Supporting early academic family medicine careers with the clinician scholar enhanced-skills program

Context The Clinician Scholar Program (CSP) is an enhanced-skills (R3) residency program to train clinician researchers/educators/leaders for academic family practice. This article intends to share Laval University’s CSP development and evaluation strategy, and provide recommendations for similar innovations in other disciplines/settings. Methods This article uses Kern’s model to present the program development, and a program-oriented approach for program evaluation, carried from 2011 to 2017 using descriptive data. Questionnaires, reflexive texts and an Objective Structured Teaching Exam supported data collection. Results Seven CSP graduates and 14 controls participated in the program evaluation. Residents were highly satisfied with the program, nevertheless they suggested to allow physicians to come back for training later in career. The CSP enriched knowledge, skills and attitudes about academic practice. CSP increased residents’ entrustment level about academic competencies. All graduates joined an academic practice within five years of program completion. Conclusion Key recommendations to implement similar programs include academic medicine core training, project- based learning with learner-centered objectives, relevant and authentic learning and assessment, and multi-level program evaluation approach. Programs should consider concomitant graduate studies and opportunity to offer such training after a few years of clinical practice to meet other needs at a timely stage of career.


Introduction
Since the beginning of 21 st century, academic family medicine has been facing various challenges, such as adjusting to new clinical demands in academic health centers, organizing and administering new initiatives in community-based education, developing and maintaining research capacity, and serving multiple missions (education, clinical care, and academic pursuits) in times of financial restraint. 1 Training and recruiting academic physicians is a major challenge, particularly early on in their career. 2 The literature describes many research, education, and leadership training programs for early-career clinicians. 3,4 However, few target residents or focus on more than one of these academic missions.
Increasing capacity in many Canadian family medicine residency programs in recent years has resulted in the hiring of a pool of clinician teachers, acting mainly as role models without necessarily having other graduate degrees besides the medical diploma. As in United States, 5,6 family medicine programs are facing the challenge of training a new wave of physicians with an interest in academia.
Since 2009, the College of Family Physicians of Canada (CFPC) has been encouraging medical schools to offer a Clinician Scholar Program (CSP) as an enhanced-skills (supplemental year) program. Currently, most CSPs offered in Canada are researchoriented and offered in English. Université Laval's CSP is intended to train clinician researchers, educators and leaders in clinical and academic francophone settings, promoting scholarship 7 in all three academic missions.
As proposed by Thompson,5 this article intends to share our CSP development and first five years' program evaluation strategy and provide recommendations for similar academic fellowship in other settings.

Program development and overview
The CSP aims to train competent faculty who are aware of the importance of scholarship as a way to e64 enhance their institution's national and international outreach, as well as their own. Residents involved in this program mostly complete it as a full-time PGY3, but may also spread it over PGY2 and PGY3 during completion of their second year of family medicine residency training. The CSP curriculum starts with a core Academic Medicine rotation where all residents are trained around academic practice requirements, strategies, and its expected scholarship. An elective in clinical research, medical education or academic management/leadership then allows them to enhance their skills in a one of these academic missions, and clinical activities are spread over the rest of the year (Table 1), to provide residents with a clinical and academic schedule similar to the one they will manage in their future practices.
The Family medicine and emergency medicine department chair and the family medicine program director at Laval University initially approached the future CSP program director (who had recently completed the Academic Fellowship program at the Department of Family and Community Medicine, University of Toronto) to discuss local needs around training for academic practice. Needs assessment included discussions with local faculty, analysis of the CFPC standards for the new CSP programs, and a literature review. The program therefore built on similar existing programs. 2,5,6 This article uses Kern's steps to present the program development 8 ( Figure  1).
Most faculty for the CSP had already completed graduate studies in research, medical education or management/leadership programs. The others were already involved as faculty development workshops facilitators. At the beginning of each academic year, 1 As stated in the 2014 edition of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (http://www.pre.ethics.gc.ca/eng/policypolitique/initiatives/tcps2-eptc2/chapter2-chapitre2/): "Quality assurance and quality improvement studies, program evaluation personalized training around metasupervision is provided by the program direction to the preceptors in teaching units attended by CSP residents in the medical education track .

Program evaluation.
Program evaluation was carried out from 2011 to 2017 using descriptive data based on a program-oriented approach. 9 Kirkpatrick's classification of training outcomes 10 structured the data collection. Although program evaluation activities do not fall within the scope of research ethics board review at our institution1, we respected voluntary participation (not mandatory for promotion), informed consent and confidentiality in data management and reporting results.

Reaction.
We assessed reactions to the program activities using a feedback questionnaire at program completion, providing a satisfaction score (product of relevance (/5) x met expectations (/3)) and assessing general satisfaction and workload. Since the Medical and Academic Leadership/Management elective was particularly innovative, we analyzed the strengths and avenues for improvement of this rotation with a preceptor survey.

Learning.
We assessed learning using a retrospective pre-post self-evaluation questionnaire. 11 Selfassessment scales regarding achievement of program evaluation objectives drew on Bloom's (knowledge), 12, 13 Simpson's (skills), 14 and Krathwohl's (attitudes) 15 taxonomies. We also asked each resident to identify three take-home messages from the program.

Behaviour.
We assessed the impact of the CSP on resident behaviour also using a retrospective pre-post self-evaluation questionnaire, 11 as well as content analysis of reflective texts written by residents upon completing the program, applying a framework for analysis relating to the three academic missions.  •Each resident also defines personal objectives together with the program director to establish learning plan that is adapted to the resident's needs and periodically reviewed.
Teaching/ assessment strategies •CSP curriculum (see Table 1): •Core Academic Medicine rotation •Research, Education or Management/Leadership elective •Assessment: portfolio-based, documenting with a reflective approach the competencies developed throughout the program.
•Portfolio review with program director every 3 months for feedback and guidance.

Implementation
•Program promotion: residency programs promotion events, website •Program committee * ensures the consistency of the program's content and structure, along with continuous quality improvement; it is also in charge of resident admission, assessment, and support.

Results
Five to seven CSP of the 7 graduates (71-100%) and 14 of the 20 new clinical faculty who joined our department between 2011 and 2015 (control group, 70% response rate) took part in the program evaluation (variable number of participants for each type of evaluation). One third of graduates and 20% of the control group held graduate degrees in addition to their medical degree.

Reactions to the program
The general satisfaction with the program was high (4.7±0.5/5). The workload was appraised as demanding to very demanding (4.3±0.5/5). The most appreciated activity was the Academic Medicine intensive workshops (score 14.3/15, n=7). All graduates would recommend the program to colleagues interested in academic practice.
Program evaluation specific to the Medical and Academic Leadership/Management elective has highlighted the various levels of practicum exposure (clinical: local/regional/provincial; academic: teaching site/program/department/faculty level), as well as the resident project spinoffs for the teaching site. Suggested improvements included focusing on some activities and choosing a limited number of supervisors to enhance educational continuity, dispersion across activities and supervisors, better defining resident and supervisor roles and responsibilities, and allowing later enrollment into the program, i.e. after at least 2-5 years of clinical practice including experience in leadership/management.

Learning
The learning self-assessment reflects higher-level objective achievement in the cognitive, psychomotor, and affective domains at the end of the program ( Table 2). The residents' take-home messages highlighted their learning in relation to scholarship, including the importance of rigor and impact of academic work (n=7), critical thinking (n=2), clinicalacademic work balance (n=2), career planning (n=2), and leadership (n=2). A number of residents also mentioned educational strategies (n=2) and approaches to educational innovation (n=1), selfdirected learning (n=1) and networking (n=1).

Behaviour
The perceived entrustment level for various academic competencies progressed throughout the program. In addition, content analysis of the reflexive texts written by residents (n=6) at program completion highlights the development/improvement of a number of behaviours associated with practice in the three academic domains ( Table 2): graduates value the scholarship approach, understand their teaching role for which they use a range of strategies, and are confident about taking on academic responsibilities making use of their management skills and with the help of the network they have developed during their training year. More particularly, residents taking the Medical Education elective demonstrated an improvement of their OSTE score by 14.4% compared to the control group residents (6.6%).

Results
Intention to practice in an academic setting five years of graduation was similar between graduates (4.8±0,45/5) and controls (4.9±0.36/5). Despite small sample size, available research/leadership opportunities, academic workload and seeking professional-personal life balance seem to influence CSP graduates' intention to practice in an academic setting five years after graduation, whereas the possibility to practice in a large urban center, reduced clinical exposure and available teaching opportunities seem to have more influence on other new clinical faculty. (Figure 2 -Supplemental digital content).
CSP graduates' academic productivity seemed relatively comparable to that of the control group. However, CSP graduates had slightly more opportunities for national outreach (Table 3 -Supplemental digital content). All CSP graduates joined an academic practice within five years of program completion (4 within and 3 outside the Laval University network). e69

Discussion
The CSP at Université Laval offers a francophone training environment for a new wave of academic family physicians working towards a scholarship perspective. It is one of the rare programs targeting basic skills development in the entire range of academic medicine missions. Some schools have developed similar programs, but we found only two who have published their program description and/or evaluation. The first, from the Department of Family Medicine of the University of Western Ontario (London, ON, Canada) aimed "to produce academic family physicians who exhibit […] outstanding clinical skills, professional interest in the organization and transmission of knowledge, and a scholarly approach through research and skills of leadership. 19 However, this program did not involve residents, but faculty members. Outcomes from this program included changes from private practice and lecturer to positions as assistant/associate/full professor and chairman/director, taking positions of responsibility for teaching and administering educational schemes. Graduates also produced substantial scholarly contributions. The other program we could find was the O'Connor Stanford Leaders in Education Residency program (Stanford University School of Medicine, California, USA) focuses mostly on teaching and scholarly projects, with leadership training components. This program increased confidence in teaching skills, and increased scholarly work output. 20 While we noticed an interest in the CSP during residency program promotion events or information requests, more specific data about impact on applicants to our family medicine residency program would be helpful.
The reactions to the program are strongly positive, particularly for the academic medicine rotation. This is probably related not only with its content (principles of scholarship being new for many residents) and structure (project-based learning), but also by residents' discovery of and involvement in a new community of academic practice. In general, our program resulted in learning, behaviours, and results that are comparable to those obtained in related programs, with similar challenges. 3, 6, 21-25 Despite the absence of obvious impact of the CSP on the factors influencing intention for academic practice, it succeeds in providing tools supporting early academic career.
This program development and evaluation has certain limitations. To date, the CSP has mostly attracted applicants for the Medical Education track. The Clinical Research track might be more attractive if combined with a master's degree, therefore facilitating a clinician-researcher career for graduates. Furthermore, the limited number of applicants for the Medical and Academic Leadership/Management track suggests that interest in and need for this type of training emerges later in one's career. We are currently considering the possibility of offering this training after a few years of clinical practice in addition to the current third year residency enhanced-skills program. Other limitations result from political pressure to take on unattached patients in Quebec since 2014 26,27 (with a growing number of family physicians focusing on clinical practice to the detriment of their academic involvement), which undeniably affected the program's recruitment capacity and might explain decreased academic productivity following the program. Finally, the small size of the contingent of residents we can enroll and the choice we made of choosing an outcomes-based evaluation strategy do limit the conclusions we can draw from the program evaluation. Assessment of other aspects than outcomes (ex.: context, input, process 28 ) would also be relevant for program directions. Nevertheless, our program evaluation strategy provided some qualitative data reinforcing that we meet the training needs of the new generation of family medicine faculty.
Université Laval's CSP is a unique francophone residency program supporting new family physicians in an early academic career, balancing their clinical and academic roles with confidence in an environment fostering scholarship, mentorship, and networking. Program structure and content appears easily transferable to other specialties. We are confident that other medical schools should succeed in implementing similar programs in their own setting, to prepare the next generation of academic medical faculty. Key recommendations to implement similar programs (Box 1) include academic medicine core training, project-based learning with learnercentered objectives, relevant and authentic learning and assessment, and multi-level program evaluation approach. To meet other needs at a timely stage of career, programs should consider concomitant e72 graduate studies and offering such training after a few years of clinical practice.
Acknowledgements: The authors wish to thank Caroline Simard, Luc Côté and Abaca Traduction for their helpful comments on the manuscript.

Appendix A Box 1 -Key recommendations for development, implementation and program assessment of an academic medicine program
Based on the program evaluation results and consequent reflective analysis by the program committee members, further academic medicine programs should: Consider academic medicine core training at the program outset, to ensure strong bases for all residents, networking and engagement in their new community of practice.
Focus on learner-centered objectives, using project-based learning to foster intrinsic motivation for learning.
Engage residents in "real life": help them manage clinical, academic and personal life schedules, using a horizontal curriculum; use relevant and authentic assessment strategies, having them build their teaching dossier as a portfolio documenting their competency achievement through the program.
Encourage residents to pursue graduate studies concomitantly with their third-year clinical scholar residency program.
Consider offering an academic leadership program after a few years of clinical practice, since interest in and need for training as an academic leader seems to emerge later in career.
Adopt a multi-level program evaluation approach to foster scholarship in this field and provide evidence-based support for further program development. Assessment of other aspects than outcomes (such as context, input or process) would also be relevant for program directions. e75 Appendix B Table 3  Appendix C

Figure 2 -Factors influencing the intention to practice in an academic setting five years after graduation
Factors influencing the intention to maintain an academic practice five years after graduation assessed using a questionnaire based on three social cognitive theories: theory of reasoned action 29 , theory of planned behaviour 30 and interpersonal behaviour theory 31  Acts as a mentor to guide his or her colleagues in their literature search and directs them to more specialized sources when needed (11) x Providing constructive criticism of colleagues' academic work Comments mainly on the strengths and refers to a few points for improvement in a cursory manner Provides balanced comments of strengths and points for improvement (8) Provides constructive comments of strengths and points for improvement, supported by references, and offers relevant rectifications (13) x Adopting a clinical "coaching" approach in his or her daily supervision activities * Mostly validates the clinical conduct of the learner. Acts intuitively or understands and applies some recognized educational principles in relation to clinical supervision. Maintains at times a supervisor-trainee hierarchy.
Teaches various CanMEDS-FM competencies along with validating clinical conduct. Analyzes educational principles and identifies those that are most relevant to use depending on the clinical supervision situation, and encourages a "learning position" (11) Acts as a leader** and scholar in relation to clinical supervision (14) x Adopting a competency "coaching" approach throughout the learner's training * Acts intuitively or applies some recognized educational principles in relation to feedback and mentorship. Maintains at times a supervisor-trainee hierarchy.
Refers to a set of educational principles and identifies those that are most relevant to use depending on the feedback and/or mentorship situation, and encourages a "learning position" (11) Acts as a leader** and scholar in relation to feedback and mentorship (14) x Developing a training curriculum outside the clinical setting * Acts intuitively when planning the curriculum.
Refers to a set of educational principles and applies those that are Demonstrates leadership** and scholarship in curriculum e79 order to advance his or her projects x Exercising a range of management skills Exercises some management skills in a spontaneous and intuitive manner Exercises a number of management skills in a conscious manner (11) Acts as a mentor with his or her peers when exercising management skills (14) x x x Soliciting the relevant university and healthcare system authorities for the purpose of his or her projects Requires close supervision from some relevant authorities for the purpose of his or her projects.
Needs distant supervision from a number of relevant authorities for the purpose of his or her projects.
Acts as a mentor with his or her peers to help them soliciting relevant authorities for the purpose of their projects (14) x x x Exercising various modalities of influence in relation to management (power, authority, leadership, political skill) Exercises some modalities of influence in his or her management activities in a spontaneous and intuitive manner Consciously experiments with a number of modalities of influence in his or her management activities (8) Adjusts his or her modalities of influence to the management activity concerned (11) * Fundamental teaching activities framework 5 . In order to meet the entrustment level requirements for clinician scholars in the early stages of their