1. Join the conversation! Our Twitter hashtag is MSE12 Community Preceptor Payment and Recruitment: Clerkship Director Survey Results The Group on Medical Student Education Survey Subgroup: Lisa Slatt, MEd Kate Margo, MD Chris Jerpbak, MD David Power, MD, MPH David Anthony, MD

2. Agenda I.Introduction/Background Information: Lisa Slatt, MEd II.Literature Review: David Anthony, MD III.Survey Demographics: Chris Jerpbak, MD IV.Preceptor Payment/Rewards: Kate Margo, MD V.Preceptor Recruitment: David Anthony, MD VI.Attrition/Termination of Preceptors: David Power, MD, MPH VII.Discussion/Comments

3.  69% response rate: 92/133 respondents  65% Public, 34% Private, 1% Military  Number of clerkship students/year:  134 mean  Range: 8-340 Survey Background Information

4. Survey Background Information: Regional Breakdown *one response from Puerto RicoN=92*

5. Impact of teaching on preceptors Motivations for preceptors – Why teach? Data on rewards and incentives Data on monetary rewards for teaching Literature Review

6. Data are limited for medical students Boex, et al. Acad Med 2000 Costs at teaching practices 26-34% higher than non- teaching practices Bowen and Irby, Acad Med 2002 – Review Community preceptors extend their workdays Lower level trainees cost more than higher Adams and Eisenberg, JGIM 1997 – Systamitc Review Estimated cost of $100-$200 per day per medical student Literature Review: Impact of Teaching on Preceptors

7. Latessa et al. Acad Med 2007 Survey of NC preceptors High satisfaction with precepting students (93%) Intrinsic rewards Starr et al., Acad Med 2003 focus groups “Feeling intrinsic satisfaction” But rewards would be nice Baldor et al., Med Educ 2001 – Survey of New England primary care preceptors Teaching ‘enhances enjoyment’ and ‘knowledge’ Disrupts flow and decreases productivity Literature Review: Motivations for Preceptors

8. Kumar, et al., JGIM 1999 Survey of clerkship directors in FM, IM and Peds Literature Review-Rewards and Incentives AwardFM %IM %Ped % Monetary 221318 Educational opportunities897370 Gifts404171 Teaching awards454653 Academic appointments909592 Special recognition letters796265 Appreciation letters848174

9. Kumar, et al., Teach Learn Med 2002 Survey of FM, IM, Peds preceptors (46% responded) 37% reported receiving payment for teaching Literature Review-Rewards and Incentives RewardMean RankSD Personal satisfaction5.161.48 Educational opportunities4.101.42 Academic appointments3.971.27 College awards and recognition3.001.40 Payment for teaching2.921.89 Gifts and services2.531.48

10. Baldor et al., Med Educ 2001 Survey of New England primary care preceptors Rated benefits not important to very important Academic appointments, CME, faculty development, computer linkages rated highly Monetary rewards rated highly by 47% More often MDs at academic medical centers ‘Stressed’ preceptors more likely to value money Literature Review-Rewards and Incentives

11. Ashar, et al., JGIM 2007 Johns Hopkins Evaluation of teacher ratings before and after implementation of paid faculty for clinical skills course – 19% salary support Paid faculty more likely to have academic appointments, advanced degrees, faculty development Teacher ratings went up for all 6 evaluation domains Literature Review: Monetary Rewards

12. Peters, et al., Acad Med 2009 Harvard Evaluated impact of increase in payment of primary care faculty on retention Stipends raised from ~$600-900 to $2,500 in 2003. Retention rate was 76% before pay increase Retention rose to 86% after pay increase (92% in last year of study) Teachers rated the stipend as lowest in providing satisfaction Literature Review: Monetary Rewards

13. Precepting students is costly to preceptors Preceptors primarily report intrinsic benefits as motivators for teaching Monetary rewards may increase quality of teaching Monetary rewards are rated low in importance, but appear to enhance retention of preceptors Literature Review: Summary

14. Survey Demographics: Clerkship Design N = 92

15. Survey Demographics: Combined Primary Care Clerkships

16. Survey Demographics: Clerkship Design

17. 16 weeks in year 1, 20 weeks in year 2 12 weeks Survey Demographics: Clerkship Length - Longitudinal

18. Survey Demographics- Clerkship Design: Both Percentage of Students Assigned to Each SchoolBlockLongitudinal A: East Tennessee State University9010 B: University of California SF7525 C: Florida International Univ COM50 D: Duke973 E: University of North Dakota12.587.5 F: University of Arkansas973 G: Yale7525 H: University of Hawaii8020 I: University of Minnesota8218

19. Survey Demographics: Clerkship Length - Block Weeks Block mean=5.65 weeks

20. 23 % replied “Yes.” o Internal Medicine = 2 o Both IM and Peds = 7 * Question asked only in re-survey: N=31 Survey Demographics: Use Preceptors Other Than Fam Med*

21. Survey Demographics: In-patient Experience

22. Survey Demographics: Time on In-patient Service # of responses

23. 75% replied “Yes” Survey Demographics: Use Sites Needing Housing Percentage of clerkship students sent to sites that require housing. 0-10% 36% 11-40% 31% 40-100% 32% 33% of “home” students have to travel 50-60 minutes to their site

24. Survey Demographics: Housing payment sources School of Medicine - 30% Area Health Education Centers (AHEC) – 36% Hospital or program where student assigned – 57%

25. Comments / discussion?

26. 16% (n=15)pay their preceptors 64% public medical schools Clerkship length: 4-8 weeks Payment ranges: $93-500/week Most of the money goes to private practices Preceptor Payment: Overview

27. AHEC – 25% School of Medicine – 56% Department – 44% Departmental grant – 13% Preceptor Payment: Funding Sources

28. Access to school library - 83% Access to electronic resources - 70% Reduced price or free CME - 38% Email address - 37% Use of school facilities (gym etc) – 18% Free or discounted software – 11% Tickets to athletic or other events – 6% Other (appointments) Preceptor Payment: Non-monetary Rewards

29. Comments / discussion?

30. Preceptor Recruitment: Who is responsible for recruiting preceptors? N=93

31. Vice Chair (1) Regional Site Directors (2) Dean’s Office/Medical School (2) Students (1) No one/none needed (3) State Academy (1) Preceptor Recruitment: Examples of “Other” Recruiters

32. Preceptor Recruitment: How do you evaluate your preceptors? N=94

33. Preceptor Recruitment- Do your preceptors evaluate their experience with you Yes Written Electronic Site Visits Informally No N=93

34. No clear standards Patterns are locally determined Recruitment primarily falls to CDs and Med Student Education Directors A minority of CD’s provide forum for preceptors to evaluate their experiences Preceptor Recruitment: Insights about Recruitment and Evaluation

35. Preceptor Recruitment: Competition for preceptors N=94

36. Preceptor Recruitment: Student competition for preceptors N=38

37. Nurse Practitioner students (8 schools) Off-shore medical students Our own Internal Medicine Clerkship Students Advanced practice nurses and NPs Preceptor Recruitment: Who are the “other” students?

38. Preceptor Recruitment: Preceptors payment for “other” students

39. Comments / discussion?

40. Preceptor Attrition: Have any preceptors voluntarily stopped teaching in the last 3 years?

41. Range: 1 – 20 Average: 6 Preceptor Attrition:

42. The 15 clerkship directors who pay community preceptors were 2 times (CI: 0.4 – 10.4) more likely to respond yes, that community preceptors had voluntarily quit in the past 3 years, p = NS. Preceptor Attrition: Analysis, logistic regression

43. Preceptor Termination: Have YOU terminated specific preceptors in the past 3 years?

44. Clerkship directors who pay community preceptors were 72% LESS likely (CI: 0.06 – 0.85) than those who do not pay to have dismissed a preceptor in the past 3 years, p =0.28. Preceptor Termination: Analysis, logistic regression

45. “Unwilling to evaluate effectively” “Preceptor went heavily into cosmetic/money making ventures” “Professionalism issues” “Preceptor so inundated with paperwork, etc. now with no time for teaching” “Inappropriate behavior on part of preceptor” “Changes in their practice” “Only let the student shadow and not do anything” Preceptor Termination: Reasons

46. “I cannot disclose” “Not good teaching sites” “Poor evaluations or too few patients” “Harassment of student” “Poor evaluations” “Not good teacher. Serious professionalism concerns.” “Poor evaluations and no response to feedback” “One w/Medical Board issues” Preceptor Termination: Reasons, cont’d.

47. “Students report preceptor not using/not interested in evidence in practice” “Did not meet students' needs, conflict of belief systems (very opinionated preceptor)” “Not enough patients seen in clinic practice” “Preceptor burn out” “Students reported he consistently made many negative comments about his patients” “Too busy/having other students at the same time” Preceptor Termination: Why?

48. Educational reasons: 25% Professionalism reasons: 25% Practice location: 25% Miscellaneous: 25% Preceptor Termination: Categories for dismissal

49. Clerkship directors who pay community preceptors were 17% less likely to cite educationally related reasons for dismissing a preceptor and 58% more likely to cite ‘practice location’ issues, p = NS. Too few numbers to examine ‘professionalism’ issues. Preceptor Termination: Analysis, odds ratio

50. Group SAM (a la Tufts) Annual newsletter Annual teaching awards Write ups in local AAFP magazine Seats at local football games Prime students to ooze gratitude! Knowing majority schools do not pay What seems to help?! (since MSE 2010)

51. Comments / discussion?

52. Acknowledgements: Clerkship directors Reid Johnson, UNC-Chapel Hill Jill Johnson, U Minnesota