Placing students in high-quality, community-based clinical training sites is becoming increasingly difficult. The number and size of medical schools are growing, and clerkship directors face increasing competition for a limited number of community-based teaching sites.1 As required by the Liaison Committee on Medical Education (LCME), medical schools must ensure the quality of this training by providing ongoing faculty development for community-based teachers.
A 2013 survey of all deans of medical and allied health professions schools found that more than 80% of respondents in each type of institution (MD-granting schools, DO-granting schools, physician assistant programs, and nurse practitioner programs) were concerned with the quantity and quality of clinical training sites. Most of the deans who responded indicated that the greatest difficulty was to secure primary care teaching sites, and the top two specialties with difficulty finding sites were pediatrics and obstetrics–gynecology. Orienting and training faculty were identified as key barriers to recruiting and retaining community preceptors and community-based teaching sites.2 The Alliance for Clinical Education, a national collaborative of eight disciplines’ clerkship directors, recently focused on this crisis, and included recommendations about faculty development such as orienting preceptors and staff, providing preceptor incentives, streamlining assessment tools, assisting with quality improvement projects at the site, and assigning students longitudinally.3
Published reports of faculty development programs describe a variety of approaches to faculty development for community-based preceptors, without clear evidence supporting any one particular format. One example is the Preceptor Development Program, developed by the Mountain Area Health Education Center of Asheville, North Carolina, which has reached over 500 clinical preceptors of health professions students. The three-year program includes materials on nine core topics, with formats that include seminars, monographs, Web modules, and one-page summary “thumbnails.”4 The literature defines additional formats including a preceptors’ listserv, an electronic clinical teaching discussion group, interactive Web-based teaching scenarios and cases, CD-ROMs, on-site technology support, and audio modalities.5–8
Clerkship directors are challenged to deliver faculty development to community-based faculty who practice at varying distances from the university, face increasing clinical productivity demands, and demonstrate diverse training needs.4 Clerkship directors are tasked with selecting the optimal format and content because of the low level of supporting evidence on best practices published in the literature. The literature includes examples of diverse delivery formats addressing a variety of topics relevant to community-based faculty, with outcome measures of satisfaction, continuing medical education (CME) use, and program use.4,5 Surveys that assess the impact of these methods are plagued by low response rates, but in general, faculty development is positively received.5 Furthermore, it is possible that a number of other factors may influence the effectiveness of faculty development outcomes, such as medical school characteristics, clerkship and clinical training site characteristics, quantity of delivery and delivery method, and faculty perceptions of barriers and incentives.
This study provides the first comprehensive description, to our knowledge, of faculty development for community-based preceptors teaching in family medicine clerkships. We designed questions to quantify requirements, delivery methods, topic selection, and barriers perceived by clerkship directors. We also tested several hypotheses: Clerkships that pay preceptors should be more likely to require faculty development; financial support for the clerkship director’s time should correlate positively with delivery of face-to-face preceptor training; and the percentage of protected time for clerkship directors should correlate positively with the number or length of visits provided to community-based preceptors.
We gathered and analyzed data as part of the 2015 Council of Academic Family Medicine’s (CAFM’s) Educational Research Alliance (CERA) survey of family medicine clerkship directors. CAFM is a joint initiative of four major academic family medicine organizations: the 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 cross-sectional survey of clerkship directors is distributed annually to the institutional representatives of qualifying medical schools. The institutional representative is the clerkship director at the main campus of the school or their designate. Qualifying medical schools are accredited by the LCME or Committee on Accreditation of Canadian Medical Schools and are located within the United States of America, the Commonwealth of Puerto Rico, and Canada. To qualify, the school must have students who complete a family medicine clerkship or a primary care clerkship that has a required family medicine component with a family medicine educator responsible for that component. In 2015, there were 125 U.S. and 16 Canadian unique individuals identified as family medicine educators directing a family medicine or primary care clerkship.
Community-based faculty were defined as “teachers who practice off campus and who do not have a primary appointment in your department or institution.” Respondents also answered questions about regional campuses, defined as “geographically separate from the main campus, typically have students spend a block of time on site, and have an administrative structure with official ties to the Dean’s Office.”
Members of CAFM-affiliated organizations were invited to propose survey questions for inclusion into the CERA survey. Following an open call for proposals, the CERA steering committee for the clerkship director survey reviewed all proposals. Approved projects were assigned a CERA research mentor to help refine questions. Each research team is limited to submitting 10 questions on their respective topic. The final drafts of survey questions were then modified following pilot testing.
We distributed the survey via e-mail invitation to 125 U.S. and 16 Canadian family medicine clerkship directors between November 1, 2015, and December 31, 2015. Invitations to participate in the study included a personalized greeting and a letter signed by the presidents of each of the four sponsoring organizations with a link to the survey, which was conducted through the online program SurveyMonkey. We also contacted nonrespondents through personal e-mail and telephone calls to verify their status as clerkship directors and to check accuracy of e-mail addresses. Questions covered participants’ demographic characteristics, type of faculty development offered and time spent on faculty development, whether requirements existed for faculty development or pay was offered, how the need for faculty development was determined, institutional benefits provided to community-based faculty, and barriers to delivering faculty development to community-based faculty. The survey used multiple choice, Likert scales, and free-text responses for data collection. The study was approved by the American Academy of Family Physicians institutional review board.
The deidentified data set received from CERA was imported into Statistical Package for the Social Sciences (SPSS) statistical software, version 22 (IBM SPSS Inc., Armonk, New York) for data analysis purposes. We conducted descriptive statistical analysis identifying measures of central tendency, variability, and associations.
A total of 112 out of 141 clerkship directors (79% response rate) responded to the survey. Sixty of the 112 responding clerkship directors were female (54%). Tables 1 and 2 present frequency data describing characteristics of the medical schools surveyed and their family medicine clerkships.
One hundred (89%) clerkship directors reported offering faculty development to community-based preceptors, whereas only 17 (16%) indicated that they had a faculty development requirement. Table 3 displays the faculty development activities offered, with personalized feedback based on student evaluations, site visits, and face-to-face preceptor development sessions as the most common. At a typical site visit, clerkship directors reported spending between 0 and 100 minutes interacting with community-based faculty, with the most common lengths of time selected being 60 minutes (26/97; 27%) and 30 minutes (19/97; 20%). Thirteen of 97 (13%) respondents reported spending no time interacting with faculty. In terms of face-to-face faculty development, 32 (29%) clerkship directors reported not offering it at all, whereas 49 (44%) offered between 1 and 3 hours annually. The majority of clerkship directors, 73 (65%), reported not paying community-based faculty, whereas the average payment per week of those who reported paying was $263 (SD = $134.20). It’s worth noting that only 28 (28%) of the U.S. clerkship directors reported paying community-based preceptors, compared with 11 (100%) Canadian clerkship directors (P < .001). Significantly more Canadian schools were likely to have a faculty development requirement compared with those in the United States: 5 (46%) versus 12 (12%), P < .001.
The most common methods used to determine faculty development needs were informal conversations with preceptors (85; 76%) and teaching evaluations provided by students (68; 61%). Among the nine clerkship directors who selected other (8%) for their needs assessment strategy, the most common answer was that “none” was performed. The most frequently reported evaluation strategy to determine the effectiveness of faculty development programs was an evaluation of those programs by participating community-based faculty. These evaluations helped determine participant satisfaction with the faculty development activity (46; 41%) and participant self-assessment at the end of the activity (34; 30%).
The institutional benefits provided to community-based faculty are described in Table 4. Faculty appointments/affiliations, access to electronic libraries, and free CME credits were the most common benefits provided, offered by 100 (89%), 92 (82%), and 59 (53%) institutions, respectively. Less common incentives offered included recognition by medical schools (30; 27%), signage for offices (32; 29%), and providing tax incentives (3; 3%).
Table 5 describes clerkship directors’ rating of difficulty level in overcoming barriers to delivering faculty development to community-based faculty. Preceptor time availability was selected as the most challenging barrier to overcome, rated as difficult or very difficult by 96 (90%) respondents. Other significant challenges include geographic distribution of preceptors (87; 81%), financial resources (80; 76%), clerkship director dedicated time (62; 59%), and competition from other programs (59; 55%).
We explored potential relationships between the characteristics of medical schools and faculty development programs. Significant bivariant positive correlations were found between clerkship directors who reported requirements for faculty development and paying preceptors (P < .05) and faculty development requirements and offering face-to-face activities (P < .01). Chi-square tests showed no significant association between the type of institution (public vs. private) and whether community-based faculty were paid for teaching. Furthermore, no statistically significant associations were found between required faculty development and offering site visits, or the percentage of protected time for clerkship directors and the number or length of visits provided to community-based preceptors.
To the best of our knowledge, this study is the first comprehensive description of faculty development for community-based preceptors engaged in the family medicine or primary care clerkship. These data provide some guidance for educational leaders interested in supporting and developing community-based faculty as educators.
The growing need to recruit and develop community-based faculty to train medical students has led to our current crisis.3 Medical schools are increasingly reliant on community-based faculty to deliver clinical experiences in family medicine, as well as other specialties such as internal medicine, pediatrics, and obstetrics–gynecology. Without the participation of community-based preceptors, many medical schools would not have enough clinical training sites for students. Perhaps in response to this crisis, providing payment to community-based preceptors for teaching activities is also becoming more common. The percentage of medical schools paying community-based preceptors for family medicine clerkship teaching activities was 23% in 2012, and increased to 35% in 2015, at the time of this study.9 Our findings demonstrate a correlation between paying preceptors and requiring community-based preceptors to complete faculty development activities. Perhaps schools that pay preceptors feel justified in requiring faculty development, such as the six-hour faculty development requirement that community-based preceptors for the Florida State University College of Medicine must meet before being assigned a student.10 As more schools pay community-based preceptors, there may be a parallel increase in faculty development requirements. In Canada, all responding clerkship directors indicate that they are currently paying community-based preceptors for clinical teaching and are more likely to require community-based faculty to complete faculty development.
Preceptor time availability was rated as the most difficult barrier to overcome in delivering faculty development for community-based faculty. Thus, creative methods to meet increasing faculty development demands may include experimentation with technologies such as listservs and online discussion modules. Physicians might listen to a podcast during their commute or while at the gym; podcasts may provide another example of effective and time-saving educational technology for faculty development.
Our findings show that many institutions are not completing a formal needs assessment to determine faculty development topics for community-based faculty but, instead, rely on informal conversations and teaching evaluations. Many institutions reported no needs assessment at all, and less than half reported an evaluation of the faculty development programs that were offered. When evaluation was reported (n = 91), 41% were based on satisfaction and less than 15% measured a commitment to change. This study highlights a need for improved needs assessments and faculty development program evaluation, critical steps in any effective curriculum.11
Paying preceptors and funding clerkship director time may permit schools to enhance faculty development program activities and effectiveness. The finding we report may encourage clerkship directors to employ innovative faculty development methods, such as online modules, that permit the preceptor to access faculty development resources on an as-needed basis, without compromising clinical productivity. Further study is needed regarding measurement of best practices for faculty development activities for community-based preceptors, including outcome measurements to assess the effectiveness of methods and content.
This study has several limitations. The survey was directed only to family medicine or primary care clerkship directors, and the findings may relate more to outpatient rather than inpatient practice. The survey did not distinguish between training in the community-based office or hospital settings. For any specialty that engages faculty in community settings, however, most of the findings such as methods for delivering faculty development are likely applicable.
This study may also have been limited by response bias. Only those clerkship directors who chose to respond to the survey completed the questions. A response rate of 79%, however, argues for good representation of all schools. Though a survey-based study proves association and not causation, the descriptions and correlations may still provide ideas for implementation and further evaluation. This survey was not able to determine how community-based preceptors might respond to alternative curriculum delivery methods.
A final limitation is that the study only inquired about medical school overall payment to community-based preceptors and did not inquire about any other financial incentives, such as state tax deduction or credit. Further studies could address what types of financial incentives are most strongly correlated with faculty development activities and requirements, and explore this connection between payment and faculty development more explicitly.
Our findings raise many other questions for further study. For example, the most frequently mentioned mode of faculty development in our survey was feedback to community-based faculty, but the responses did not include details regarding how this is done. Clearly, further investigation of best practices for providing feedback to preceptors needs to be explored. The impact of competition amongst medical schools for community-based faculty also needs to be evaluated. Do schools offer more benefits to preceptors in areas of the country with higher levels of competition between medical schools for community training sites? Another area of inquiry is best practices for site visits, determining whether site visit interventions are associated with better outcomes for the community-based faculty, students, clerkship staff, and patients.
A positive correlation between paying community-based preceptors to teach and participate in faculty development may not indicate any improvement in outcomes that matter, such as quality of teaching and learning. Future studies could investigate which faculty development activities achieve the highest-quality outcomes with the least burden to the preceptor. Do online modules work as well as face-to-face workshops? What is the role for peer–peer interaction during faculty development? Perhaps through improving faculty development activities, preceptors will not only gain competence in teaching but also feel more positive about continuing to teach. Ultimately, clerkship directors may have less difficulty in retaining excellent community-based faculty for teaching.
One approach for future faculty development programs could emphasize how students can add value to clinical practices. A 2011 survey of community-based preceptors from a variety of disciplines reported that working with medical students negatively affected patient flow, work hours, and income.12 With self-employed or physician-owned practices declining in prevalence, hospital systems that employ preceptors may be less willing to support the costs of medical education.3 To counterbalance the costs of precepting, the theme of value-added medical education is evolving; identifying authentic roles in which students bring value to the clinical setting is a growing area of discussion in the literature.13 Additionally, the Society for Teachers of Family Medicine has outlined strategies to augment students adding value to the outpatient office practice.14 Future research can clarify whether this thematic emphasis for faculty development improves satisfaction of the student and preceptor, and even the health care of patients.
Acknowledgments: The authors are grateful to LaVon Edgerton, grants compliance analyst, Department of Geriatrics, Florida State University College of Medicine, and Tana Jean Welch, PhD, assistant professor, Florida State University College of Medicine, for providing additional manuscript assistance.
1. LePage P, Courey S, Fearn EJ, et al. Curriculum recommendations for inclusive teacher education. Int J Whole Schooling. 2010;6:1945.
2. Erikson C, Hamann R, Levitan T, Pankow S, Stanely J, Whatley M. Recruiting and maintaining U.S. clinical training sites—Joint report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey. http://members.aamc.org/eweb/upload/13-225%20WC%20Report%20FINAL.pdf
. Published 2013. Accessed January 13, 2017.
3. Christner JG, Dallaghan GB, Briscoe 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. Teach Learn Med. 2016;28:329336.
4. Langlois JP, Thach SB. Bringing faculty development to community-based preceptors. Acad Med. 2003;78:150155.
5. Bramson R, Vanlandingham A, Heads A, Paulman P, Mygdal W. Reaching and teaching preceptors: Limited success from a multifaceted faculty development program. Fam Med. 2007;39:386388.
6. Lie D, Boker J, Dow E, et al. Attributes of effective community preceptors for pre-clerkship medical students. Med Teach. 2009;31:251259.
7. Malik R, Bordman R, Regehr G, Freeman R. Continuous quality improvement and community-based faculty development through an innovative site visit program at one institution. Acad Med. 2007;82:465468.
8. Willett LR. Brief report: Utilizing an audiotape for outpatient preceptor faculty development. J Gen Intern Med. 2006;21:503505.
9. Anthony D, Jerpbak CM, Margo KL, Power DV, Slatt LM, Tarn DM. Do we pay our community preceptors? Results from a CERA clerkship directors’ survey. Fam Med. 2014;46:167173.
10. Fogarty JP, Littles AB, Romrell J, Watson RT, Hurt MM. Florida State University College of Medicine: From ideas to outcomes. Acad Med. 2012;87:16.
11. Kern DE, Thomas PA, Hughes MT. Curriculum Development for Medical Education: A Six-Step Approach. 2009.2nd ed. Baltimore, MD: Johns Hopkins University Press.
12. Latessa R, Colvin G, Beaty N, Steiner BD, Pathman DE. Satisfaction, motivation, and future of community preceptors: What are the current trends? Acad Med. 2013;88:11641170.
13. Gonzalo JD, Lucey C, Wolpaw T, Chang A. Value-added clinical systems learning roles for medical students that transform education and health: A guide for building partnerships between medical schools and health systems. Acad Med. 2017;92:602607.
14. Steiner B; Society for Teachers of Family Medicine, Medical Student Education Committee. Strategies to ensure that students add value in outpatient offices. http://www.stfm.org/Portals/49/Students%20as%20Added%20Value.pdf
. Published June 2016. Accessed January 12, 2017.