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Do We Pay Our Community Preceptors? Results From a CERA Clerkship Directors’ Survey

David Anthony, MD, MSc; Christine M. Jerpbak, MD; Katherine L. Margo, MD;
David V. Power, MB, MPH; Lisa M. Slatt, MEd; Derjung M. Tarn, MD, PhD

Background and Objectives: Family medicine clerkships depend heavily on community-based family physician preceptors to teach medical students. These preceptors have traditionally been unpaid, but in recent years some clerkships have started to pay preceptors. This study determines trends in the number and geographic region of programs that pay their community preceptors, identifies reasons programs pay or do not pay, and investigates perceived advantages and disadvantages of payment.

Methods: We conducted a cross-sectional, electronic survey of 134 family medicine clerkship directors at allopathic US medical schools.

Results: The response rate was 62% (83/132 clerkship directors). Nineteen of these (23%) currently pay community preceptors, 11 of whom are located in either New England or the South Atlantic region. Sixty-three percent of programs who pay report that their community preceptors are also paid for teaching other learners, compared to 32% of those programs who do not pay. Paying respondents displayed more positive attitudes toward paying community preceptors, though a majority of non-paying respondents indicated they would pay if they had the financial resources.

Conclusions: The majority of clerkships do not pay their community preceptors to teach medical students, but competition from other learners may drive more medical schools to consider payment to help with preceptor recruitment and retention. Medical schools located in regions where there is competition for community preceptors from other medical and non-medical schools may need to consider paying preceptors as part of recruitment and retention efforts.

(Fam Med 2014;46(3):167-73.)

The United States currently faces both a lack and misdistribution of primary care physicians, problems that the Association of American Medical Colleges (AAMC) anticipates will worsen by 2025.1 Further, these challenges will likely be brought into a harsher light as the full impact of the broader health insurance coverage provided by the Affordable Care Act unfolds in the coming years, as was seen in Massachusetts following the passage of its own health care reform act.2 In response, the Council on Graduate Medical Education (COGME) and others have called for a physician workforce comprising at least 40% primary care physicians.3 Achieving this goal will require widespread exposure of US medical students to primary care physicians during their medical training.

At many US medical schools, the family medicine clerkship represents the longest and most direct exposure of medical students to primary care. Most family medicine clerkship directors depend heavily on community-based preceptors to provide clinical experiences and teaching for their students. Yet the demands of such teaching by community-based preceptors conflicts with the clinical productivity demands of most family physicians. Research demonstrates that hosting medical students in primary care practices often increases the length of the workday and comes at a cost of between $100 and $200 per day.4,5

Prior research has identified that most community-based preceptors cite intrinsic benefits as motivators for teaching.6-10 The role of monetary payments to preceptors, also used at some institutions, has been less well researched. Baldor et al found that more than half of primary care physicians cited “payment to compensate lost time/income” as “important” or “very important/necessary.”8 In that study, faculty at academic health centers and those who cited that hosting medical students increased their stress were more likely to value monetary payments. In a study of a primary care clerkship, Peters et al found that a sizable increase in an existing stipend led to an increase in the retention rate of community-based preceptors, though those faculty ranked the stipend low as a motivator to teach.11 There have been no published data on the extent to which family medicine clerkship directors pay community-based preceptors to host students or on their opinions about the benefits and barriers of such payments.

Between 2010 and 2011, the survey working group within the Society of Teachers of Family Medicine Group on Medical Student Education conducted an electronic survey of clerkship directors exploring recruitment and payment issues for community physicians who teach clerkship students. They found that 16% of clerkship directors reported paying community preceptors.12 After these data were presented at a national meeting, discussions revealed that several schools were about to commence similar payments. In addition, several attendees voiced concerns about the potential detrimental effects of paying community preceptors. In particular, some felt that monetary payments were not sustainable and devalued the perceived intrinsic benefits of hosting medical students.

Consequently, the authors decided to re-survey the national pool of family medicine clerkship directors in 2012, this time as part of a larger Council of Academic Family Medicine Educational Research Alliance (CERA) survey of clerkship directors. This study was developed with the following objectives: (1) to determine trends in the number and geographic region of programs who pay their community preceptors and how much is paid, (2) to identify reasons programs pay or do not pay, (3) to identify perceived disadvantages of payment, and (4) to identify perceived values of payment.

 

Methods

 
 

Survey Participants and Method

This study is an analysis of data obtained as part of the 2012 CERA survey. CERA is a joint initiative of all four major US academic family medicine organizations (Society of Teachers of Family Medicine, North American Primary Care Research Group, Association of Departments of Family Medicine, and Association of Family Medicine Residency Directors).

The investigators submitted questions for inclusion in the CERA survey. The survey was designed as an omnibus survey incorporating several distinct subprojects focusing on different topic areas. Family medicine clerkship directors at allopathic medical schools in the United States were identified for participation. Because there is no centralized list of clerkship directors, names and contact information of clerkship directors were solicited through communication within the STFM Group on Medical Student Education. There were 134 active unique individuals with valid email addresses confirmed. The study was approved by the American Academy of Family Physicians Institutional Review Board.

The survey was conducted between July 2012 and September 2012. Family medicine clerkship directors were surveyed electronically with an initial email invitation to participate, which included a personalized greeting, a letter signed by the presidents of each of the four participating organizations urging participation, and a link to the survey. Nonrespondents were sent up to two follow-up emails encouraging participation.

Survey Items

Respondents were asked basic demographic information about their schools and clerkships. This included the geographic region of the school (as defined by the US Census Bureau’s nine Census Divisions and Puerto Rico), whether the school is public or private, whether there is a mandatory family medicine clerkship, and how many students are in each medical school graduating class. Clerkship demographics included whether the clerkship is a block or longitudinal rotation, the duration (in weeks) of the clerkship, what percentage of students spend at least half of their time with a community preceptor, and what percentage of students spend time at community sites that require an overnight stay. We defined community preceptors as “teachers who practice off campus and who do not have a primary appointment in your department or institution.”

We asked respondents if they currently pay any of their community preceptors to host students. Those who responded positively were further asked what percentage of community preceptors they currently pay (1%–25%, 26%–50%, 51%–75%, 76%–100%), and to estimate how much they pay per student per week in US dollars. Respondents who reported paying community preceptors were further asked to rank the top three reasons prompting their institutions to start such payments. Possible reasons for paying included: “We have competition from other schools/learners,” “It is the right thing to do,” “It is necessary to provide high-quality education to students,” “It helps with the recruitment of new preceptors,” “It helps with the retention of current preceptors,” “We have the funds to do it,” and “Other.”

Respondents who reported not paying community preceptors were asked to rank their top three reasons for not paying. Possible reasons for not paying included: “We do not need to pay in order to get adequate numbers of community preceptors,” “We do not have the funds,” “We do not want to set a precedent for paying community preceptors,” and “Other.” We also asked non-paying respondents to answer “yes” or “no” to the following questions: “If you had the resources, would you pay community preceptors?” and “Are you actively trying to find funds to pay community preceptors?”

All respondents were asked to rank their first three choices among a list of possible disadvantages to paying community preceptors. Possible disadvantages included: “It sets a precedent for our department to pay community preceptors,” “It sets a precedent for our institution to pay community preceptors,” “It sets a precedent in the region to pay community preceptors,” “We cannot afford it,” “It devalues teaching,” “I see no real disadvantages,” and “Other.”

To investigate the degree to which clerkship directors face competition for teaching provided by community preceptors, all respondents were asked to indicate all types of other learners for whom their community preceptors received monetary payments. For this item, they were asked to select all applicable responses from a list including: third- /fourth-year allopathic US medical students, third-/fourth-year osteopathic US medical students, third-/fourth-year medical students from non-LCME/AOA-accredited schools, fourth-year medical students on electives, preclinical medical students, physician assistant students, nurse practitioner/advanced practice nursing students, nursing students, pharmacy students, other students, none, and “I don’t know.” Responses were dichotomized into “reports payments for any other learners” and “reports no payments for any other learners/Don’t know.”

Lastly, all respondents were asked to rate their level of agreement to five statements regarding paying community preceptors (4-point Likert scale ranging from “strongly disagree” to “strongly agree”). These statements included: “Paying family medicine community preceptors to teach medical students appropriately places value on the teaching provided by these preceptors,” “Paying family medicine community preceptors devalues the intrinsic rewards of clinical teaching,” “Paying family medicine community preceptors aids in the recruitment of high-quality clinical teaching sites,” “Paying family medicine community preceptors aids in the retention of high-quality clinical teaching sites,” and “Paying family medicine community preceptors is not financially sustainable.”

Analysis

We calculated descriptive statistics to describe reported characteristics of clerkships and medical schools and used chi-square tests to assess differences between clerkship directors whose programs pay their preceptors versus those whose programs do not pay. We also graphically illustrated the geographical regions of programs paying preceptors and the total number of clerkship directors responding from each region.

For items in which respondents were asked to rank their top three choices among a list of options, we tabulated the number of respondents selecting each option and also converted responses into a simple weighted score. We granted scores of three for first choice responses, two for second choice responses, and one for third choice responses.

Clerkship director attitudes to the five Likert-scale items were considered as continuous variables ranging from 1–4, with higher numbers indicating stronger agreement. We compared the average responses between paying respondents and non-paying respondents using t tests. To see if competition for teaching provided by community preceptors (in the form of payment for teaching other types of learners) is associated with clerkship directors’ reports of payment, we compared this dichotomous variable among paying respondents and non-paying respondents using a chi-square test. All analyses were performed using IBM SPSS version 19.0 and Microsoft Excel 2010.

 

Results

 
 

Eighty-three of the 134 clerkship directors surveyed provided responses complete enough to analyze (62% response rate), and 19 (23%) currently pay their community preceptors. Table 1 displays the characteristics of the respondents’ schools and clerkships. Of note, there were no differences between paying and non-paying respondents regarding public school status, required clerkship, whether the clerkship is a block rotation, the number of students per graduating class, the duration of block clerkships, the percentage of clerkship students who spend at least half their time with a community preceptor, or the percentage of clerkship students placed at sites far enough away as to require lodging. Figure 1 depicts the regional representation of the respondents, as well as their payment of community preceptors. The majority of paying respondents (11 of 19) came from two geographic regions (New England and South Atlantic).

Table1
Figure1

 

 

Community preceptor payment ranged from $20–$500/week/student (median of $170/week/student). Figure 2 displays the raw and weighted frequencies of reasons for paying reported by paying respondents. The reasons with the highest weighed scores were “It is the right thing to do,” “We have competition from other schools/learners,” “It helps with the recruitment of new preceptors,” and “It helps with the retention of current preceptors.”

Figure2

Of 62 non-paying respondents, 57 said they do not have the funds, 29 said they did not want to set a precedent, and 29 said they do not need to pay in order to get adequate preceptors. Forty-seven of the non-paying respondents (76%) reported that they would pay their community preceptors if they had the resources, and only seven of them (15%) reported that their programs were actively trying to find such funds (data not displayed).

Figure 3 displays the raw and weighted frequencies of disadvantages to paying community preceptors cited by all respondents. The most commonly cited disadvantage was cost (77% of respondents). Eleven of 19 paying respondents selected “No disadvantages” as their first choice. A minority of respondents (20%) reported concern that payment “devalues the intrinsic rewards of teaching.”

Figure3

Respondents’ attitudes about paying community preceptors varied depending on whether or not they currently pay community preceptors (Table 2). Compared to clerkship directors whose programs do not pay preceptors, those who do believed more strongly that payment places positive value on preceptor teaching (3.58 versus 3.08 on a 5-point scale, with 4 indicating greatest agreement) and aids in recruitment (3.32 versus 2.94) and retention (3.47 versus 3.02) of quality teaching sites. Those whose programs do not pay preceptors more strongly believed that paying preceptors is not financially sustainable (3.03 versus 1.95) and that payment devalues the intrinsic rewards of clinical teaching (2.13 versus 1.16). Of note, 63% of those programs who pay report that their community preceptors are paid for teaching other learners, as compared to only 32% of those programs who do not pay (P value=.02).

Table2

 

 

Discussion

 
 

This survey reveals that a minority of family medicine clerkships currently pay their community preceptors and that the majority of those that do are clustered in two regions of the eastern seaboard. While only 23% of clerkships currently pay, this number may be growing. A previous study found a national payment rate of 16% in the 2 years preceding this survey.12

Clerkship directors appeared to have conflicting opinions about paying community preceptors. While those who do not currently pay cited more concerns about the potential downsides of payments, 76% of them reported that they would pay if they had the resources. Further, only a small minority reported efforts to secure such funding. Respondent attitudes toward paying community preceptors varied between paying and non-paying respondents, with paying respondents having more positive attitudes. Because this is cross-sectional data, it is not clear if the experience of paying leads to more positive attitudes or if those with positive attitudes are more likely to pay. Alternatively, awareness of one’s paying status may have influenced clerkship director responses to questions about their attitudes toward paying. Further studies are needed to clarify the causality between payment of community preceptors and attitudes toward payment.

These data also shed light on one potential instigator for clerkships to pay their community preceptors. Those who pay were twice as likely as those who don’t to report that their community preceptors receive payments for hosting other students. It may be that increased competition for the limited resource of community preceptors in regions saturated with learners has led to an increase in their value to local medical schools (as reflected in monetary rewards). Anecdotally, clerkship directors in regions where other schools have commenced paying have reported feeling pressure to pay in order to match the local norm. This commoditization of community preceptors may be seen as a natural progression of the increased pressure on clerkship directors to find sites for their students, though it may also have unexpected effects.

Given the possibility that clerkship directors’ attitudes toward community payments may change when clerkships begin paying preceptors, it is important to note the possibility of community preceptors changing their attitudes as well. There is some concern that preceptor payments implicitly devalue the intrinsic rewards that have long been cited by preceptors as their reasons for teaching.6-10 While only a minority of clerkship directors in this survey expressed concern about this effect, studies of community preceptors could better elucidate changes in their attitudes. Further, the effect of payment on the relationship between community preceptors and clerkship directors/medical schools also warrants additional exploration.

Limitations of our survey are the low number of programs who do pay their preceptors, so that generalizations about these sites are less robust. With a 62% response rate we may also be missing some significant areas where payment is occurring, such as the mountain states where only two clerkship directors responded. As these are cross-sectional data, it is impossible to determine if the association between paying preceptors and more positive attitudes toward such payments is a cause or effect.

The competition for community preceptors is likely to intensify. It is anticipated that many more primary care providers will be needed to achieve the goals of the Patient Protection and Affordable Care Act,13,14 resulting in a larger number of trainees from medical, nursing, and physician assistant schools wanting to place their learners in community primary care clinics. In addition, medical schools facing decreases in reimbursement for resident positions may be unable to accommodate as many medical students for training, potentially further limiting training sites for medical students. These effects will further increase the need for community preceptors. These preceptors may have increased time constraints from providing access to care for increased numbers of insured patients. Therefore, payment for teaching may become more important. Educators in areas of the country where competition is intense for community preceptors may need to consider direct financial reimbursement if they are to effectively recruit and retain community preceptors to teach their students. Given that monetary resources are scarce, clerkship directors may need to develop creative solutions for payment.

Acknowledgments: This material was presented at the Society of Teachers of Family Medicine Conference on Medical Student Education in San Antonio, TX, on January 26, 2013.

Corresponding Author: Address correspondence to Dr Anthony, The Warren Alpert Medical School, Brown University, Department of Family Medicine, 111 Brewster Street, Pawtucket, RI 02860. 401-729-2308. Fax: 401-729-2923. david_anthony@brown.edu.

 

References

 
 
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From the Department of Family Medicine, Brown University, Providence, RI (Dr Anthony); Department of Family and Community Medicine, Thomas Jefferson University (Dr Jerpbak); Department of Family Medicine and Community Health, University of Pennsylvania (Dr Margo); Department of Family Medicine and Community Health, University of Minnesota Medical School (Dr Power); Department of Family Medicine, University of North Carolina (Ms Slatt); Department of Family Medicine, University of California-Los Angeles (Dr Tarn).


Copyright 2018 by Society of Teachers of Family Medicine