Several major findings emerged from this survey. First, only 35% of clinical teachers in medical clerkships of internal medicine, paediatrics, and obstetrics and gynaecology in Israeli medical schools reported having received specific training for medical education. Of those, about one-fifth received such training only after beginning their roles as tutors. Thus, under 30% of medical students’ clinical teachers had received training prior to undertaking this important role. This rate is very low, considering the WHO recommendation [28] and the requirement in countries such as the UK [10], the Netherlands [29], and Germany [30] that anyone involved in educating medical students first undertake training for that role.
This low rate of educational training did not differ between the specialties surveyed, nor between levels of seniority or according to having an official academic appointment. Notably, a statistically significant difference in the training rate was found between medical schools. This likely reflects a low rate of participation in the survey in some schools, and not a true difference. Even in the medical school with the highest rate of educational training, the rate was only 50% – well below the European standards. This indicates that all faculties in Israel must substantially improve the training of teaching physicians. Medical education in Israel is a dynamic field that has evolved substantially in recent years [15, 23,24,25]. Opportunities for advanced studies in medical education are available in most universities that teach medicine in Israel, and academic promotion based on teaching is established in most faculties. These platforms are in line with the international committee recommendations [14].
The need to train physicians as teachers includes the need for in-depth programs of faculty development; these are essential for improving the quality of teaching and evaluation [8, 26, 31]. A policy requiring formal pedagogical training would help ensure that physicians who teach students have the requisite knowledge, attitudes and skills, and meet international standards [31,32,33]. The importance of faculty development programs is highlighted by the empowerment physicians gain when they are trained to perform functions outside their roles of physicians; for example, as managers [7] and teachers [6]. Apparently, such programs help physicians identify with their roles as teachers and managers, and contribute to their career choices.
Of the respondents to our survey who received teaching training, most undertook a short course of less than 2 days (Table 3). While short courses were once the standard [11] for training medical educators, longitudinal training over the course of a teacher’s career is preferred. Studies have shown positive effects of this approach in medical education [31, 34, 35].
The results of the survey also demonstrated gaps in the content of the training that clinician-teachers receive. The respondents indicated that the topics most studied in pedagogic training of Israeli doctors are the provision of feedback, evaluating learning, and training for interpersonal communication skills. The vocabulary that medical educators use is many times enigmatic to practicing physicians. With exposure to faculty development program, terms such as “professionalism” become a part of the vocabulary of physicians, and the use of such terms is subsequently transferred to students. Conversely, the topics that the respondents most desired instruction were the use of diverse teaching methods, the discussion of clinical challenges and principles of bedside teaching. Further, of all the topics addressed in the survey, a significant difference was found between the extent to which teachers desired the subjects be taught, and the extent to which they were reportedly taught.
Generally, faculty development programs are based on theoretical frameworks, and the experience and opinions of experts. While this content may be suitable for experts and researchers in medical education, it does not necessarily suit the needs of doctors who are primarily clinicians and who teach students as a secondary role [29]. Teaching theory must also be tailored to the relevant audience and environment, and this is a realm for experienced educators.
Our findings corroborate previous studies that found that doctors desire to improve in teaching methods and strategies [36] and are interested in training in small group work, basic teaching skills and assessment of students [11]. For these reasons, assessing the needs of participants in pedagogic training, as carried out in this survey, is of critical importance [27], and should serve as a basis for faculty development programs [26].
As noted earlier, internal factors (e.g. the desire to contribute, the recognition of the importance of teaching in a physician’s role) were rated as having more influence in increasing motivation to teach than were external factors (remuneration, academic titles). This concurs with previous studies [4, 37, 38]. This said, the standard deviations of the external factors were relatively broad, indicating that these are nonetheless important to many clinician-educators. Similarly, previous reports showed that inadequate reward for teaching reduces the motivation to teach [39]. These data are important for optimising recruitment, development, and the retention of academic faculty in clinical teaching [38].
The reported improvement in motivation following pedagogic training is an additional reason for medical schools to provide pedagogic training to their teaching staff. This suggests that tailoring training programs to the needs of clinician-teachers may further increase their motivation.
As we observed, regardless of faculty development programs, self-confidence may be short-lived. This is because lack of investment in training and personal and professional development usually leads to burnout and loss of empathy and self-confidence [7].
Participants’ perception that medical education is poorly recognized and remunerated is an important finding. Notably, such opinions did not vary by specialty, by educational or professional experience, or by academic appointment. Differences were found between medical schools in attitudes to the statement: “I believe that good teaching is appropriately recognized and rewarded”. However, we suppose that this is not a true finding, but rather represents sampling bias due to the low number of participants from two of the medical schools. The sentiments expressed by the survey participants seem to reflect a situation that has been previously described [40]. Specifically, research tends to be more valued than teaching. The former offers easily evaluated outcome measures such as the publication of articles and receipt of grants, and a tangible impact on remuneration [41] and academic promotion [42]. In principle, academic promotion committees recognize the importance of teaching [43]. However, in practice teaching does not seem to constitute a major consideration in promotion decisions [44].
Various methods have been described for encouraging and improving medical instruction. These include the establishment of academic advancement tracks on the basis of teaching and educational activity [37], the development of departmental vision and strategy to promote teaching, and the establishment of specific committees for the academic promotion of clinical teachers [45]. The Association of American Medical Colleges has developed a “toolbox” for the objective assessment of academic educational activity, and for enabling consistent ranking of teachers for academic advancement [41]. Teachers in medical schools in Israel are expected to teach in addition to performing their professional duties as physicians. Lack of allocated and regulated time for teaching is probably a main topic that must be changed to improve the way teaching is recognized and appraised.
Responses to the open question “What are the aspects of greatest importance in your opinion regarding the training of doctors for teaching in the clinical environment?” generally reflect responses to the Likert-scale questions, and strengthen the quantitative results. As noted, there was a tendency for junior and more experienced teachers to give qualitatively different responses. Veteran teachers commented more on systemic factors and more advanced aspects of medical education. In contrast, younger teachers expressed more basic needs, such as guidance in clerkship requirements, lesson planning and teaching methods. These results highlight young teachers’ struggles with even the most basic topics related to teaching, and stress the need for training before beginning their role as clinical teachers. This also underscores the changing needs of clinical teachers throughout their careers, and the need to adapt training to differing needs over the course of physicians’ careers.
The methodology of this survey subjects it to potential sources of bias. No mechanism was implemented to secure equal representation of the participating medical schools. The were significant differences between the Technion and the other 3 universities in rates, length and content of pedagogic training. In the Technion many physicians with no academic appointment received short pedagogic training. These caveats aside, the data provide a basis for understanding the needs of clinical teachers in Israel. In light of reports of the inadequacy of training clinical teachers from other regions [6, 11,12,13], the findings of our study can be extended universally. In the context of deprived resources plaguing medical systems, teaching training can empower physicians and improve their motivation and wellbeing [6]. We showed previously that allocating work time for physician empowerment can improve their performance and wellbeing [7]. Yet, the validity of our findings should be interpreted in relation to the absolute number of physicians that answered the questionnaire, and the proportion of replies that we received of the total number of invitations. The number of responses we received seems appropriate to the size of the Israeli medical system. The number of responses from the Technion Medical School was higher than the responses from other faculties, and this may represent a weakness in representation in our survey. The reply rate of 58% is similar to the rate of 59% reported by Cardemil et al. [46] and high, compared to the rate of 32% in a survey by Poncette et al. [47]. While internal medicine is the major and the lengthiest theme taught in all medical schools, the presentation of teachers from internal medicine was relatively low in the survey.
The findings of our survey should serve for planning the future of medical education in Israel. The major issues that should be addressed are inadequate training and the content of training, and the recognition and rewards of teaching medical students in academic promotion and in material benefits. These issues were also raised by the international committee which performed an external review of the medical schools in Israel in 2014 [14, 15] (for full report see appendix). Although some progress can be seen for example by the recent initiative of the Israel Medical Association with courses for physicians to be trained as medical educators and the medical educator track for promotion in some of the medical schools, a major change is needed as echoed in our survey. This change will come about only if all involved parties recognize its need, starting with the Council of Higher Education (MALAG), the universities, Israel Medical Association and finally the faculty members of the faculties of medicine. Resources should be allocated for pedagogic training including clinical (beside) teaching of physicians and the recognition of the importance of clinical teaching by all faculty members should be acknowledged and rewarded. In view of the expectations of young physicians as expressed in our survey, it is our concern that without a major change, poorly motivated teachers and low quality teaching will result in poorly educated young physicians and irreversible damage to the Israeli medical system.
