Microsoft Word - UnderstandingtheneedsofRuralarticle.docx Published by University of Minnesota Libraries Publishing Understanding the needs of Rural Preceptors from Groups Underrepresented in Medicine Erica Sutton MD, Angelita Howard EdD MBA, Ashaki Goodman Journal of Regional Medical Campuses, Vol. 3, Issue 3 (2020) z.umn.edu/JRMC All work in JRMC is licensed under CC BY-NC Erica Sutton MD, Morehouse School of Medicine, Atlanta, GA Angelita Howard EdD MBA, Morehouse School of Medicine, Atlanta, GA Ashaki Goodman, Morehouse School of Medicine, Atlanta, GA Corresponding author: Erica Sutton, MD Associate Dean, Academic Programs and Affiliations Morehouse School of Medicine 720 Westview Dr. SW Atlanta, GA 30310 Email: esutton@msm.edu Cell: 410-908-0514 All work in JRMC is licensed under CC BY-NC Volume 3, Issue 3 (2020) Journal of Regional Medical Campuses Understanding the needs of rural preceptors from groups underrepresented in medicine Erica Sutton MD, Angelita Howard EdD MBA, Ashaki Goodman Abstract Introduction Community preceptors are essential in providing sufficient training opportunities for health professional students. Recently, focus has been given to the recruitment of community preceptors from groups underrepresented in medicine (UiM) for their contributions in training a diverse and culturally competent workforce. The overall goal of this study is to review data collected from UiM preceptors and potential preceptors for unique beliefs or values that reveal their motivation for teaching. We hypothesize that community preceptors from groups underrepresented in medicine hold beliefs reflective of high levels of altruism and service. Methods This is a retrospective study of interview data collected from UiM community preceptors for developing clinical education experiences. We sought to uniquely understand the needs of these preceptors in order to develop our recruitment strategy. Each participant agreed to a structured interview and gave or denied permission to have the interview recorded. In the structured interview, community physicians were asked to answer questions about their motivation to precept medical and physician assistant students. They were further asked about their desired compensation, reservations about teaching, and interest in participating in curricular development. Results We interviewed 12 community providers: 11 physicians and one advanced practice nurse. Participants were from a broad range of specialties: Obstetrics/Gynecology (3), Surgery (3), Psychiatry (3), Family Medicine (1), Pediatrics (1), and Emergency Medicine (1). Of the providers interviewed, 10 were from groups underrepresented in medicine. All 10 of the UiM participants were physicians. All participants completed the structured interview. The answers provided in the interview were able to be grouped into themes reflecting a recurring set of beliefs and motivations. Conclusions UiM preceptors hold values reflective of altruism and a willingness to serve in the creation of the future workforce. We have found UiM preceptors possess a strong desire for training as educators. Further, UiM preceptors are incentivized by financial compensation and willing to commit their personal time to advising the medical school. Introduction Community preceptors are essential in providing sufficient training opportunities for health professional students. Given the expansion in class size and creation of regional campuses seen across the country, health professional schools are beholden to the community preceptor to meet their program objectives. Recently, focus has been given to the recruitment of community preceptors from groups underrepresented in medicine (UiM). Organizations such as the Society of Teachers of Family Medicine (STFM) are making deliberate efforts at recruiting and developing a pipeline for UiM community preceptors. Their goals are to foster mentorship, academic leadership, and scholarship among UiM community preceptors in order to achieve health equity among the patients they serve and garner the benefits of a diverse workforce for the learners they teach.1 The overall goal of this study is to review data collected from UiM preceptors and potential preceptors for unique beliefs or values that reveal their motivation for teaching. We hypothesize that Journal of Regional Medical Campuses, Vol. 3, Issue 3 community preceptors from groups underrepresented in medicine hold beliefs reflective of high levels of altruism and service. The knowledge expected to result from this study will inform medical educators as to why community physicians choose to engage as teachers. This is important to understand in a society where physician workforce shortages promote the training of more doctors, but also create more demands on the time of doctors in practice. Methods This is a retrospective study of interview data collected September 2019 through December 2019 from UiM community preceptors for the purpose of developing clinical education experiences. Participants were identified in one of 3 ways. Several participants were approached because they were existing preceptors with Morehouse School of Medicine (MSM). We felt their motivations were important to record because their experience could validate potential barriers, supporting or refuting preconceptions. Secondly, we identified community preceptors who specialized in a field where we needed more educational experiences for students. We sought to uniquely understand the needs of these preceptors in order to develop our recruitment strategy. Lastly, we approached community physicians who had expressed an interest in learning more about becoming a preceptor. We learned of their interest through direct communication at one of 2 medical society events in the community or through word of mouth. Indirect communication came by way of existing preceptors, MSM faculty members or MSM board members. Each participant agreed to a structured interview and gave or denied permission to have the interview recorded. In the structured interview, community physicians were asked to answer questions about their motivation to precept medical and physician assistant students. They were further asked about their desired compensation, reservations about teaching, and interest in participating in curricular development (Figure 1). Figure 1. Focus group questions 1. What concerns do have about teaching medical students in your practice? 2. For those of you who have students, what made you willing to teach a medical student in your practice? 3. What sort of return would make teaching students worth it for you? CME, library access, scribe services, patient referrals, monetary compensation? Pay medical society dues? Other membership dues? 4. Are you receiving enough support from the clerkship director or MSM clinical department for your role? What support would you like to see? 5. Would you be willing to serve on an advisory board for the Columbus Expansion group? Interviews were recorded electronically or via handwritten notes. Recorded interviews were transcribed. The authors [ES, AH] read the transcribed interviews and notes to identify themes in the responses. These themes were tabulated and summarized to constitute study findings. Some respondents gave more than one answer and both answers were counted. Therefore, it was possible to have more answers than participants. The use of this data for publication purposes was reviewed and approved by the Morehouse School of Medicine IRB (https://www.msm.edu/Research/hrpp/IRB/index.php). Results We interviewed 12 community providers- 11 physicians and one advanced practice nurse. Participants were from a broad range of specialties: Obstetrics/Gynecology (3), Surgery (3), Psychiatry (3), Family Medicine (1), Pediatrics (1), Emergency Medicine (1). Seven participants were community preceptors for other medical schools in the area, 5 of whom were also existing preceptors with MSM. Of the providers interviewed, 10 were from groups underrepresented in medicine. All 10 of the UiM participants were physicians. In response to the question, What concerns do have about teaching medical students in your practice? participants provided answers along 5 themes (number of responses given containing this theme): concern surrounding the quality of the experience for the students (6), if students would possess the needed procedural skills related to sterile technique (2), added work for the preceptor (2), if students would possess the needed clinical skills such as history taking and performing a physical exam (1), and professionalism related to confidentiality (1) (Table 1). Journal of Regional Medical Campuses, Vol. 3, Issue 3 Table 1. Community preceptor concerns about having a medical student participate in the practice. In response to the question, For those of you who have students, what made you willing to teach a medical student in your practice? participants provided responses along 5 themes: a culture of teaching in the practice (7), a desire to give back (5), a desire to increase the number of local practitioners (2), a practice obligation (1), a desire to ensure the quality of future practitioners (1) (Table 2). Table 2. Reasons given for community preceptors’ willingness to teach In response to the question, What sort of return would make teaching students worth it for you? participants responded along 8 themes: financial compensation via tax credit, monetary payment, loan repayment, payment of membership dues, or funds to support other professional work (10), faculty appointment (6), access to education such as continuing medical education credit or library access (5), access to research opportunities (2), access to scribe services (1), recognition for teaching (1), exposure to new learners (1), and more local practitioners (1) (Table 3). Table 3. Community preceptors’ desired return on investment In response to the questions Are you receiving enough support from the clerkship director or MSM clinical department for your role? What support would you like to see? participants responded along 3 themes: desired a better understanding of clerkship learning objectives (3), desired a better understanding of student performance/gaps (1), communication is sufficient (1) (Table 4). Table 4. Perceptions of adequacy of institutional support for existing community preceptors In response to the questions Would you be willing to serve on an advisory board for the Columbus Expansion group? participants responded yes (5), no due to time constraints (2), unsure (3) (Table 5). 0 2 4 6 8 Qu ali ty of … Pr oc ed ur al… Ad de d w or k Cli nic al sk ills Pr of es sio na li… Table 1. Concerns about having a medical student in your practice 0 1 2 3 4 5 6 7 8 Teaching in the Practice Give Back < # of local practitioners Practice Obligation Quality of Future Practitioners Table 2: Willingness to Teach 0 2 4 6 8 10 12 Co mp en sa tio n o f… Fa cu lty … CM E C re dit Re se ar ch … Te ac hin g… Ne w Le ar ne rs Table 3: Return on Investing 0 1 2 3 4 Clerkship Learning Objectives Student Performance/Gaps Sufficent Communication Table 4: Institutional Support (Current Preceptors only) Journal of Regional Medical Campuses, Vol. 3, Issue 3 Table 5. Community preceptors’ willingness to serve on institutional committees Discussion Morehouse School of Medicine is known for its commitment to serving underserved populations and for creating the healthcare workforce who will serve them. Because there is a growing need for care in Georgia’s rural populations and urban underserved populations, MSM has strategically expanded its medical student class size from 60 to 100 students per class over the last 3 years. In addition, MSM matriculated its first physician assistant class of 20 students in 2019, with 100% and 50% growth expected in the next 2years. Also, in 2019, MSM matriculated its first class into the online Master’s in Biotechnology Program and the Master’s in Public Health Program welcomed is first class of the Executive MPH degree. This brings the total MPH class size to 54 students, 50% of whom are from Georgia. MSM’s growth mirrors trends in medical school enrollment among schools nationwide. According to an Analysis in Brief published by the AAMC in 2018, by academic year 2022–2023, medical school enrollment is expected to increase by 36% over 2002–2003 levels.2 Morehouse School of Medicine, like others, needed to address clerkship site availability to support its growth. The need was most pronounced in primary care specialties. MSM ranks above the 90th percentile for placement of trainees in primary care. Among MSM’s 10-year graduates (2004-2005 through 2008-2009), 86% practice in underserved areas and 73% practice in rural areas.3 Yet, the current reality is that available faculty in rural settings is increasingly scarce. Rural clinicians are faced with more pressure for revenue- generating productivity, leaving less time for teaching.4 Thus, it became imperative to not only recruit more rural community preceptors, but to also understand what preceptors need to be effective teachers and providers. We sought first to understand barriers to teaching that may exist. When we asked, What concerns do you have about teaching medical students in your practice?, we found the most common concern about teaching was ensuring the quality of the experience for the students. Similarly, when existing preceptors were asked, Are you receiving enough support from the clerkship director or MSM clinical department for your role?, respondents asked for a better understanding of what learners were expected to know and do. These findings highlighted for us the need to further structure and formalize our communication to preceptors about medical education program objectives, course learning objectives and how the students will be assessed and evaluated. We did not find this concern to be uniquely held by UiM physicians. We did find that a centrally managed orientation allowed our institution to connect to our preceptors, several of whom had a connection to the school as alumni. Leveraging such connections aided us in recruiting UiM faculty from the community. Schools that are not designated as historically black colleges or universities could similarly benefit from deliberate inclusion of their UiM alumni in preceptor recruitment and training activities. Our findings related to what made you willing to teach mirror those of related studies. We found our preceptors were largely motivated by a culture supportive of teaching. A survey of 233 Canadian preceptors showed that their primary motivator was the enjoyment of having students in their practice (Scott).5 This finding persists in the literature across multiple preceptor groups, despite data showing that physician preceptors most often reported a negative impact of medical student interactions on patient flow, work hours, and income.6 We made a unique discovery in the return on investment valued by our preceptors by asking What sort of return would make teaching students worth it for you?. Ten out of 12 preceptors found financial compensation a meaningful incentive. In “The Community Preceptor Crisis,” the authors advocate for financial incentive to preceptors if financially feasible.7 The article further mentions the Georgia Preceptor Tax Incentive Program (GPTIP) and suggests it could serve as a model of physician compensation for other states.8 In our cohort, 4 out of 5 of our existing preceptors receive some form of financial compensation, either through the tax credit or a stipend supported by MSM. To compare these options, we modeled the maximum compensation achievable by each and found that the GPTIP offered a benefit that was equivalent to or slightly higher than direct taxable payment. While the “joy of teaching” remains a primary motivator for UiM community preceptors, our study suggests that open dialogue about financial compensation is welcome and incentivizing. This study is limited by its retrospective methodology, small sample size, and potential selection bias. Participants were identified either for having an existing connection to MSM or expressing an interest in learning more about such a 0 1 2 3 4 5 6 Yes No Unsure Table 5: Advisory Board Participation Journal of Regional Medical Campuses, Vol. 3, Issue 3 connection. This methodology could have introduced bias into the data in favor of preceptors who held positive views about precepting learners and altruistic attitudes surrounding compensation. Our findings suggest that preceptors were in favor of teaching but still contributed barriers and concerns. Participants did not appear biased toward altruism and were in fact willing to discuss their desires for compensation. The small sample size is derivative of the small numbers of rural UiM physicians who engage in teaching medical students. A better understanding of the needs of this population can inform strategies meant to grow it constituents. Future studies could both develop formal strategies to increase the numbers of rural UiM preceptors and test if these strategies are effective when implemented by primarily white institutions. Conclusions While several studies support the need for more preceptors globally, this study aims to understand the needs of rural preceptors, focusing on those underrepresented in medicine. UiM preceptors hold values reflective of altruism and a willingness to serve in the creation of the future workforce. We have found UiM preceptors possess a strong desire for training as educators. Further, UiM preceptors are incentivized by financial compensation and willing to commit their personal time to advising the medical school. It is necessary and vital that we have preceptors from groups underrepresented in medicine who are committed to lifelong learning and teaching; and, that we as an institution are committed to ensuring their success in these educational roles. References 1. Walters E. Building a diverse academic family medicine workforce: URM initiative focuses on four strategic areas. Ann Fam Med 2020;18(1):87-8. 2. Association of American Medical Colleges. Analysis in Brief 2018; 18(3). http://www.aamc.org/data/aib, Accessed March 16, 2020. 3. Association of American Medical Colleges 2020 Missions Management Tool. Website: https://services.aamc.org/dsportal2. Accessed March 2, 2020. 4. Cox, M, Irby D. A new series on medical education. N Engl J Med 2006; 355:1375-1376. DOI: 10.1056/NEJMe068211. 5. Scott I, Sazegar P. Why community physicians teach students (or not): barriers and opportunities for preceptor recruitment. Medical Teacher 2006; 28(6): 563-565. DOI: 10.1080/01421590600627375. 6. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Available at: http://www.lcme.org/publica tions.htm#standards- section. Accessed April 23, 2020. 7. Christner J, Dallaghan G, et al. The Community Preceptor Crisis: Recruiting and retaining community-based faculty to teach medical students—A shared perspective from the Alliance for Clinical Education, Teaching and Learning in Medicine 2016; 28(3):329-336. DOI: 10.1080/10401334.2016.1152899.