JUST-RELEASED CLERKSHIP STUDY: GROWING SHORTAGE OF CLINICAL TRAINING SITES CHALLENGES MEDICAL SCHOOLS

Sheri Porter

doi:10.1370/afm.1709

What has appeared to be solid progress toward growing an adequate US health care workforce could be derailed by an escalating shortage of clinical training sites to accommodate many of those learners.

That’s the crux of the message delivered in a recently released report titled Recruiting and Maintaining U.S. Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey. The report is available at http://members.aamc.org/eweb/upload/13-225%20WC%20Report%20FINAL.pdf.

The report, which was jointly developed by the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the Association of American Medical Colleges, and the Physician Assistant Education Association, chalks up the shortage, in part, to the opening of new allopathic and osteopathic medical schools, the expansion of existing schools, and larger class sizes. (Total US medical school enrollment increased by 23% between 2000 and 2010.)

The report’s authors also pointed to an explosion in the number of training programs for nurse practitioners (NPs) and physician assistants (PAs), as well as a growing number of Caribbean-based medical schools seeking US training experiences for their students.

“It’s a tsunami. And this crisis is really going to hit fever pitch in a few years,” said family physician Gary LeRoy, MD, associate dean for student affairs and admissions at Wright State University Boonshoft School of Medicine in Dayton, Ohio.

The survey on which the report was based explored the concerns of medical schools and NP and PA programs, all of which have students competing for invaluable hands-on clinical training.

The resulting report found that:

Across all 4 disciplines, most respondents said finding clinical training sites for their students had become more difficult
Most respondents said finding primary care training sites presented the greatest challenges
More than one-half of respondents felt pressured to pay for training sites
Many respondents had implemented nonmonetary incentives and alternative solutions to address training site shortages

Addressing the Problem in Ohio

According to LeRoy, Boonshoft could see its growth stunted as the shortage of clinical training sites limits the school’s enrollment capacity. And 57% of MD-granting schools that responded to the survey face the same dilemma.

LeRoy said his medical school had methodically increased its class size every few years since 2000 to a record 110 students in 2014 in an attempt to prepare for the predicted US physician shortage. The school has made other adjustments, as well.

Still, LeRoy said he draws the line at simulation-based training sessions reportedly used by some 58% of MD schools. He said the strategy “short-changes” students.

“Medicine is a people-driven profession; our patients are at the center of it all,” said LeRoy. “Even though simulators (purportedly) can teach students how to deliver a baby, put in an IV line, or how to run a code, it’s a whole different dynamic when you have a living, breathing person there in front of you. Students have to be put in those real-time, real-life environments,” said LeRoy.

Easing the Bureaucracy in Nevada

Family physician Thomas Schwenk, MD, dean of the University of Nevada School of Medicine in Reno, said the growth and expansion of medical schools is only part of the story.

“This goes beyond capacity issues. I actually think there’s something else happening, and that is a greater appreciation for the value of community-based teaching and the engagement of community-based physicians—as well as the need to diversify the experience of students,” he said.

Schwenk said he believes community physicians are looking for more than traditional perks such as parking passes or football tickets or a minimal stipend that can never really make up for the lost productivity that occurs when a physician precepts a student in his or her office.

His medical school is in the midst of creating what he called an “office of community physician faculty engagement” that will assist preceptors with all the messy issues that come with the job—from scheduling training slots to completing evaluation forms to dealing with performance issues involving student-learners.

The idea, said Schwenk, is to engage physicians through logistics and infrastructure and support. “All the physicians will have to do is what they really want to do, and that is to teach,” he noted.

Getting Back to Basics in Florida

Florida State University (FSU) College of Medicine in Tallahassee is one of the nearly 20% of medical schools cited in the report that indicated they had experienced no shortage of clinical training sites.

Dean John Fogarty, MD, credited his school’s unique model—with its 6 regional campuses and more than 2,800 community-based physicians—for ensuring that students have notable clinical experiences.

“Our students are in an office-based setting with a board-certified doc caring for 200 patients, and it’s a 1-on-1 relationship for 6 or 8 weeks,” said Fogarty. “Compare that to the typical medical student training on a hospital ward with a team where the student is the low man on the totem pole, doing the scut work, taking care of 1 to 3 patients at any given time,” he added.

FSU preceptors are paid a stipend of $500 a week for a 6-week rotation, but Fogarty insisted there was more to physicians’ interest in precepting than money. In fact, about 10% of preceptors return their checks to the school, he said.

“Our community physicians feel like they are critical to our educational program,” said Fogarty, who makes a point of visiting each regional campus on a regular basis to very publicly thank those community physicians.

Connecting With Preceptors

Charles Rhodes, MD, of Cabarrus Family Medicine in Mount Pleasant, North Carolina, admitted that teaching could slightly alter a physician’s bottom line if his or her idea of compensation was based solely on practice income.

“But there are so many upside benefits to teaching,” Rhodes said. “It keeps me fresh and current because medical students ask a lot of questions, and I find myself constantly looking up things to be sure I am giving them accurate information. Students also bring new ideas and concepts from the medical schools with them, so in teaching them, I also learn.”

Jennifer Miley, MD, is co-owner of a 3-physician private practice in Pensacola, Florida. She said teaching helps foster a feeling that she is “paying forward” the great mentoring experiences she had as a student.

“The students really add some variety to my day, which is part of the reason I chose family medicine,” said Miley.

John Bullock, MD, of Hattiesburg, Mississippi, operates a clinic in Sumrall that is part of a larger, physician-owned multispecialty clinic. “I precept students mostly to help those young people who are interested in the field get a true view of the profession and to help them decide if this is the specialty for them before they make a full commitment,” he said.

Aaron Garman, MD, serves as the medical director of a federally qualified community health center in Beulah, North Dakota. “Helping teach medical students is one of the pleasures of practicing in general, and it gives me great pride to help educate students and get them excited about medicine,” he said.

“Their enthusiasm is contagious and helps foster the love of my job. The only drawback is time itself—not having time to spend with students and only getting to work with them for 1 month at a time.”