Building capacity for clinical care while sustaining the academic mission

Academic medicine requires a challenging balance of responsibilities as physician, teacher, and scholar. We are very fortunate to work alongside supportive colleagues and learners who somehow make it all work, most of the time. Still, the past few years have made this balance precariously difficult. The current mismatch of clinical providers to patients requiring care is impacting not only our patients, but also clinician wellbeing, our residency program accreditation, and the ability of our faculty members to secure the necessary time to fulfil their academic responsibilities. We need to re-set the balance of faculty within the department such that we can accomplish all our goals – clinical care, teaching, and scholarship.

Patient care will always – should always – take precedence over other academic responsibilities. Thus, ensuring there is sufficient capacity to provide that care is critical to sustaining the academic mission. The skilled clinician within our academic environment serves not only as a role model for learners, but also as a go-to expert on challenging cases, content expert and knowledge user in clinical research and quality improvement initiatives, and innovator in care delivery. This is why several years ago we established our Master Clinician designation – to recognize these very special people.

However, within the Temerty Faculty of Medicine at the University of Toronto, there has been no formal process by which to recruit full-time clinical faculty members whose primary focus is on clinical care. Unlike some universities, we do not have a “clinical faculty” stream. Our teaching hospitals therefore rely heavily on Clinical Associates, and increasingly Hospitalists, to provide clinical coverage, many of whom, if offered, would prefer to be full-time DoM clinical faculty members. Thus, as part of a multi-pronged approach to addressing the health human resource issues we are facing, the department has requested and received approval to establish a new Academic Position Description (APD) - the Academic Clinician. The primary academic responsibility of the Academic Clinician will be to provide, advance & promote excellence in clinical care in a scholarly manner. 

Through the establishment of the Academic Clinician APD, the DoM wishes to:

1. Enhance recognition in a tangible way the importance of excellent patient care and the individuals providing it.
2. Strengthen the provision of care by highly qualified physicians in our fully affiliated teaching hospitals.
3. Enhance faculty members’ capacity to focus on other academic activities, including teaching, education, quality and innovation, and research.  

The Academic Clinician Position Description

Academic Clinicians will be full-time clinical faculty members.

They will be recruited through a formal search process, be members of their hospital / departmental practice plan, go through Continuing Faculty Appointment Review, and be eligible for senior promotion just as all other full-timers do.

The goal of creation of this new APD is to meet the current clinical needs within our teaching hospitals, enabling those with other APDs to fulfill their academic commitments to teaching, QI, and research. Thus, we do not anticipate the recruitment of large numbers of Academic Clinicians.  Recruitment will only be considered in the following circumstances:

1. There is clear unmet need for clinical care in the specialty that is negatively impacting the academic mission (teaching/education/scholarship) OR physician well-being; AND
2. There are insufficient eligible candidates for recruitment in other APDs. 

Requirements for appointment as an Academic Clinician

Academic Clinicians will be expected to have demonstrated their capacity for provision of high-quality patient care & interest in advancing evidence-based, innovative, person-centered clinical care. This may be demonstrated through residency and/or fellowship training. Individuals may be recruited to this APD directly following residency or after completion of some sub-specialty fellowship training. Advanced training in teaching, QI or research will not be required. As such, we anticipate that most Academic Clinicians will be recruited at the rank of Lecturer.

Will individuals requiring academic licensure be eligible for this APD? 

Individuals with restricted practice licensure, i.e., requiring academic licensure by the CPSO to engage in clinical practice, must be eligible for appointment at the rank of Assistant Professor and thus, must complete advanced training and demonstrate scholarship related to the role for which they are being recruited. Recruitment at the rank of Lecturer is not permitted. It is currently unclear if the CPSO will accept recruitment of a faculty member at the rank of Assistant Professor and in the Academic Clinician position description, as generally academic licensure is provided to enable significant dedication of time to education, research, or other scholarly activities.

Criteria for Junior Promotion from Lecturer to the Assistant Professor

As for all clinical faculty members, junior promotion requires completion of advanced training and demonstration of scholarship relevant to the position. We anticipate that Academic Clinicians may seek junior promotion based on specialty fellowship completion and advancing professional practice in their clinical discipline (i.e., creative professional activities), such as a peer-reviewed publication relevant to their work, developing a new model of clinical care or a clinical innovation. Unlike faculty members in other APDs, however, Academic Clinicians will not be expected to advance to the rank of Assistant Professor by CFAR.

Expectations at Continuing Faculty Appointment Review (CFAR)

Given the primary focus on clinical care delivery, we are developing a novel evaluation process for the Academic Clinician. These faculty members will be expected to demonstrate expert clinical practice congruent with the CanMEDs roles via peer practice review & 360-degree evaluation of interdisciplinary clinical stakeholders. These assessments will be developed over the coming months. In addition, as for all full-time clinical faculty members, the Academic Clinician will be expected to demonstrate behaviour consistent with expectations at the hospital, university and CPSO in their interactions with colleagues and learners, to be engaged as collaborators in quality improvement and clinical research initiatives, e.g., pilot testing a new process, and to demonstrate citizenship through administrative service.

Eligibility for Senior Promotion

As for all clinical faculty members, Academic Clinicians will be eligible to seek promotion through the ranks on any one or more of excellence in teaching, research, or creative professional activities. They will be held to the same criteria as for all other Temerty faculty members.

What is the effect, if any, of this new APD on our Clinician Teachers?

Our hope is that the effect will be positive! For years now – well before the COVID pandemic – our CTs & learners have articulated that the pressures of high volumes of patients requiring their attention have undermined the collective educational experience. We also heard this at our Royal College accreditation of several programs. We are hopeful that by creation of this new APD for use in specialties where this is an issue, e.g., General Internal Medicine and Medical Oncology, our CTs will have more time to spend engaged in teaching.

We know you will have more questions about this new APD. While the APD itself has been agreed upon and approved at the faculty level, the details regarding operationalizing the APD at the level of the hospitals and hospital practice plans is ongoing. As you know, all full-time faculty members must be full members of a conforming practice plan. The DoM practice plans are managed locally by the departments of medicine/emergency medicine at each fully affiliated teaching hospital where decisions are made regarding allocation of resources, including AFP funding. The PICs are working together to ensure fairness, transparency, and equity across sites with respect to this new position description. More details to come.

If you have additional questions, please reach out to me directly – g.hawker@utoronto.ca .  As always, your suggestions and feedback are welcome.