(
www.ruralmedicaleducation.org/precept.htm )
revised 2/18/2003
The few remaining preceptorships have reminded us the importance of two concepts in medical education: the relationship between the teacher and the learner and the need for doctors in training to practice as much like doctors as good medical practice will allow. Sadly they also remind us how challenging it to train physicians in today's chaotic health care environments.
Better have the right admissions in place for best utilization of this model, see Family Physicians Are Different
Medical Education Retardation - problems in current education
Current medical education faces overwhelming challenges to core endeavors such as education and teaching.
Preceptorships restore the kind of hands-on education lost in current medical education.
Preceptorships have demonstrated equality in the usual medical education evaluations.
Preceptorships have equaled or exceeded traditional modes of medical education in measures using evaluation methods more appropriate for primary care.
Detailed studies have emphasized the importance of preceptorships and community-based instruction.
Continuity of instruction over many months is an advantage for preceptorships.
Continuity of care in most rural areas facilitates the learning experience.
The quality and qualities of preceptors enhance the preceptorship experience
The previous deficiencies of preceptorships have been successfully addressed by improved quality of the preceptors and the addition of coordinators, rural visits, and the electronic modes of communication, making it town plus gown instead of town vs gown.
Rural experiences are a key preparation for underserved rural practice.
Training involving role modeling may be important for efficiency of practice and retention.
Recent studies led by Paul James document that there is no difference in the education provided, regardless of the site of training. This was a study involving 8 states and the development of a 33 item MedEdIQ. There was actually a trend toward better education provided farther from the academic medical center.
Paul A. James, MD:Family Medicine Faculty
Only a few decades ago, there was little need to discuss the generalist perspective in medical training. Generalism was the only perspective of the time. About 50 years ago we crossed the great divide, leaving generalist-based training farther and farther behind. Specialism and the emphasis on technology, research, and clinical income have taken over. As with other areas of our lives, technology has shaped us in some cases as much or more as we shape it. Technology and Family Medicine
This means that generalist students, residents, programs, faculty, and departments face increased obstacles. Other visible impacts involve medical school curricula, accreditation requirements Accreditation and Demands of Rural Practice , and changes in infrastructure. Less visible medical school changes have taken place. These have to do with career expectations and orientation, student groups, peer pressure, urban training environments, and the influences of faculty or key medical school leaders. Ludmerer and others have described these as " the hidden curriculum."
Those involved in attempts to graduate more primary care physicians for rural and underserved areas face formidable obstacles. Most medical students fail to meet minimum requirements for comfort with primary care such as the 6 month comfort level documented by Verby in RPAP studies Verby Articles. At three months students were overwhelmed by rural primary care, at 6 months they were neutral, and at 9 months they did not want to leave rural primary care preceptor-based training.
The leap to underserved rural practice has become more and more difficult
fewer rural background students are admitted, (Kassenbaum AAMC)
few students are oriented toward locating practices in towns of less than 10,000, serving the underserved, and prioritizing people over income
students and residents train in environments hostile to generalist training,
students and residents have not had specific training for rural practice including regular and frequent rural experiences.
Changes in one month or a few months or a year will not address these problems. One of the ways that we become aware of how much we have changed is to experience the power of a different approach. Sometimes we can return to past principles and apply them, not just in part, but in a coordinated fashion across many years. When a few students go through a coordinated generalist program of selections, curricula, hidden curricula, graduate programs, and into practice, we can see a difference in the final product. Rural Contributions of the UNMC Department of Family Medicine As we begin to rediscover some elements of generalist-based medical education, we are beginning to experience some of the great potential that is there.
The demands of rural practice have resulted in some necessary interventions, such as preceptorships. Often these were led by rural practitioners who were trained in more generalist-friendly times and locations. Preceptorships have contributed greatly to the contrast between current traditional medical education and former generalist-based training. Long term preceptorships have magnified these differences and evaluations of such studies give hope for even better medical education.
Interestingly, there is a great divide between established medical education and proponents of preceptorships dating back over 100 years. Flexner and other reformers considered preceptorships to be the enemy of quality medical education. At this time the existing preceptors and the proprietary schools were not noted for their quality of teaching or medicine. Money or services were often exchanged for very little in the way of medical education. The Flexner reforms resulted in the establishment of certain criteria that medical educators of the time felt represented the best chance for a quality medical education. Accreditation and Demands of Rural Practice Of course these were not the original reformers who had walked the walk, they were already becoming separated from the initial ideals that drove the reforms The Five Generations of American Medical Revolutions
Some would still question the value of preceptorships even though they are supervised by academic programs. Some would see this as students with some of the best patient materials and learning opportunities working with the best clinicians with good to excellent teaching skills supervised by those who can increase the quality of teaching progressively over the years. For decades if not centuries there have been town vs gown discussions. In a nutshell, preceptorships resolve this by being town plus gown, the best of both.
Unfortunately this is not enough for some medical educators who continue to question preceptorships (as well as some desperate legislators who threaten the very existence of such forms of teaching).
The sad fact is that preceptorships have continued to maintain their quality over the years. It is traditional medical education that has deteriorated under the assault of major enemies. Perhaps one of the more dramatic impacts over recent decades is the decline in hands-on medical education opportunities. Learning by working closely with patients is a time-honored method. It is a key Flexnerian (Flexner) concept as well. Two major factors that impede medical education include the liability crisis and the loss of continuity of care.
The threat of lawsuits intrudes in medical education as supervising teachers are less likely to trust learners with procedures and patient care decisions. Residents losing out on opportunities are less likely to share them with earlier year residents or students. This results in a more passive observational mode for medical education. This is not a good way to learn medicine.
Continuity of care in this nation has been virtually exterminated by changes in insurance plans and the mobility of patients and physicians. Only rural and some underserved areas maintain some remnant of continuity. Continuity of care promotes a quality doctor-patient relationship. This relationship allows doctors to know more about patients and vice versa. The additional trust and knowledge of one another allows learners to participate more actively. Urban academic locations have little continuity left. Urban community physicians rarely get to know patients as changes in their practice locations, the constant shifting sands of insurance plans, and patient transitions such as changes in jobs and locations disrupt the doctor-patient relationships. Millennium Conference and Rural Medical Education
Urban training centers have also lost training opportunities through lost patient volume. The main factors include the loss of indigent centers and movement of Medicaid patients to non-academic settings through managed care changes.
Rural training environments have changed in positive directions. The smallest and most isolated locations no longer have physicians or hospitals. The remaining locations have better facilities and a greater variety of practitioners. Students rate rural preceptorships, even as short as 2 months in length, as their best learning experiences in the clinical years Nebraska Rural Family Practice Preceptorship Rated Best. Mercer students rate the preceptor as more important than the preceptorship (Mercer). Continuity of care, the willingness of preceptors to work more extensively with students, and the respect shown the students by the community are all factors. These are not necessarily due to rural location itself, because some urban locations have retained some of these characteristics, but rural areas more consistently have preserved these important factors.
Even though many in medical centers are blind to the yearly deterioration of medical education, there is evidence from outside the centers. Discussions with Canadian academic family physicians reveal that Canadian medical students have been regularly disappointed with rotations in the United States at medical schools. They would rather stay in Canada where they can do more. Students involved in preceptorships in the states have been disappointed when forced to finish their clinical studies at academic centers.
Studies by Gjerde and others note that preceptorships are comparable. Quality in Rural Medical Education. These all involve just a few months of training. The major drawback to preceptorships has been the burden of teaching assumed by the preceptor, usually noted as one extra hour a day (Vinson). Despite this burden, preceptors continue to teach. It is possible that there are factors yet to be understood about preceptorships. More global studies demonstrate some of the positive aspects of teaching students and suggest a break-even point at 4 months where the contributions of the students make it worthwhile for the preceptor http://www.regional.org.au/au/rrh/2001/010302_83.htm#TopOfPage . Others called for more studies like this one where more global measurements are made rather than more simple studies that examine the requirements of teaching . Impact of medical students on rural preceptors
No longer is equivalent medical education a concern. For those familiar with the benefits of preceptorships, the question has become, why not more preceptorships? This is even more important in primary care preparation for underserved areas!
Sadly the deterioration of medical education in traditional settings continues. Increased regulations, increased numbers of learners per population of patient, decreased respect for learners, increased needs for income generation, loss of continuity, liability concerns, increased emphasis on research and external funding, and increased need for efficiency in teaching institutions are all powerful and progressive trends that will continue to drive traditional medical education in a negative direction.
Studies document the superiority of preceptorships vs traditional medical education. Evaluations by students note preceptorships to be their best clinical experiences Nebraska Preceptorship. Long term rotations were also noted to be higher in quality in Australia where students spending the third year in rural practices did better than those in traditional locations www.ruralhealth2002.net/abstracts/Worley_P.html or Can a Rural Medical Education be a Better Education? Actually studies demonstrating superiority have long been in the literature. Verby compared Rural Physician Associate Program students doing 9 months with a rural preceptors with those back on campus. The RPAP students equaled or bettered their traditional peers in 23 measures involving clinical, behavioral and procedural areas. These measures were more consistent with generalism, which has more dimensions that simple clinical measures. Although the margins were not dramatic in some areas, there is more to evaluations than direct comparison. The academic prowess of the two groups, their so-called starting point, is important to consider. The RPAP group scored lower than the traditional group on cognitive areas prior to the rotation. To start our lower and end up equivalent or better is confirmation of better quality. Verby Articles The Worley articles are more recent verifications of the quality of preceptorship training.
The ratings of preceptorship
graduates by program directors deserves mention.
These evaluators rate RPAP
students and the RMED students from Syracuse (12 months rural preceptorship in
the M-4 year) as consistently among their best residents. The support for this comes from family
practice program directors on list serves, discussions, and from RPAP
http://www.rpap.umn.edu/ and RMED
http://www.upstate.edu/fmed/rmed/faqs.shtml. North Dakota
has a long term preceptorship also
http://www.med.und.nodak.edu/depts/fammed/Rome/Goals.htm .West Virginia,
East Tennessee State, and Illinois Rockford have shorter versions.
Another key component of long term preceptorships is continuity of instruction.
Having one or two preceptors follow a student over a 9 month period has
advantages compared to the 20 or 30 different teachers that a
traditional student will encounter.
Longitudinal Teaching, Pro and Con Preceptors get to
know their students well over time. Many use this knowledge of strengths and
weaknesses to guide future student encounters and assignments. They sometimes get to know one another so
well that impairment in student or preceptor has been discovered, something not
even the best licensure boards and investigators can do. The flip side of a
closer preceptor-student interaction is that students see more of the
challenging side of medical practice. They see the challenge of balancing
family, personal, and practice demands. They see the ridiculous mess of the
health system and how it particularly impacts upon physician authority and
autonomy. In academic centers they do not see this aspect in their attendings or
in the academic viewpoint of the
practice of medicine. Of course not integrating these areas into their training
means that learners come out deficient in key areas of medicine, the
relationships of physicians beyond patients.
Detailed studies have shaped more
recent medical schools, including the newest allopathic medical school at Florida
State. FSU conducted perhaps the most extensive and expensive series of consultations,
investigations, and studies in its efforts to design the best medical school to
graduate students to serve rural, minority, and geriatric populations. This
study resulted in a school with more of a generalist perspective, including a
decentralized clinical component. Preceptorships influenced the design of
the medical school in several areas
http://med.fsu.edu/pdf/02_train_retain_phys.pdf.
Bias 1 - The preceptors are poor quality physicians.
Fact - The past 30 years have seen preceptors prepare for practice longer and in higher quality programs than ever before Preceptors Are Quality Teachers . They are practicing medicine 100% of the time. Many have discovered that faculty doing less than 50% clinical practice may not have the amount of experience or the priority on patient care that makes the best teachers and role models for primary care learners. Teachers in academic circles have many other duties and distractions (See The Academization of Family Medicine). Seeing patients is only a part of their lives. For preceptors, seeing patients is their life.
Paul James did a multi-site study of
academic and community-based education. His studies noted no difference in the
quality of teaching with a trend toward better teaching as the distance
increased from the academic center. This was just below the level of
significance.
About the project About
the method
Defining Good Teachers
also James
PA, Shipengrover JA, Crosson J, Young LB, Kernan JB, Heaton CJ, Holmes D.
Primary Care Education: Measuring Instruction to Improve Quality. Academic
Medicine, Vol. 77, No. 9/September 2002. and
James PA, Kreiter CD, Shipengrover J, Crosson J, Heaton C, Kernan J. Students on
the Clinical Race Track where they ran and how they ran. A generalizability
Study of a Standardized Rating Form Used to Evaluate Instructional Quality in
Clinical Ambulatory Sites. Academic Medicine, Vol 76, No. 10/October Supplement
2001.
Bias 2 - Faculty development of preceptors is a challenge. A valid critique of preceptorships in the past was that was difficult to train preceptors to improve the quality of instruction. Today's preceptorships have made great strides.
Fact - In the past there were few rural medical education resources such as rural faculty or coordinators. Some rural experiences continue to be passive, informal electives arranged over the phone with little documentation of teaching or educational quality.
Fact - In established long term preceptorships, the preceptors begin faculty development when they are students doing the preceptorship. Since 1971 over 900 students have graduated from the RPAP program. Some 400 have returned to rural Minnesota. Many have become rural preceptors. Over 60 RPAP students havereturned to the practices where they did their preceptorship. They have a local frame of reference involving their experiences as students, their knowledge of the practice, and their experiences as teachers that can greatly improve the quality of instruction for students spending months at such locations.
Fact - Required rural preceptorships have supervising faculty, coordinators, testing, and formal curricula. Even so rural preceptors are scattered over a wide range of locations. The best way to deal with this has been rural visits. Directors of rural preceptorships must be willing to travel and must have know how to interact with preceptors and rural leaders. Phone calls and emails cannot improve preceptors and preceptorships. The personal touch is necessary. Individuals such as Joe Hobbs (Invisible Faculty Article), Jack Verby, and Wally Swentko have demonstrated these necessary skills. Georgia preceptors become faculty, as much a part of the department of family medicine as any located at the main campus. Rural visits are also supplemented by mandatory gatherings of preceptors.
The use of rural doctors as teachers was once a major question. Again it is important for those bound in academic centers to examine preceptorships from different perspectives. For the student, what better teacher to have for clinical medicine than one who has devoted his or her life to such efforts? Many rural doctors, myself included, have at times feared that they were less than adequate when circumstances returned them to academic centers, the supposed seat of all knowledge and expertise in medicine. Time and again we have all discovered that anything less than 100% patient care means that clinicians are losing valuable time and experience that would make them better clinicians. Other studies have demonstrated the value of community faculty Interdisciplinary Generalist Project Findings
Academic Impacts on Family Physicians The Academization of Family Medicine
Most of us know the tremendous contribution of coordinators to educational programming. The consistency of evaluation, improvements in grading, and increase in communications is a function of top-notch coordinators.
The contribution of the internet makes coordination and educational programming much easier and more consistent. Internet-based experiences, didactics, and materials have made rural experiences more consistent.
The best of teaching at academic centers can be married to the excellent preceptorship experience for an even better graduate.
A very few programs have integrated the generalist and rural perspectives across a wide range of years in medical school and residency. Graduates of such an effort give a picture of what is possible. In Nebraska students visit rural practices for 3 weeks in the first year of training and 2 months in the third year. The first two years of medical school also involve regular small group activities with primary care preceptors helping to impart key elements of doctor-patient relationship, primary care concepts, and underserved medical practice. Students choosing specialized family medicine graduate programs have a more seamless transition into advanced primary care practice preparation. Some enter at the beginning of the fourth year into the Accelerated Residency Program Track or the primary care track, a feeder for the rural training tracks in Nebraska. They continue to have more and more challenging rotations over their graduate training and a required 2 month rural training experience. They supplement their training with rural moonlighting and finish their graduate training with a one year rural and procedural fellowship. The graduates are comfortable even in the smallest rural locations and often go out to practice with one of their fellow residents that they have worked with in training for a few years (stageman and bowman).
It is difficult to separate the admissions process (rural background, family practice interest, maturity) from the integrated training curricula and the rural experiences all along the pipeline. All contribute to a preparation for rural practice that allows graduates to locate in even the smallest towns. The same is true of the RPAP program where half or more of candidates come from Duluth where the same admissions criteria apply Duluth Plus RPAP.
Rural experiences and preceptors are important components of preparation for rural practice. Students and residents in academic centers rarely see the non-clinical lives of their academic faculty. For better or for worse, they see the total picture during long term preceptorships. The "worse" part is all of the hassle factor that can drive all physicians wild, particularly in primary care. The "better" part is that students have a (hopefully) more relevant role model in the preceptor as a physician who has learned to balance medicine and other dimensions. This could mean a boost to the emotional IQ that is not measured other than perhaps improved versatility and the potential to make decisions using factors beyond the traditional clinical dimensions.
Our view of recruitment of rural physicians and retention of such physicians in rural practice is changing.
Recruitment has much to do with rural background, interest in full scale family medicine, service orientation, and lifestyle interests.
It is not training in family medicine that enables rural practice, rather significant numbers of students who plan rural practice and choose family medicine as the best route to their career goal.
Nearly half of rural physicians are from urban backgrounds and less is known about their reasons for the choice of rural practice.
Retention in rural practice is increasingly viewed as a function of the environment of training.
Speculation would have the above factors expressed as a function of the emotional IQ or versatility or adaptability of the graduate faced with factors in the community involving practice, personal, and family variables.
Long term rural preceptorships can be
convicted on the basis of motive,
opportunity, and means. The fact is that Flexner and
others who initiated changes that terminated the preceptorships a century ago,
would in 2002 broadly support them because of the patient contact and the
quality of education. Rural medical educators have overcome the challenges of
medical education and working with rural communities to provide superior form of
medical education.
Robert C. Bowman, M.D.,
Co-Chairman Rural Medical Educators Group of the National Rural Health Association
UNMC Dept of Family Medicine Director of
Rural Health Ed and Research
983075 Nebraska Medical Center
Omaha, NE 68198 3075 (402) 559 8873 or fax at
8118
Email: [email protected]
http://www.ruralmedicaleducation.org
RPAP started because a rural legislator in a power position
(appropriations) said UMN would not get any funds from the state unless
they started graduating docs for rural MN