Virginia Apgar Academy of Medical Educators Membership
Application 2022-2023
DEADLINE: TUESDAY, JANUARY 30, 2024
NAME: _________________________________________
DEPARTMENT: _________________________________________
Your Academic Title: _________________________________________
TABLE OF CONTENTS
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Summary Statement (1 page)
How I would like to contribute to the Academy (1 page)
Letter of nomination
Supporting document – evidence of excellence
CUIMC CV format with Enhanced Educational Goals
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Summary Statement – 1 page, 12 pt, 1 inch margins
This one-page document should guide your reviewers through your enhanced CV.
Remember that you are demonstrating your excellence, experience, and evidence of
engagment in at least two areas of medical education. They are:
• Direct teaching
• Instructional Development and Curricular Design
• Advising and Mentorship
• Educational Administration and Leadership
• Educational Research or Publication
Use this statement to highlight your accomplishments in the areas of your greatest
strengths.
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How I would like to contribute to the Academy – 1 page, 12 pt, 1” margins
Your willingness to become an active, contributing member of the Academy is
very important to us in our selection process. Please use this essay to describe to us the
ways that you would like to contribute to the Academy. You can highlight your expertise,
interests, enthusiasm, past experiences etc. We are also interested in ways that you have
already been engaged in a community of educators, either here at P&S or on a national/
international level.
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Letter of Nomination
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Supplemental Document – Evidence of Excellence
1-2 pages, 12 pt, 1” margins
Please use these 1-2 pages to document your excellence in the 2 areas of medical
education that you are highlighting. You may include quantitative and qualitative
evidence. If you are including narratives from students or mentees, please excerpt the
material rather than including individual letters, e-mails etc.
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CV FORMATTING TEMPLATE
Please refer to CUIMC Format for Curriculum Vitae for all instruction.
This is a template for formatting the CV in Wo
rd. Please convert from PDF to Word. You may replace
the “Jane Doe” information with your own data without losing the columns, spacing, and formatting of
the document. If you are unable to successfully convert this PDF to Word, please request from Renee
Saindon ([email protected]) a Word version be emailed to you directly.
D
ate of preparation: [TODAY’S DATE]
Jan
e Doe, MD
45 East 99
th
Street #56
New York, NY 10165
212-998-5454
Jd559@cumc.columbia.edu
P
lace of Birth: New York, NY
Citizenship: USA
ACADE
MIC APPOINTMENTS, HOSPITAL APPOINTMENTS, AND OTHER WORK
EXPERIENCE
A
cademic Appointments
05/2010 - present
Columbia University College of Physicians & Surgeons
Associate Professor of Medicine at CUIMC
New York, NY
01/1998 –
05/1999
Columbia University College of Physicians & Surgeons
Assistant Professor of Medicine at CUIMC
New York, NY
01/1997 –
01/1998
Columbia University College of Physicians & Surgeons
Instructor in Medicine
New York, NY
H
ospital Appointments
05/2010 - present
New York-Presbyterian/Columbia University Medical
Center
Associate Attending
New York, NY
01/1998 –
05/1999
New York-Presbyterian/Columbia University Medical
Center
Assistant Attending
New York, NY
ED
UCATION
Columbia University, College of Physicians & Surgeons
MD, May 2004
New York, NY
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Cornell University, College of Arts and Sciences
BA in English, May 1999
New York, NY
T
RAINING
07/2009 –
12/2009
Department of Medicine, Columbia University
Cardiology fellow
New York, NY
07/2005 –
06/2009
Department of Medicine, Columbia University
Cardiology Chief Resident
New York, NY
07/2004 –
06/2005
Department of Medicine, Columbia University
Cardiology Intern
New York, NY
E
XPLANATION OF GAPS IN WORK/TRAINING/EDUCATION
L
ICENSURE AND BOARD CERTIFICATION
LICENSURE
BOARD QUALIFICATION
HON
ORS AND AWARDS
ACADE
MIC SERVICE
P
ROFESSIONAL ORGANIZATIONS AND SOCIETIES
• MEMBERSHIPS AND POSITIONS
• CONSULTATIVE (FEDERAL, STATE, PRIVATE)
• JOURNAL REVIEWER
• EDITORIAL
F
ELLOWSHIP AND GRANT SUPPORT
Include dates, grant title, granting agency, grant number, direct support funds, and your role.
Include the PI if other than yourself.
• PRESENT SUPPORT
• PAST SUPPORT
• PENDING SUPPORT
E
DUCATIONAL CONTRIBUTIONS
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• Direct Teaching/Precepting/Supervising
• Development of instructional material and curriculum used locally
• Advising and Mentorship
• Educational Administration and Leadership
• Instructional/Educational Materials used in Print or other Media
• Community Education
Educational roles
1. Direct teaching/precepting/supervising experiences (in reverse chronological
order)
Academic
Year(s)
Title of course/mentoring
relationship
Type of learner Your role
Contact
with
learners
in hours/
year
Mean
Number
of
learners/
year
2015-17 Teaching Interviewing
1
st
year medical
students
Instructor 6 50
2014 Teaching physical diagnosis
2013
Body, Health, and Disease
Small group, cardiology section
Etc.
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2. Instructional Development and Curricular Design (in reverse chronological
order)
Academic
Year(s)
Course/educational
innovation
community Your role Brief desription
2006
New
instructional
videotapes for
team-based
learning
VP&S –
department of
XX
Primary
developer
I led a team that
conceptualized and created 5
videotapes for enhancing this
learning in our clerkship.
2004
Etc.
3. Advising and Mentorship (in reverse chronologicl order)
Academic
Year(s)
Name of mentee Status Accomplishments
Contact
with
mentee in
hours/yea
r
2006-
present
Sam Jones
Medical
student
Co-published paper in Academic medicine
20+
2005
10
Etc.
4. Educational Administration and Leadership (in reverse chronological order)
Academic
Year(s)
Leadership role Community Major accomplishments
2006-
present Residency
Training
Director
Columbia
University
Dept of XX
Recent site visit (2008) with 5 year accreditation;
new curriculum instituted 2009; new advances in
technology 2010; 2011 grant to study outcomes
related to new evaluation methods
2004
REPORT OF CLINICAL AND PUBLIC HEALTH ACTIVITIES AND INNOVATIONS
• Practice or Public Health Activities
• Clinical or Public Health Innovations
• Clinical or Public Health Administration and Leadership
• Additional Clinical or Public Health Service Activities
P
ATENTS & INVENTIONS
• Patents
• Patent Applications
PUBLICATIONS (LIST IN REVERSE CHRONOLOGICAL ORDER, BY CATEGORY)
• ORIGINAL, PEER-REVIEWED RESEARCH PUBLICATIONS IN PRINT OR OTHER MEDIA
• OTHER PEER-REVIEWED PUBLICATIONS IN PRINT OR OTHER MEDIA
• REVIEWS, CHAPTERS, MONOGRAPHS, EDITORIALS
• BOOKS/TEXTBOOKS FOR MEDICAL OR SCIENTIFIC COMMUNITY
• MEETINGS/INVITED ORAL AND POSTER PRESETNATIONS
• CASE REPORTS
• LETTERS TO THE EDITOR
• OTHER MEDIA
• THESIS
• OTHER NON-PEER REVIEWED PUBLICATIONS IN PRINT OR OTHER MEDIA
• NON-AUTHORED PUBLICATIONS
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INVITED AND/OR PEER-SELECTED PRESENTATIONS AT REGIONAL, NATIONAL OR
INTERNATIONAL LEVELS: