The apprentice system or preceptorship has been misjudged on numerous occasions. There remains a strong medical education bias due to past situations. These situations have changed and the preceptorship methods have improved accordingly. Some of the best medical education is done in preceptorships. Not only that, but preceptorships promote improved distribution of physicians. This is something that we should remember in Family Medicine as our numbers of graduates choosing rural has stagnated at about 600 despite major increases in total numbers of graduates.
The mid 1800's were most challenging for medicine. The poor conditions spawned the public health movements, the American Medical Association, and the roots of health regulation. Preceptorships are widely held to have contributed to the problem, but preceptorships are only as good or bad as the preceptor. The quality of doctors has improved dramatically in 150 years and so has the quality of preceptorships. In recent decades studies have documented the differences between GP's and residency trained FP docs. Family Medicine has done a good job, but there is more to do.
A more obvious reason for the problems in medical education back at the turn of the last century was the proprietary system that cranked out doctors in exchange for tuition dollars. The conditions were poor to worse and the curricula was non-existent. There was no control for quality.
Preceptorships even then had a plus side. Studies reviewing doctor location in Tennessee revealed that doctors that trained with preceptors located about a buggy ride's distance apart. When a town grew or a doctor was lost, another would take up a preceptorship in a nearby location and then return to care for the town. It appears that they exchanged services for their education more than pay, although this is sketchy. Maldistribution was not a problem, even in rural areas, except in the most isolated locations.
It is important to remember that the quality of the education was dependent on the preceptor. Even in the past 50 years, most studies of preceptorships have involved one month rotations. Obviously one month in 4 years is a small time period, especially in the final year. Also the studies did not include the curricula. Most importantly the studies did not include the impact of the preceptor. Mercer studies show that the preceptor is far more important than the preceptorship.
The situation now is much different. In the last 30 years, the quality of physicians has improved. Interdisciplinary Generalist Project Findings Unfortunately the bias against preceptorships has not. Nearly all were extinguished from medical education. In a few states, the actions of family practice and rural physicians were able to maintain preceptorships in the face of curricular change.
The main reason for improvements in the quality of the preceptorship is that the preceptors themselves have changed. They are much better in quality. Uniformity in training has accomplished this, but it has impeded physician distribution.
More at Why a Preceptorship Is Better
that could impact medical education, but not as badly as declining education in medical centers
I. The changing physician role in rural communities as we move from solo to salaried,
a. the leadership role in the hospital and community (young docs are not getting involved in network development and other areas)
b. the impact on retention as physicians no longer have an investment, but a salaried job
II. Continued challenges to the rural hospital and the need to transition to a rural health system rather than a single organization
III. Higher education changes that threatened to further curtail the flow of all young professionals to rural areas
a. cutbacks make it easy to cut preprofessional preparation at small colleges (except RHOP)
b. rural kids forced to train in large urban colleges, meet urban and specialized spouses
c. despite best intention, spouse cannot go
Continued need to educate state and Higher Education leaders about how we get rural providers so that we can continue to meet state needs
a. can no longer depend on transfers of funds from feds, medical schools
b. support from medical associations, especially national, diminishing
Denial and Paralysis of Higher Education, medical, and state Leadership
Focus on dollars, survival, limitation rather than state needs and innovation
IV. Expanding and changing clinical role of all physicians, rural and urban, will cut into education participation in practice, in medical schools, etc.
Overall it seems that the problems with medical centers continue to weaken medical education faster than any of these factors impact rural preceptorships.
Robert C. Bowman, M.D.