Exploring the boundaries between clinician and teacher

Clinician teachers (CTs) play a pivotal role in medical student education. Medical schools depend on them to deliver their clinical curriculum and, thus, spend significant time and effort on recruitment and retention. The dual role of CTs as practicing physicians and medical educators, however, brings both opportunities and challenges.1 CTs are expected to seamlessly integrate their clinical and educational roles in clinical settings that seem to have ever-increasing demands. Unfortunately, the circumstances and contexts that would allow them to do so, or would foster success more generally, remain unclear. It is highly welcomed, therefore, that Brouwer et al., through the lens of boundary theory,2 present work in this issue of Medical Education3 that sets out to understand the contexts and processes that help CTs create value for students, colleagues, and the medical school. The researchers perceived boundaries between the clinical and educational contexts that CTs have to adeptly reconcile to be able to harmonize their clinical and teaching responsibilities and legitimize their value as CTs. To bridge the two contexts, CTs often use boundary objects,2 such as teaching a student about the treatment of hypertension while taking care of a patient who presents in clinic with elevated blood pressure. The harmonization of the clinical and teaching roles brings credibility and value to CTs' roles and nurtures a safe learning environment where students feel appreciated and empowered to actively engage. During these patient encounters, CTs role-model behaviours, compassion, empathy, and communication skills that can influence students' professional identity formation and career choices.4 CTs have to harmonize their clinical and teaching responsibilities and legitimize their value as CTs. Equally important, however, is CTs recognizing and admitting their own limitations and uncertainties about patient care to learners. Acknowledging and accepting vulnerability can be a powerful tool for teachers,5 nurturing a safe learning space where learners feel legitimized to express their own limitations. Commitment to self-reflection, self-improvement, and lifelong learning, therefore, are not only fundamental milestones in CTs' personal and professional growth as clinicians, but they strengthen CTs' value as teachers.6 Beyond individual benefits, such commitment can be a catalyst for establishing an institutional culture of community where collaboration, mutual trust, and support prevail.7 In such communities of practice, clinicians and CTs can develop informal or formal channels for peer mentorship and sharing of teaching recommendations that create value for junior CTs with less experience.8 Commitment to self-reflection, self-improvement, and lifelong learning strengthen CTs' value as teachers. Thinking through how to establish such a culture, it is noteworthy that the study3 also highlighted the importance of institutional support and resources for CTs' success. Support becomes increasingly important in CTs' efforts to bridge the clinical and educational contexts under time constraints, competing priorities, and increasing demands for clinical productivity. Sufficiently allocated time, equipped space for teaching, and faculty development resources are essential to fostering clinicians as teachers and legitimizing their value. Formally recognizing CTs' contributions to the clinical and educational mission through awards, appreciation events, promotion, and other incentives (e.g., stipends and funds for professional development) can validate their credibility and empower them to maximize their full potential in their dual role. Many CTs feel undervalued and disengaged from the medical school, but continue to teach because of inspirational role models encountered during their own medical training as well as the sense of self-fulfilment that comes from giving back to the profession.1 CTs who feel valued, however, are more satisfied and willing to continue teaching.9 Given the increasing difficulties in recruitment and retention of CTs, it is critical for medical schools to allocate resources strategically to prioritize and support CTs' needs. Formally recognizing CTs' contributions can empower them to maximize their full potential in their dual role. Given that the study3 focused on CTs with educational responsibilities either in the classroom or clinical settings where teaching occurs outside of direct patient care delivery it is also important for medical schools to be mindful of the increasingly diverse characteristics and experiences among CTs. Much of clinical teaching now takes place in busy clinical settings that are geographically isolated from the main campus. As a result, many CTs practice in remote locations, which can leave them feeling disconnected, with limited opportunities for engagement in the medical school and faculty development programs.1 Many CTs, in turn, have limited guidance on teaching expectations or feedback on their teaching performance from the medical school.9, 10 The Alliance for Clinical Education, which represents US national medical education organizations in eight specialties offering clinical clerkships, has called this issue a crisis, thereby emphasizing how concerning this state should be.11 It is also important for medical schools to be mindful of the increasingly diverse characteristics and experiences among CTs. Considering the increasing number of medical schools that establish regional campuses and use community-based clinical settings for student training, resources to foster CTs' growth as teachers becomes even more important because community-based CTs often face greater challenges in bridging the educational context with their own busy and remote clinical practice.1 Faculty development can be a way for medical schools to better engage their community-based CTs in their community of medical educators, offering mentorship and educational sessions that are flexible and adaptable to CTs' needs.10 CTs who attend faculty development programs have self-reported improvement in their teaching skills, confidence, and self-efficacy.12 Bouwer et al. push us to think further though by emphasizing the importance of CTs challenging educational thinking and practice, of bringing about curricular change and innovation while increasing their own educational expertise to truly gain a sense of belonging as a clinician educator. To do that effectively, CTs need to be empowered and trusted. Therefore, faculty development should offer more than workshops, but must prioritize opportunities for CTs to challenge their assumptions about their professional roles and identify how they can create value for their clinical practice, learners, peers, and the medical school through their educational engagement. Faculty development must identify opportunities for CTs to create value for their practice, learners, peers, and medical school through their educational engagement. While the present study illustrates the value of holding leadership roles in the medical school or the healthcare system in terms of creating opportunities for active engagement and self-perceptions of value, the multitude of roles that CTs hold suggests a need for future research exploring the value of CTs beyond the clinical and educational spaces if we are to fully understand how these additional roles interact and impact CTs' value and credibility as teaching clinicians. Frameworks, such as the Clinician Educator Milestones,6 may offer additional ways to evaluate and better understand the value CTs bring to stakeholders and the medical school mission, but it is critical that we realize we are so far just scratching the surface. The author has nothing to report. The author declares no conflicts of interest. The author has nothing to report.