work devoted to medical education (includingteaching, evaluation, administrative work, research in medicaleducation), clinical work and research other than in medicaleducation; the amount of time outside working hours devotedto medical-education activities including preparation; thedegree of emphasis on medical education in their institution;and personal interest in medical education. Two questionsaddressed research output in medical education, specificallyasking about the number of articles published as first authorand as co-author. Expertise and educators need for trainingwere also explored. Expertise was rated for 12 importantdomains of medical education using a 5-point Likert scale(1 very low; 5 very high): general principles of teaching,stimulating students in self-directed learning, facilitatingproblem-based learning as a tutor, technical-skills training,communication-skills training (e.g. giving feedback), devel-opment and/or usage of computer-based training, tutortraining, mentoring, curriculum development, studentassessment, course and curriculum evaluation and researchmethodology in medical education. A different type ofquestion required respondents to select a maximum of 6 outof 12 areas of medical education in which they perceived aspecial need for further training. This question was followedby four items in which respondents used a 5-point Likert scale(1 very low; 5 very high) to rate their need for: experi-enced senior medical educators as role models in theirinstitution, financial support for medical-education projectsat their institute, national and international networking withmedical educators and more recognition for their medical-education work in their institution. Respondents were alsoinvited to provide free-text responses with regard to the threemain problems they face as a medical educator and for whichthey feel a special need for support and/or change. In a finalitem, respondents used a 5-point Likert scale (1 very low;5 very high) to rate the extent to which they consideredthemselves to be medical educators.Administration of the surveyOn two occasions between August and September 2005,an email was sent by the office of the Association of MedicalEducation in Europe (AMEE, www.amee.org) to all addresseson the AMEE mailing list, comprising AMEE members andAMEE conference visitors (n 2200). The email contained anintroduction to the survey and a link to the web-based surveytool. There were no additional e-mails or phone contacts.Study populationAll persons on the AMEE mailing list (n 2200) were invitedto participate. AMEE has an explicit international focus, andthe AMEE conference represents the largest internationalmedical education meeting worldwide.Statistical analysesPercentages were calculated for demographical data. For age,involvement in medical education and working experiencein a health profession, mean values were calculated in termsof number of years. For the items on perceived expertise in12 different domains of medical education, means andstandard deviations were calculated. Based on those partici-pants who had selected a maximum of 6 of 12 areas of medicaleducation which they considered important for further train-ing, we calculated the percentage of participants who hadselected each area. Two researchers independently identifiedthemes and sub-themes in the free-text responses on per-ceived challenges and the need for support. Consensus wasachieved by means of comparison and discussion. Relevanceand consistency of the analysis was checked for by theresearch team.Ethical approvalThe ethical review committee of the University of Heidelbergdid not consider the study to require approval. We confirmthat participation was voluntary, that participants cannot beidentified from the material presented and that no plausibleharm to participating individuals can arise from the study.ResultsSampleCompleted questionnaires were returned by 860 of the 2200individuals who were sent the invitational e-mails (39% rateInternational medical-educator survey913Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14For personal use only.of return). Table 1 presents participants characteristics.Engagement in medical education resulted in an averageof 10.3 (10.1) extra hours working time per weekbeyond regular working hours. Ratings were very high forinterest in medical education (4.63 0.61) and emphasis onmedical education in respondents institutions (3.85 0.97).Respondents strongly regarded themselves as medical educa-tors (3.86 0.96).According to information from the AMEE office, partici-pants characteristics appear to correspond rather well to thoseof AMEE members. However, given that most of the charac-teristics are not included in the AMEE-member database, it isnot possible to demonstrate that respondents were generallyrepresentative of the members of the AMEE mailing list.Medical education expertise and need for furthertrainingFigure 1 illustrates medical educators self-assessed expertisein 12 important domains of medical education. Figure 2illustrates the need for further training in 12 important areas ofmedical education.Challenges to medical educatorsA total of 1836 comments were made by the 690 participantswho provided at least one free-text answer. Figure 3 presentsthe main categories of perceived challenges that resultedfrom the content analysis of respondents answers. Table 2summarizes participants opinions concerning main challengesand problems. For each category, characteristic citations arepresented.While the responses regarding perceived expertise didnot differ across continents, continent-related differences wereobserved with respect to the reported needs for training andperceived challenges (data not shown).DiscussionSummary of major findings and representativenessof the studyThe results of our international web-based survey of medicaleducators show that respondents main areas of expertisegenerally comprise principles of teaching, communicationskills training, stimulation of students in self-directed learningand student assessment. A need for further training isparticularly perceived with regard to the development ofmedical education research methodology, computer-basedtraining, curriculum evaluation and curriculum development.The main challenges to emerge from the qualitative analysiswere a lack of academic recognition and funding, facultydevelopment, time for medical education issues and institu-tional support.Despite the moderate response rate of 39%, this survey isunique in light of the fact that respondents represent aworldwide sample of medical educators from 76 countries,working in different fields and in different positions.The geographical distribution of response percentages reflectsthe geographical distribution of AMEE members.The characteristics of the surveyed participants indicate thatwe reached dedicated medical educators who have a stronginterest in medical education and who are experts in this field:respondents reported devoting almost two-thirds of their timeto medical education issues; 16% held a masters degree and7% a PhD degree in medical education. On average, respon-dents had been actively involved in medical educationfor more than 12 years. They indicated a strong interest inmedical education and viewed themselves to a large extent asmedical educators.Self-perceived expertise of medical educatorsWell-designed medical curricula and high-ranking medical-education research publications clearly indicate that there isTable 1. Characteristics of 860 medical educators questionedabout expertise, needs and challenges.CharacteristicsPercentage/Mean(SD)SexMale 53.3Female 46.7Mean age (years) 47.5 (10.3)ContinentEurope [UK] 58.3 [25.1]America [USA] 20.0 [11.0]Asia 14.7Africa 3.19Australia and Oceania 3.55Professional backgroundMedical 68.1Education 11.7Basic sciences 10.4Psychology 5.85Nursing 4.77Physiotherapy 0.72Pharmacy 0.60Other 14.6Work statusEmployee 34.4Leading position 25.8Chairman 13.5Independent/self-employed 6.4Academic achievementPhD degree 26.3Professor 27.0Work settingUniversity hospital 76.1Non-university hospital 7.13Community-based sector 5.14Private sector, company etc. 1.99Other 9.70Mean working experience in health professions (years) 19.9 (11.1)Mean active involvement in medical education (years) 12.9 (10.4)Proportion of work devoted to . . .. . .Medical education (including teaching, evaluation,administrative work, research in medical education)63.0 (30.6). . .Clinical work 24.4 (27.8). . .Research (not medical education) 12.4 (17.6)Degree in medical educationMaster 16.2PhD 7.09Planned 36.9Authorship of medical education articlesFirst authorship 57.0Co-authorship 60.9Notes: Results are presented as percentages of participants. Age, workingexperience and active involvement in medical education are reported in years.S. Huwendiek et al.914Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14For personal use only.considerable expertise in medical education. However, dataon medical educators self-assessed expertise are scant. Thisstudy shows that medical educators see their main expertise aslying in general principles of teaching, communication skillstraining, stimulating students in self-directed learning andstudent assessment. This is not surprising, given that theserepresent core skills for medical educators. General principlesof teaching, communication skills training and assessmentactivities are often part of faculty-development programmes(Steinert et al. 2003; Clark et al. 2004) and reflect keycompetencies in the day-to-day work of medical educators.This is also supported by a study by McLeod et al. (2004), whofound that experienced teachers possess reasonable knowl-edge of basic pedagogical principles. Other domains such asprinciples of self-directed learning have received widespreadattention (Spencer & Jordan 1999; Ludmerer 2004).Need for further trainingDespite the evidence of general educational expertise,however, participants considered their expertise with respectto new technologies such as computer-based training and1 2 3 4 5General principles of teaching Communication skills training (e.g. giving feedback)Student assessmentStimulating students in self-directed learningCurriculum developmentMentoring Course and curriculum evaluationTutor training Faciliating Problem-based learning as a tutorTechnical skills training Research methodology in medical education Development and/ or usage of computer-based training Figure 1. Self-assessed expertise of medical educators in 12 important domains of medical education rated on a 5-point Likertscale (1 very low; 5 very high).0 % 10% 20% 30% 40% 50% 60% 70%Research methodology in medical education Development and/or usage of computer-based trainingCourse and curriculum evaluationCurriculum developmentStimulating students in self-directed learningStudent assessment Facilitating problem-based learning as a tutor Mentoring Tutor training Communication-skills training (e.g., giving feedback)Technical-skills training General principles of teaching None Figure 2. Percentage of rating by medical educators (n 860) about different areas of medical education as being among the sixmost important areas for further training.International medical-educator survey915Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14For personal use only.0% 10% 20% 30% 40% 50%Academic recognitionFundingFaculty developmentTime for medical education issuesInstitutional supportTeaching skillsCurriculumAssessmentNetworkingMethodological expertise and researchRole modelLack of staffStudent problemsFigure 3. Percentage of participants who named at least one problem in relation to medical education and who mentionedspecific items as being problematic.Table 2. Opinions of 690 medical educators concerning main challenges and problems.Categories of response (1st to 13th) and characteristic citations1. Academic recognition for involvement in medical education is low in comparison to clinical work and biomedical research.Recognition for the profession of medical educator is low (most recognition is for clinical performance and research activities)Prestige for medical education is lowerNo career awards for activities in medical education2. Funding for medical education is insufficient.Limited financial support in medical educationCollege financial investment in education is insufficient3. Need for more faculty development and scholarshipNeed for more faculty development in teaching/learningNeed for greater assistance in promoting faculty development in medical education, including financial assistance to achieve this4. Protected time for medical education issues is too scarce.Time for teaching is not recognized as working timeInsufficient time for education and educational research5. Institutional support for medical education issues including organizational structures is too low.Inadequate administrative supportLack of dedicated organizational structures to support curriculum development and research in medical education research within the medical school(that provides practical support as well as a physical base for staff involved in this activity)6. Teaching skills of medical teachers are not sufficient (especially modern technology etc.).Lack of knowledge and skills in education (people feel they dont need any training, because education is something you just do)Lack of skills using modern technology in education7. Curricula are not adequate because of e.g. overload or lack of integration of clinical and preclinical subjects.Inadequate curriculaIntegration of clinical and preclinical studiesCurriculum overload8. Assessment skills of teachers and standard-setting procedures are not sufficient.Lack of standard setting in examinationsPoor assessment skills9. Need for networking both internationally and within institutions (e.g., clinicians and educators)Insufficient international exchange programmes about medical educationLack of cooperation between clinicians and educators10. Research in medical education is of low quality, underfinanced and not sufficiently taught.The generally low quality of medical education researchNeed for more training in educational research methodology11. There is a lack of role models in medical education.Lack of leadership in medical educationSenior medical researchers as role-models not medical educators12. There is a lack of skilled educators.A lack of competent personnelCritical mass of skilled educators at institution small13. Problems from the students side are lack of motivation.Students are sometimes not sufficiently motivatedS. Huwendiek et al.916Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14For personal use only.medical-education-research methodology to be low. Theseaspects also topped the list of areas in which further trainingwas considered necessary. Excellent research in medicaleducation requires specific expertise in different fields.Biomedical expertise is required on the one hand (what isclinically relevant?) and methodological expertise in bothquantitative and qualitative approaches on the other. Whilequalitative approaches differ from the classical approachesemployed in biomedical research, they are highly suitablefor medical education. In medical education, double-blindedtrials are, for example, not a realistic option. This limitationis generally recognized and there have been very recent effortsto promote other research methodologies in medical educa-tion; the Association of American Medical Colleges, forinstance, sponsors the Medical Education Research Certificateprogramme and AMEE offers a workshop on ResearchEssential Skills in Medical Education (RESME) Programme.The second greatest need for further training reported byrespondents relates to the use of information and communi-cation technology (ICT) in medical education. ICT represents arelatively new and promising tool for medical education(McKimm et al. 2003), and additional expertise is required withrespect to both designing and integrating this approach intothe medical curriculum (Cook 2005). The need for trainingin curriculum and course evaluation was of high priority for43% of participants. This is not surprising, given the imperativenature of rigorous evaluation of any curriculum reform inensuring that we are doing the best we can for our studentsand our patients (Jones et al. 2001).Challenges for medical educatorsQualitative analysis of responses to open questions showedthat the main challenges pertained to a lack of academicrecognition and funding, faculty development, time for med-ical education issues and institutional support. At least 7 of the13 perceived challenges included problems arising fromstructural deficits (Challenges 1, 2, 3, 4, 5, 10 and 12).Although various authors have called for better promotionprospects for medical educators (Golub 2005) and moreinstitutional and individual incentives (Jones et al. 2001; Parryet al. 2008), there are no research data that so clearly documentthe wish of medical educators for more academic recognition.At most university hospitals, clinical work and biomedicalresearch are rewarded and recognized to a much greater extentthan is the case for medical education. This lack of recognition ismirrored by a lack of funding the second most frequentlymentioned challenge. The increasing threat posed by a lackof funding to medical education was recently addressed byParry et al. (2008) and Albanese et al. (2008); Reed et al. (2005)found that the majority of the published medical educationresearch was not formally funded, with studies that did receivesupport being substantially underfunded.Participants expressed a further need for more facultydevelopment and scholarships in medical education.Leadership for change comprises a core of respected andskilled teachers, who form the centre of effective curriculumreform (Jones et al. 2001). Although there have beenreports on successful faculty-development programmes(Jones et al. 2001; Armstrong et al. 2003; Cooke et al. 2003;Gruppen et al. 2003; Thibault et al. 2003), such programmesare not established everywhere. In order to create a commu-nity of effective agents for change, it is important thatmore medical educators are able to benefit from faculty-development programmes and take part in masters or PhDprogrammes in medical education. The third most frequentlycited challenge in our survey was a lack of protected time formedical education issues an aspect which was also identifiedby Steinert et al. (2003).Strengths and limitationsThe strengths of our study lie in the international sample, thehigh number of respondents and the use of open and closedquestions. Further, this is the first study to explore systemat-ically the expertise, needs and problems of an internationalcommunity of dedicated medical educators. This study addsnew knowledge by investigating the expertise of and chal-lenges faced by medical educators. Results echo, in part, thatwhich others have found or proposed in more limited settings.The finding that medical educators widely perceive a need forgreater academic recognition, funding and further qualificationin medical education research is new.Several limitations of this study should be considered ininterpreting the results. First, because we surveyed medicaleducators worldwide, it was necessary to use a self-reportquestionnaire instead of more objective measurements whichwould have enhanced the validity of the inferences made fromthe data. Second, the 39% survey-response rate is modestalthough comparable to other email surveys. We cannot,however, be certain that the results are fully representativeof members of the AMEE mailing list and medical educators ingeneral.ConclusionsThere is a widely perceived need for greater academicrecognition and funding of medical education activities tomeet the needs and challenges of medical educators. Formalprogrammes in medical education such as masters degreesand PhD programmes are of vital importance when it comesto preparing a new generation of highly qualified medicaleducators who are able to ensure sustained high standards inmedical education. Such a continuously evolving, high-qualitymedical education system represents a prerequisite for thecontinuous delivery of high-quality medicine. In the currentinternational community of practice, we consider the choicesthat are made concerning the distribution of resources for thedevelopment of teachers to be fundamental to the future ofmedical education and the health of society.AcknowledgementsWe would like to thank the numerous colleagues who gavetheir time freely and participated in this study. The authorswish to acknowledge the generous assistance of Ron Hardenand Pat Lilley in sharing the AMEE 2005 mailing list for thisInternational medical-educator survey917Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14For personal use only.research. We are grateful to Mereke Gorsira and Dawn Girlichfor excellent help in proof-reading the manuscript.Declaration of interest: The authors report no conflicts ofinterest. The authors alone are responsible for the content andwriting of this article.Notes on contributorsSOREN HUWENDIEK, MD, MME (Univ. Bern,) is a paediatrician, one of thecurriculum co-ordinators, chairman of the centre for virtual patients and e-learning commissioner at Heidelberg Medical Faculty. His fields of interestare virtual patients, problem-based learning and communication-skillstraining. He is the winner of the AMEE Miriam Friedman Ben-David NewEducator Award 2009.STEWART MENNIN, PhD, is a former assistant dean for EducationalDevelopment and Research and professor emeritus, Department of CellBiology and Physiology, University of New Mexico School of Medicine,Albuquerque, New Mexico, USA. His interests relate to how conceptsof complexity and complex adaptive systems can be applied to healthprofession education.PETER DERN, MD, MME (Univ. Bern,) works as a specialist at the UrologyDepartment of the University Hospital of the Albert-Ludwigs University ofFreiburg. Besides general urology, he is especially involved in paediatricand reconstructive urology. He is an instructor in the faculty-developmentprogramme of the deans office, teaches undergraduate students and isinvolved in curriculum development.MIRIAM FRIEDMAN BEN-DAVID was a professor of Medical Education,formerly Co-Director of the Clinical Skills Certification Programme at theEducational Commission for Foreign Medical Graduates (ECFMG) andassociate dean at the Medical College of Pennsylvania, Philadelphia.Her main areas of interest were physician and student assessment,programme evaluation and development of leadership in the medicalprofession.CEES VAN DER VLEUTEN, PhD, is the chairman of the Department ofEducational Development and Research and Scientific Director of theSchool of Health Professions Education at Maastricht University, Faculty ofHealth, Medicine and Life Sciences.BURKHARD TONSHOFF, MD, PhD, is professor of Paediatrics andPaediatric Nephrology at the University Childrens Hospital Heidelberg,Germany. He currently holds the position of a vice chairman of theDepartment of Paediatrics I (General Paediatrics, Metabolism,Gastroenterology and Nephrology) and is the director of the paediatricrenal transplantation programme.CHRISTOPH NIKENDEI, MD, MME, works at the University of HeidelbergMedical Hospital and is responsible for the longitudinal skills labcurriculum at the Medical Faculty and the skills lab training andeducation of final year students at the Medical Hospital. ChristophNikendei is the winner of the AMEE Miriam Friedman Ben-David NewEducator Award 2008.ReferencesAlbanese M, Mejicano G, Gruppen L. 2008. Perspective: Competency-basedmedical education: A defense against the four horsemen of the medicaleducation apocalypse. Acad Med 83:11321139.Armstrong EG, Doyle J, Bennett NL. 2003. Transformative professionaldevelopment of physicians as educators: Assessment of a model.Acad Med 78:702708.Clark J. 2005. 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