I came off my first clinical rotation feeling defeated. It had not been a good experience and I was quietly questioning whether I had made the right choice in going into medicine at all.
My next rotation was with Dr. Mason, a local family physician in our community who would become one of my enduring role models. On my first day, he sat me down, took one look at me, and began asking me questions about myself the same way I would come to learn that he would interview a patient. Carefully. With respect. Without rushing. With real curiosity about who I was and what I had been through. Then he stood up and said,
"Well, then, let's go see some patients together."
That sentence shaped the rest of my career.
What happened over the following weeks was not mentorship in the abstract. It was one faculty clinician, one learner, one patient or family, repeated in real rooms with real stakes. I call it the golden triangle of clinical learning, and I believe it is the irreducible unit by which clinicians are formed. Right now, that learning relationship is being eroded from all sides. Educators are losing the agency to protect it. Learners are losing the cultural pull toward it. Conversations about faculty burnout have misnamed the problem, and conversations about learning have missed it entirely. And those of us best positioned to guard this practice are the ones being squeezed hardest of all.
This golden triangle is not just precepting or mentorship. It is not teaching as a soft skill or an obligation bolted onto clinical practice. It is real clinical practice extended to fundamentally incorporate the learner. The same diagnostic skills clinician faculty apply to their patients—interview, observation, calibration, judgment—are the skills they apply to the learner alongside them. Dr. Mason did not teach me simply by seeing patients together. He taught me by caring for patients with me, having first taken the measure of who I was and what I needed. The result is something nothing else in our curriculum can produce: clinicians formed in the care of patients by clinicians who know them both well.
Today what is eroding this relationship is not the volume of teaching, nor the volume of patient care itself. It is the volume of documentation for the sake of compliance with an ever-growing set of requirements, layered on from the clinical side and the education side both, and paired with the assumption that the clinical faculty member has unlimited time, unlimited mental capacity, and no agency to say "no, that is not where my attention belongs." Death by a thousand drop-down-and-clicks. The personal ROI, the golden moments in teaching, have worn very thin.
There's a lot of challenges in medical education now. And they're not necessarily that new. One issue that we've really been struggling with now, probably for decades, is faculty having the time to teach. So whether you're a basic scientist and you're engaged in your struggles to get and maintain funding, or you're a clinical faculty member who is constantly pressured to see more patients and be more clinically productive, it can just be very, very hard for faculty to really have the time to teach sometimes in the ways that they would like. And that includes providing students with feedback. We particularly see this as a challenge in the clinical setting. Faculty want to do right by the students, they want to teach students. It's why they're at an academic medical center. But again, it's that balance of all the pressures that they face that get in the way.
~ Amy Wilson-Delfosse, PhD
Senior Associate Dean for Medical Education,
Case Western Reserve University School of Medicine
I think too of Dr. Harris, my pediatric preceptor in rural New Hampshire, who practiced out of a mobile home with his wife as his only staff. He always had a student because he both loved to teach and needed the help, and he trained us up quickly so we could be useful. The community adored him. Years later, when I returned to Dartmouth as a clerkship director and was sending my own students his way, he called me to task. He didn't have time, he said, to ensure they were "getting all of that required curriculum from me." His final phrase has stayed with me: “Instead, I’ll focus on the real job you are asking me to do.” He was telling me, plainly, that the requirements I was placing on him were squarely in the way of doing for my own students what he had done for me: taught me how to be a clinician by caring for patients with me. And he was right. Since then, I have watched these clinician faculty, who have dedicated themselves to being on the front line of where teaching meets patient care, be driven out of it fastest.
The biggest challenge is time. Faculty wear a lot of hats. We are multitasking. We are teaching. We're trying to do scholarship. We're seeing patients throughout the day in the clinical realm for many of us. We want to be innovative. We want to be interactive with our students, but we have a lot going on. We are so pressed for time, and we're tired. That's one of the biggest, biggest challenges for us.
~Kelsey Dougherty, MMSc, PA-C
Assistant Professor,
University of Colorado Child Health Associate/
Physician Assistant Program (CHAPA)
At the same time, our learners are being pulled away by a test prep culture that has crept up from K–12, through higher education, and now landed hard in clinical training. We helped create that culture, even as we lament it. The countervailing gravitational pull from the Dr. Masons and the Dr. Harrises has weakened, and the gravitational pull of test prep is winning. Students are increasingly absent from this golden clinical learning triangle even when they are physically in the room. The pressures have stolen their caring too.
We, as clinical educators, sit squarely in the middle of all of this. We are the guardian of the triangle. It is, more often than not, all of our origin story. We became educators because of the influence of clinicians like Dr. Mason and Dr. Harris in our own training. And we are now structurally responsible for both maintaining this relationship and enforcing the very requirements that erode it. We are feeling the squeeze worst of all, particularly among our junior and underrepresented minority faculty.1
I know the counter arguments. Isn't this a romanticized version of clinical training? Medicine has changed. Patients are frustrated, asking more of us and the system that too often gives them less. Our learners, and even our junior colleagues, grew up through a test prep culture that started long before they reached us. You cannot reconstruct an apprenticeship model from an era that no longer exists.
That is fair, and it is exactly why guarding this critical component of clinical training matters more now, not less. When the golden triangle is healthy, patients feel listened to, attended to, honored as part of a teaching relationship the system stands behind. When it is eroded, when the faculty clinician is no longer a meaningful part of the interaction, patients are left feeling like second-class citizens, ‘seen’ yet not seen by a student the system seems to have handed them off to. The pressures on patients and learners are not reasons to give up on this practice. They are the reasons it must be closely guarded.
For us as clinical educators, I challenge the usual question "How do I find the time?" Instead, we should begin by asking:
“What do I need to stop doing or improve in order to guard and grow patient-centered learning, because that is my most important job?”
Three principles, drawn from what I am seeing across our community:
Clinical educator agency is not a luxury. It is the precondition.
Standing firm in our agency is what allows our clinical teaching faculty to do the same. The most valuable thing a faculty clinician does at the bedside cannot be done while complying with infinite documentation. We have to stop treating our faculty's time, and our own, as the variable that absorbs every new requirement. In order to support the most important things, we need to shift the question from “What else can we ask of them?” to “What can we stop asking of them?” Some documentation is genuinely needed; some genuinely is not. Sorting that, and then putting real infrastructure in place to handle what is not the faculty clinician's highest-value work, is the leader's job.
Build or buy the scaffolding for everything else.
The use of high-quality curated tools and resources to provide required standardization and scale enables clinical faculty to focus on the individualized instruction only they can provide. Dr. Harris was right that the educational burdens placed on him took him away from the job I had asked him to do. The fix was not to give up on the curriculum. The fix was to stop using his time to ensure its delivery.
The countervailing gravity is ours to create.
If test prep culture is pulling our students away, then it is up to us to pull them back and to name and make clear what clinical learning gives them that test prep cannot. Standing by our principles, in the face of their pushback, is itself an act of leadership. Acting on it is an imperative.
For the first time in a long time, real tools are arriving that can take on what was never the human's job to begin with: the documentation, the paper-pushing, the compliance load that has truly eroded real bedside teaching. I am staying in this job rather than retiring because I can once again see a way to put faculty and learners and patients back together, in the rooms where they belong, doing the work only humans can do: listening, reasoning, teaching, healing. The invitation Dr. Mason extended to me is still possible for our learners: let’s go see some patients. The question is whether we, as educators, have the will to reimagine the world and stand guard while they do.
In the next post in this series, I want to look at one of the strongest forces pulling our learners out of this work: the test prep culture we built, and the diagnostician we have quietly stopped aspiring to be.
At Aquifer, we have built our work around a single conviction: the faculty clinician's time belongs in the triangle, and the rest of the curricular load belongs somewhere else. Supporting educators in the development of strong clinicians in this way is our mission. Our Consortium-developed content (including virtual patient cases, formative assessments, and educator resources) exists so that when faculty and learners are together, that time can be spent on what only they can do. Everything we create is guided by the same purpose: helping educators focus their attention where it has the greatest impact on learning—and reducing the friction that pulls them away from it. That is the work we are trying to protect.
To learn more and access our playbook, see Clinical Learning, Reimagined.
1 Myers O, Vick K, Greenberg N, Sood A. Faculty retention at a school of medicine, 2010–2022. Chronicle of Mentoring & Coaching. 2023 Nov;7(SI16):388–393. PMCID: PMC10768923. PMID: 38187463.