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This profile of Stephen Abrahamson, Ph.D., Sc.D., is the first of six profiles to appear as part of the Exemplar project focused of six retired medical educators who transformed the field of medical education. The exemplars, all graduate degree recipients in education were interviewed by six senior present-day medical educators using a common protocol designed to elicit career chronology and the significant contributions of educationists to medical education of Dr. Abrahamson's profile was based on an in-depth two-day interview, examination of a comprehensive list of his publications, the history of the Society of the Directors of Research in Medical Education, and unsolicited conversations with several of his colleagues. Dr. Abrahamson began his career teaching high school, later receiving a masters and doctorate degrees, in preparation for a career as a teacher-educator. Through collaboration with Dr. George Miller, Dr. Abrahamson began his career as an educationist in medicine - one who studies the education process and prepares others to become teachers - by teaching medical school faculty about the science of education. Dr. Abrahamson's career was devoted to applying his evidence-based education approach to the newly emerging profession of medical education. An examination of his career shows that he made four vital contributions to medical education - defining the educationist role, serving as a teaching/mentor/network builder/friend to medical educators, curriculum change agent and innovator at USC, and demonstrating and articulating the value of offices of medical education and research in medical education. More broadly, Dr. Abrahamson identified three major contributions made by educationists to the field of medical education: the application of education principles to instructional/assessment innovations (e.g., programmed patients), an evidence-based approach to assessing education, and faculty development/teacher training. Based on his half-century of experience in medical education, Dr. Abrahamson outlined seven lessons for success as an educationist in medicine.

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Changes in faculty roles and demographics necessitate a re-examination of the types of professional development opportunities offered in academic institutions. A distance-based consulting program was designed to assist faculty development projects as they progress through all stages of faculty development: needs assessment, project design, implementation, and, in particular, program evaluation and dissemination of results (i.e., presentations and published articles). The progress of 17 faculty development projects in primary care educational sites that received assistance in the United States and Canada was tracked over two years. Three factors were identified as having the most impact on the success of faculty development projects: (1) funds committed to and designated for faculty development; (2) funded, protected time for at least one person to implement the faculty development initiative; and (3) an environment capable of supporting faculty development initiatives (e.g., no major budget shortfall, few faculty transitions, a strong mission, no threat of mergers). Only a few of the participating sites reached the stage of evaluating and publishing articles about the outcomes of their projects within the designated 15-month time frame, with many sites reporting environmental impediments to project success. The authors describe the institutional characteristics that facilitated project success, assess the usefulness of distance-based consulting efforts, and offer recommendations for future distance-based consulting programs. They conclude by noting that the personal touch (i.e., one-on-one contact with consultants) is what is most appreciated, and that excellent one-on-one, in-person assistance may be inherently more effective than even the best-run distance-based consulting.

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Society's changing needs, advancing knowledge, and innovations in education require constant changes of medical school curricula. But successful curricular change occurs only through the dedicated efforts of effective change agents. This study systematically searched and synthesized the literature on educational curricular change (at all levels of instruction), as well as organizational change, to provide guidance for those who direct curricular change initiatives in medical schools. The focus was on the process of planning, implementing, and institutionalizing curricular change efforts; thus, only those articles that dealt with examining the change process and articulating the factors that promote or inhibit change efforts were included. In spite of the highly diverse literature reviewed, a consistent set of characteristics emerged as being associated with successful curricular change. The frequent reappearance of the same characteristics in the varied fields and settings suggests they are robust contributors to successful change. Specifically, the characteristics are in the areas of the organization's mission and goals, history of change in the organization, politics (internal networking, resource allocation, relationship with the external environment), organizational structure, need for change, scope and complexity of the innovation, cooperative climate, participation by the organization's members, communication, human resource development (training, incorporating new members, reward structure), evaluation, performance dip (i.e., the temporary decrease in an organization's performance as a new program is implemented), and leadership. These characteristics are discussed in detail and related specifically to curricular change in medical school settings.

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PURPOSE: To assess the effect of the W. K. Kellogg Foundation's five-year (9/91 to 9/96) primary care curricular change initiative involving seven sites and 27 schools with respect to courses offered, graduates' specialty choices, and valued school features (e.g., reputation, research, productivity, school climate) and to track how well the schools possessed or developed the processes associated with enduring curricular change. METHOD: Information was collected via pre- and post-surveys of faculty and students, site visits, annual reports, and medical students' specialty match results. RESULTS: In general, the schools either possessed or developed the institutional, curricular design, and curriculum features associated with successful curricular change. Further, the initiative had a positive or neutral impact on most of the valued features: 199 courses were revised or developed, including 138 offered in the community, involving 141 interdisciplinary faculty. Comparing 1991-1997 data, the average percentage increases in students' selecting primary care from the involved schools were greater than the national percentages. In 1997, a larger percentage of project school graduates selected primary care than the national average. CONCLUSION: Medical schools can make major curricular changes and achieve intended outcomes (e.g., new and/ or revised courses, multidisciplinary instruction, instruction in the community, and changes in specialty choice), and this can occur without negatively impacting other valued school aspects.

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PURPOSE: What constitutes effective leadership in a collaborative effort to achieve enduring curricular and student career changes? This question was investigated as part of a larger evaluation of the W. K. Kellogg Foundation's Community Partnership Health Professions Education, a five-year initiative involving projects at seven sites. The goal was to produce more primary care health providers by making enduring curricular change. METHOD: Data were collected from participants with respect to predictors of project success and leaders' use of 16 behaviors via telephone interviews, mailed surveys, and focus groups. Focus groups also gathered project leaders' views of skills and knowledge necessary for effective leadership. RESULTS: Leadership strategies associated with positive outcomes were: consistent leader; use of multiple cognitive frames, especially a human resource frame; use of a broad range of leadership behaviors, particularly participative governance and cultural influence; and a majority of community representatives on the partnership board. The primary leader, compared with a leadership team, is most influential in achieving positive outcomes. CONCLUSION: Effective leaders use a broad array of behaviors, but particularly emphasize the use of participative governance and culture/value-influencing behaviors. In addition, the more frequent use of these behaviors compared with the use of organizational power behaviors is important. It is helpful to perceive the project from a human-relations frame and at least one other frame. Using a leadership team can be helpful, especially in building coalitions, but the importance of the primary leader's behaviors to project outcomes is striking.

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The evaluation literature often debates whether evaluators should be flexible in evaluation design and activities in order to collaborate with program directors and be responsive to programming needs. Two conditions are specified under which evaluation flexibility is not only desirable but essential. Two examples from the cluster evaluation of the W. K. Kellogg Foundation's Community Partnerships for Health Professions Education initiative are provided to illustrate why flexibility under these conditions proved to be essential. One of the examples, related to the "community" involvement in the initiative, illustrates the need for flexibility as programs experience goals clarification. The other example, related to the coincidental national health care reform efforts, illustrates the need for flexibility both to capture programs' efforts to protect their integrity and to ensure against spurious conclusions as a result of external turbulence in policy environments. How the cluster evaluation team addressed these issues is also described.

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This evaluation highlights several points to be considered by others instituting multidisciplinary approaches to health professions education. Community-based, multidisciplinary experiences appear to reinforce support students' interests in pursuing primary care careers. The multidisciplinary, community-based approach to health professions education did not affect academic learning. Project leaders and students reported no risks in terms of board scores between CPHPE students and others in traditional programs. The multidisciplinary, community-based approach to health professions education created opportunities at some sites for students to see "team medicine" in action. It was practical and helped students to understand how they could be more effective in their roles as opposed to competitive. Students require socialization within their own individual disciplines as well as socialization across disciplines. The differences in the structures of traditional health professions education schools interfered with the development of multidisciplinary contexts for learning at some sites. Campus faculty were not necessarily socialized to engage in multidisciplinary efforts. Their disciplines generally do not recognize and reward this behavior. Early and continuous faculty development may significantly help projects to improve communication and develop a better understanding of the contexts of curricular changes across disciplines. This evaluation was exploratory. Further research is needed to better understand what forms of multidisciplinary curriculum are most effective and economically feasible, what forms survive over time, and whether the intended final outcomes of the CPHPE initiative are achieved, not only with medical students but also with the other health professions students.

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There is a critical need for medical schools and universities to consider strategies beyond corporate-style downsizing to address revenue needs and reposition their organizations. The author presents considerable evidence and three reasons to reject downsizing as a way to facilitate long-term organizational success. Instead, she recommends that institutions use a comprehensive approach to individual and organizational development to assure a flexible, enduring organization. Specifically, medical schools and universities should take an institution-wide perspective and approach to continually training, retraining, or reassigning faculty and should continually adapt their organizational structures and procedures as necessary to achieve changing institutional goals. The result will be the retention of able and dedicated faculty, who will be crucial in helping their schools continue to be successful while adapting to a changing world.

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BACKGROUND AND OBJECTIVES: Several recurring conclusions about the changed conditions and future needs of faculty emerged from the articles in this dedicated issue. Faculty work is becoming more differentiated; time is increasingly constrained; and faculty are working in more diverse settings. Faculty reward structures and career ladders are changing, and acquiring additional competencies in new areas is essential. Although less then anticipated, there is some research to guide the development of programs to prepare faculty for these changes. Based on these conclusions, it is expected that in the future, faculty and program chairs will seek a tight match between what a faculty development effort addresses and the responsibilities of faculty participants and/or the goals of the department or program. The following trends are expected: 1) Regional/national comprehensive programs will often be the best choice for new faculty since many departments and residencies will not have sufficient resources to support their own faculty development programs. 2) Research-oriented faculty will be expected to devote 2 years or more to formal training. 3) Experienced faculty and department/program leaders, many of whom are graduates of our faculty development programs, will need advanced training in targeted areas, through on-site, contextualized education or through individualized programs--perhaps electronic. 4) Organizational development will be needed to help departments and programs make changes in missions and processes and to maintain a sense of community. At the same time that new models must be created to meet these future faculty development needs, support for such programs has decreased. Both local and national sources must be recommitted to support faculty development programs and research so we may advance our understanding of cost-effective approaches to faculty development. Funding agencies need to change their guidelines to match the current needs for development and limit funding to programs designed on evidence.

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A large body of research on medical students' choice of primary care specialties has been published. However, the literature is difficult to interpret because of multiple biases, design weaknesses, small numbers of subjects, inconsistencies in both dependent and independent variables, and conflicting results. These weaknesses have been noted by authors who have reviewed the work in this area, but the authors have given little direction for ways to improve and build upon the current state of the literature. This paper provides a quantitative description of the content of the specialty choice literature. As part of a larger project that included an exhaustive literature analysis, all research on primary care specialty choice published between 1987 and 1993 was collected and summarized according to study questions, designs, data sources, samples, theory, and outcome variables. Portions of this information were used to rate the quality of each study, yielding a score from zero to 100 that indicated the trustworthiness of the study's conclusions. Overall, the studies examined were found to use predominantly cross-sectional designs and to lack theoretical basis. Special curricular tracks, student personality, and self-reported influences were the most frequently studied determinants of primary care specialty choices. The results confirm previous qualitative descriptions of the state of the literature on specialty choice, and lead to recommendations for approaches to improve the quality of further work in this area. The research agenda that emerged from the larger project is also presented.

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BACKGROUND: Successful higher education faculty, those who get promoted and tenured, who get recognized for contributions, who produce more and significant research, frequently consult colleagues. This article summarizes what is known about colleague relationships with the hope of stimulating further research to extend current conclusions to medical school faculty. METHOD: In the spring of 1992, a systematic literature review was conducted using database searches and author review of 137 selected books and articles using a standard protocol; preference was given to articles that were data-oriented, used quality designs, and related directly to the topic. RESULTS: Forty-seven "best" sources, published between 1963 and 1991, were included in the review of (1) types and configurations of colleague relationships, (2) forming and maintaining colleague relationships, (3) colleague effects on faculty success, (4) functions of colleague relationships, (5) changes in colleague relationships over a career, and (6) effects on methods, size, and configuration of colleague relationships. CONCLUSION: Among the conclusions reached are that (1) there are a variety of types or configurations of colleague relationships, all with different functions and effects on faculty performance; (2) dyadic conceptions of colleague relationships are insufficient to explain the functions of colleague relationships; and (3) the most important source for developing colleague relationships is professional associations, while the least important source is one's own institution.

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This paper analyzes and synthesizes the literature on primary care specialty choice from 1987 through 1993. To improve the validity and usefulness of the conclusions drawn from the literature, the authors developed a model of medical student specialty choice to guide the synthesis, and used only high-quality research (a final total of 73 articles). They found that students predominantly enter medical school with a preference for primary care careers, but that this preference diminishes over time (particularly over the clinical clerkship years). Student characteristics associated with primary care career choice are: being female, older, and married; having a broad undergraduate background; having non-physician parents; having relatively low income expectations; being interested in diverse patients and health problems; and having less interest in prestige, high technology, and surgery. Other traits, such as value orientation, personality, or life situation, yet to be reliably measured, may actually be responsible for some of these associations. Two curricular experiences are associated with increases in the numbers of students choosing primary care: required family practice clerkships and longitudinal primary care experiences. Overall, the number of required weeks in family practice shows the strongest association. Students are influenced by the cultures of the institutions in which they train, and an important factor in this influence is the relative representation of academically credible, full-time primary care faculty within each institution's governance and everyday operation. In turn, the institutional culture and faculty composition are largely determined by each school's mission and funding sources--explaining, perhaps, the strong and consistent association frequently found between public schools and a greater output of primary care physicians. Factors that do not influence primary care specialty choice include early exposure to family practice faculty or to family practitioners in their own clinics, having a high family medicine faculty-to-student ratio, and student debt level, unless exceptionally high. Also, students view a lack of understanding of the specialties as a major impediment to their career decisions, and it appears they acquire distorted images of the primary care specialties as they learn within major academic settings. Strikingly few schools produce a majority of primary care graduates who enter family practice, general internal medicine, or general practice residencies or who actually practice as generalists. Even specially designed tracks seldom produce more than 60% primary care graduates. Twelve recommendations for strategies to increase the proportion of primary care physicians are provided.

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Literature analyses and syntheses are becoming increasingly important as a means of periodically bringing coherence to a research area, contributing new knowledge revealed by integrating single studies, and quickly informing scientists of the state of the field. As a result, there is a need for approaches that can provide replicable, reliable, and trustworthy results. Over the last decade many researchers have begun using the statistical meta-analysis approach to integrate studies. However, the single studies conducted in many areas are not of the type amenable to statistical meta-analysis but are more appropriate for non-statistical analysis and synthesis. The present paper describes (1) a rigorous approach to conducting a non-statistical meta-analysis of research literature and (2) an example of how this approach was applied to the literature of determinants of primary care specialty choice published between 1987 and 1993. This approach includes model development, literature retrieval, literature coding, rating references for quality, annotating high-quality references, and synthesizing only the subset of the literature found of sufficient quality to be considered. Also, the basic results of each included study are reported in the synthesis so that readers have before them all the "data points" used in the synthesis. Thus, readers can draw their own interpretations without having to re-collect the data, just as they would be able to do in any single study that presents original data as well as conclusions and discussion.

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BACKGROUND: A number of studies have attempted to identify the components of the clinical teacher role by examining learners' numerical ratings of items on researcher-generated lists. Some of these studies have also compared different groups' perceptions of clinical teaching, but have not directly compared the perceptions of first- and third-year residents. This study addressed two questions: (1) What do residents consider important components of the clinical teacher role? (2) Do first- and third-year residents perceive this role similarly? METHOD: A content analysis was performed on the comments written on evaluation forms by 268 residents about 490 clinical teachers over a five-year period (1980-81 through 1984-85) at a large family practice residency. Of 5,664 forms completed by the residents, 2,388 (42%) contained written comments; comments were on 1,024 (46%) of the first-year resident's forms, 701 (41%) of the second-year residents' forms, and 663 (39%) of the third-year residents' forms. Themes in these comments were coded into a coding dictionary of 157 categories, within 37 clusters, within four roles. RESULTS: The ten highest-ranked categories (Global; Teaching: General; Knowledgeable; Gives Resident Responsibility; Supportive; Miscellaneous; Interested in Teaching; Clinical Competence; Makes Effort to Teach; and Gives Resident Opportunity to Do Procedures) accounted for 41% of the themes coded. The first- and third-year residents differed in the clusters they used to describe their clinical teachers on evaluation forms (chi 2 = 149.86, df = 36, p < .0001). CONCLUSION: The results suggest that content analysis can be used to validly and reliably study residents' written evaluative comments about their teachers. This study contributes to the definition of the clinical teacher role, showing the relative importances of its components, and also supports Stritter's Learning Vector theory, finding the anticipated differences between the comments made by first- and third-year residents.

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BACKGROUND: Heart attack and stroke are still prevalent causes of death and disability in the U.S. adult population (1, 2). Studies (3-9) have shown that modification of hypertension, smoking, and hypercholesterolemia can reduce risks for atherosclerosis and subsequent cardiovascular events. Therefore, it is important that physicians be skilled in assessing and modifying patients' overall cardiovascular risk. This study compares acquired knowledge of second-year medical students about cardiovascular risk assessment with knowledge in a selected group of practicing primary care physicians, who are members of the medical school's clinical faculty, using a new experimental testing technique called the tailored response test (TRT). METHODS: Students performed a structured cardiovascular risk intervention on a patient in primary care clinics. Their acquired knowledge was then tested using the TRT, which contained 43 discrete judgments about a clinical case. Test scores of students and faculty were compared. RESULTS: Both students and faculty demonstrated knowledge about the most important risk factors, appropriate screening tools, and interventions. However, the selected physicians did not demonstrate knowledge of certain important risk assessment and intervention recommendations, based on national standards. Only 38% of faculty and 27% of students were aware that a "fasting" serum cholesterol is not needed for screening, 30% of faculty believed that if cholesterol was over 300 they would "probably prescribe medicine" before other intervention strategies were tried, and 32% of faculty and 30% of students would order a screening chest X-ray, which is incorrect in the case history. CONCLUSIONS: The TRT, in contrast to self-report surveys, demonstrates that important cardiovascular risk assessment and intervention knowledge, with implications for cost effectiveness in health care delivery, has not penetrated to a selected group of physicians who are members of the medical school's clinical faculty and therefore serve as role models for medical students. This is disturbing, in light of current emphases on cost effectiveness in health care. Greater undergraduate curricula and CME emphasis on cardiovascular preventive practice is needed, such that almost 100% of students and faculty demonstrate knowledge, and practice, of preventive medicine according to national standards. In turn, groups developing national standards are enjoined to design and implement effective approaches for disseminating these recommendations.

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What environmental factors stimulate and maintain research productivity? To answer this question, the authors conducted an extensive review of articles and books on research productivity published from the mid-1960s through 1990. This review revealed that a consistent set of 12 characteristics was found in research-conducive environments: (1) clear goals that serve a coordinating function, (2) research emphasis, (3) distinctive culture, (4) positive group climate, (5) assertive participative governance, (6) decentralized organization, (7) frequent communication, (8) accessible resources, particularly human, (9) sufficient size, age, and diversity of the research group, (10) appropriate rewards, (11) concentration on recruitment and selection, and (12) leadership with research expertise and skill in both initiating appropriate organizational structure and using participatory management practices. Some of these characteristics are not surprising, although some findings were unexpected, such as that participative governance correlated consistently with research productivity. The differential impact of each of these 12 characteristics is unclear. It is clear, however, that the leader has a disproportionate impact through his or her influence on all of the other characteristics. Yet, an overarching feature of these characteristics is their interdependency. These factors do not operate in research groups as isolated characteristics. Rather, they are like fine threads of a whole fabric: individual, yet when interwoven, providing a strong, supportive, and stimulating backdrop for the researcher. The authors conclude that while at a distance the productive research enterprise looks like a highly robust entity, upon closer inspection it is revealed to be a delicate structure highly dependent on the existence and effective working of numerous individual, organizational, and leadership characteristics.

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