BACKGROUND AND PURPOSE
At the 2012 American Physical Therapy Association's (APTA) Combined Sections Meeting (CSM), “the construct of a process for developing a shared vision for physical therapist clinical education began.”1 As a result of this discussion, APTA organized a task force to promote optimal clinical educational experiences (CEEs) for physical therapist (PT) students that would strengthen the partnerships between all levels of PT education programs and clinical practice. Dunfee2 outlined several challenges to the provision of quality CEEs in her guest editorial in the Journal of Physical Therapy Education. These challenges included, but were not limited to, the productivity demands on clinical facilities and the regulatory and reimbursement environment. These factors have an impact on the ability of clinical facilities to provide CEEs for students and, as Blau et al3 described in their research, have often had negative influences on clinicians’ perceptions of their work environment.
The challenges to the provision of CEEs are not unique to the physical therapy profession or to practice in the United States (US). In medicine, Von Below et al4 reported that facilitators who supervised students during CEEs took pleasure in being clinical teachers and felt that these experiences were worthwhile. However, these facilitators also reported that they lacked support from their superiors for their role as clinical teachers and, furthermore, the authors noted a tension between productivity demands and contributing to the education of future professionals. In 2008, Rodger et al5 reported findings from an international, interdisciplinary discussion about key issues related to clinical education (CE) and practice placements. In their report they noted that detrimental influences on CEEs have included fiscal constraints, changes in practice models, and reduced staffing.
Prior to the APTA CSM, the New England Consortium of Academic Coordinators of Clinical Education (NEC-ACCE) organized a meeting, in the spring of 2011, with the PT education program directors and directors of clinical education (DCEs) of the 17 member institutions to discuss contemporary concerns regarding physical therapist education. NEC-ACCE membership includes all DCEs from the 17 PT academic programs in a 6-state area, including Maine, New Hampshire, Vermont, Massachusetts, Connecticut, and Rhode Island. The impetus for this meeting was based on NEC-ACCE member experiences that indicated that clinical facilities were having greater difficulty accommodating requests for student CEEs. During the all-day workshop, this select group of stakeholders discussed the challenges associated with CE from multiple perspectives. At the conclusion of this meeting, participants expressed a common concern that CE may not be sustainable in its current form. Similar to the premise of a “shared vision for PT education” that would later be promoted at the 2012 APTA CSM, the consortium recognized that it did not have enough direct information from the wide breadth of clinical personnel who served the needs of the academic institutions and students. Participants acknowledged that more information was needed from regional clinical educators to make informed decisions about how academic programs and clinical educators could work collaboratively to meet the challenges surrounding the provision of CE. The NEC-ACCE charged a 6-member task force to gather this information and report back to the group. Specifically, the task force's objectives were to obtain New England clinicians’ feedback on: (1) the variables that impact physical therapy practice and CE; (2) how to strengthen the partnership between academic programs and clinical facilities; and (3) possible strategies to manage the challenges associated with CE.
A series of regionally based focus group discussions were organized to maximize clinician feedback on the status and future of physical therapist education. The goal was to hear from clinicians about their thoughts and experiences from working with PT students during CEEs. Another goal was to share the results of these discussions with the broader physical therapy community, so institutional review board approval from 2 academic institutions was obtained to ensure the ability to disseminate the findings.
NEC-ACCE members were asked to assist with recruitment of participants, using a “snowball sampling” method via emails to clinical coordinators of clinical education (CCCEs) and clinical instructors (CIs). This method of participant recruitment is described by Sadler as using “affinity organizations.”6 PTs from New England were recruited as a convenience sample of clinicians who represented the common core group of clinical educators in New England. The investigators made a conscious decision that all PTs, regardless of their years of clinical experience and teaching, should be invited to participate in the focus group discussion. All PTs are eligible to be CIs after a year of experience, and PTs with less than a year's experience have recent perspectives about being student PTs. Therefore, it was decided that the opinions of any PT who chose to participate in the focus group discussion would be valuable. Finally, the investigators recognized that there are other stakeholders, such as clinical facility administrators, who have an impact on and opinions about the future of CE. With this in mind, when invitations were sent, recipients were encouraged to invite other employees who they felt were influential in decisions about CE.
Because participation in the focus group discussions was voluntary, researchers wanted to host focus groups in places, and at times, that would be most conducive for CIs to attend. Therefore, CCCEs were personally contacted to host focus group discussions at their facilities. Consortium members contacted sites that had known space available for meetings, were at clinical sites throughout New England, and could easily accommodate clinicians within and outside their own facilities. Once a site agreed to host a focus group discussion, invitations were sent via email, posted fliers, and personal phone calls to CCCEs and CIs within the geographic region, usually within 1 hour travel time from the clinic. The researchers did not know ahead of time how many people would attend each focus group; therefore, they did not have the opportunity to influence the number of attendees for each meeting.
Focus group methodology is recognized in the literature as an accepted method for qualitative research7–11 and was selected as an optimal way to gather perspectives from clinical educator colleagues, which would lead to more enriched discussions. Creswell7 suggests that using interviewees who “are similar and cooperative with each other”(p.124) is a good strategy when organizing focus groups.
Knodel10 states that the first step in focus group methodology is to set objectives and clarify the concepts being investigated.(p36) The objectives of the focus group were identified and clearly presented to all participants using a standard protocol developed by the NEC-ACCE task force. Prior to discussion, a 10-minute slide show was presented at each session to provide standardized information to all participants on contemporary issues in clinical practice as well as professional visionary CE goals. The content of the slide show was based on the initial conversations that the consortium had with various stakeholders during the spring 2011 NEC-ACCE meeting, which served as the impetus for this work. This provided a common framework for discussion during each focus group.
Focus groups were organized at convenient times and locations throughout New England to maximize participation and engage clinical educators with different levels of experience and clinical roles, in order to collect a breadth of information.
Thirty-three focus groups were conducted in 4 New England regional areas as follows: 8 in Eastern Massachusetts; 9 in the Western Massachusetts, Connecticut, and Rhode Island area; 8 in Vermont; and 8 in the New Hampshire and Maine area. There were 257 participants with a range of 2–21 participants in each group: 11 focus groups of 2–5 participants, 17 groups of 6–12 participants, and 5 groups of 13–21 participants. Demographic information sheets were completed by 235 participants, and the demographic data for this group of participants is described in Table 1.
As mentioned previously, a 10-minute slide show outlined objectives for the focus group discussion, providing a framework from which participants could construct their comments. These objectives were based on the outcomes of the Spring 2011 NEC-AC-CE meeting, during which concerns about the contemporary environment of physical therapist education were discussed. The objectives were to identify: (1) the variables that impact physical therapist practice and CE, (2) how to strengthen the partnership between academic programs and clinical facilities, and (3) possible strategies to manage the challenges associated with CE. The slide show reviewed background information including the major influences on the physical therapy profession, APTA's vision that all PTs will be doctors of physical therapy, and projections by the US Bureau of Labor Statistics regarding the growth of the physical therapy profession. The slide show also gave an overview concerning the changes in physical therapist education, which included the growth in PT education programs, a trend toward longer CEEs, regulatory and reimbursement issues, and increasing student debt. The slide show also described national, regional, and local strategies that had been implemented to support CE.
To help validate the elements of the focus group presentation before beginning the discussions, the task force members engaged other NEC-ACCE member DCEs to discuss the content of the slide show and the questions that were to be posed to participants. After the slide show and questions were validated, the primary investigators provided training to other DCEs on how to use the slide show to standardize the information conveyed and structure the focus group process.
The focus groups were conducted as follows, A DCE from the NEC-ACCE moderated the discussion. A second DCE manually recorded each participant's comments. Most, but not all of the moderators and recorders were task force members. After the introductory presentation, under the overarching issue of discussing an alternative model of CE designed to prepare students for practice that will more adequately serve all stakeholders, 5 questions were posed to the groups for discussion:
- What should the academic-clinical partnership look like?
- Where should the locus of control for CE lie in the future?
- Should we continue to prepare generalists, or move toward specialty practice?
- What are your developmental needs to support your role as educators?
- What are some strategies to manage the current challenges?
Participants had time to discuss and respond to each question. Conversation was facilitated by the lead DCE, using a neutral, structured protocol, asking for clarification of comments as needed. The discussion groups were scheduled to be approximately 1.5–2 hours long.
Participant comments were not audiorecorded. The recorder's task was to type each person's response to the discussion on a standardized recording sheet. The recording sheet included the name of the site at which the focus group was hosted, the question posed to the focus group, and each participant's comments recorded on a separate line under the question that was posed.
Data Collection and Analysis
The recorded responses were checked for accuracy by at least 1, and most often 2, participants in the discussion group. An iterative process of coding, categorizing, and analyzing participant comments was used to identify predominant responses for each question. The data analysis was guided by the qualitative research processes outlined by Corbin and Strauss.11 This process included reading, discussing, and rereading participant comments in each focus group. The investigators began with an inductive approach to coding the data. They worked in pairs and subsequently shared their initial coding with a second pair of investigators. A 2-level process of paired reviews identified the initial coding (Figure 1). As described by Wolf,12 24 initial coding categories, across all 5 questions (Figure 2), were defined as “repetitive, recurrent topics that emerge during analysis.”(p.317) This iterative process of analyzing data resulted in the identification of 2 primary themes: economics and communication/collaboration. Using a process of consensus, the groups identified participant statements that they felt supported the 2 primary themes. This process is an accepted method of data analysis, as described by Huberman and Miles.13 They state, “When a theme, hypothesis, or pattern is identified inductively, the researcher then moves into a verification mode trying to confirm or qualify the finding.”(p.86)
In spring 2012, the investigators presented the preliminary data analysis and reported relevant quotes to support this analysis to PT education program directors, APTA invited speakers, and CCCEs, some of whom had been focus group participants. This active discussion and examination of data on each of the 5 questions served as a validation of the analytical process by the investigators. Another measure to ensure the validity of the data analysis included engaging an outside consultant with experience in clinical practice and research methodology to advise the investigators and comment on the process, data analysis, and interpretation, and also to discuss measures to mitigate investigator bias.
Focus group analysis identified 2 major themes from the discussions: the importance of communication/collaboration and economic factors of CE. This report focuses on the economic impact of CE on physical therapist practice; the other major theme, communication and collaboration, has been reported separately.14 Subthemes for economic impact were identified as follows: (1) influences of payers for physical therapy services, (2) concerns about how CE impacts productivity and personnel, and (3) strategies to offset some of the perceived costs of CE.
Influences of Payers for Physical Therapist Services
Reimbursement for physical therapist services has an impact on the expected productivity of PTs in a variety of settings. The impact that these productivity demands have on PTs and CE are reflected in the following statements:
CIs can't take students back to back to back because of productivity requirements; this limits the number of students the clinic can take overall.
We need to know how to balance CE in the clinic with productivity. The fear is that productivity will decline if a CI has students because of the time needed to educate them.
Expectations for clinicians’ productivity are high and the number of students versus mentors is an issue.
Additionally, the trend of increasing patient copayments has affected how much patients are willing to access physical therapist services for a given injury and their expectations of the value of each therapy session. Participant statements about these reimbursement trends, as it relates to the inclusion of students managing patients’ care, include:
We have had a recent complaint that a patient does not want to pay for services from a student.
Private practices seem to have patients who want to be seen by the PT. Copays make it hard for patients to justify seeing a student. Students need to do a good job making the patients feel comfortable.
Regulatory concerns related to Medicare have also had an impact on CE. Medicare B guidelines15 stipulate that only the services provided by the licensed PT can be billed to Medicare and paid. As of October 1, 2011, the regulations for Medicare Part A state, “the student and resident [patient] no longer need to be within the line-of-sight supervision of the supervising therapist. CMS will allow the supervising therapist to determine the appropriate level of supervision for the student.”16 However, for individual therapy to be billed, only 1 resident can be treated by the student and supervising therapist.16 These regulatory issues pose considerable challenges for administrators in clinical facilities as they attempt to accommodate students’ needs to participate in patients’ plans of care. Clinicians from clinical facilities stated:
Medicare guidelines killed [skilled nursing facilities] last year. The ‘line of sight supervision’ was very limiting for both students, who were ready to be more independent, and CIs, in terms of productivity.
It is tougher in the [skilled nursing facility] setting because of Medicare requirements. It is hard to project what changes there will be 2 years from now, and this affects planning for students.
There is a major issue in the limitation of students seeing Medicare patients. It is a problem for sites both in terms of productivity and having enough number of patients for students to see.
Having a student impacts productivity. Medicare has made it harder to justify having students. It used to be that having an ‘early’ student was not cost effective; however, gaining a more experienced student was beneficial. In outpatient clinical settings, this is not the case anymore with changes in Medicare.
Concerns About How CE Impacts Cost to the Facility and Personnel
These reimbursement issues may have had an adverse influence on CE because of overall concerns and perceptions about students’ impact on the overall, perceived “cost” associated with CE. As noted by some participants, higher-level administrators in clinical facilities perceive that there are costs associated with having students in their departments. Although clinicians often want to support CE, they may not obtain the necessary support from their administrators to provide this service. This concern is reflected in the following statements:
The other critical stakeholders are PT managers, or people in charge of the budget. There is a strong cry about how much [CE] is costing us. Students do cost money. Facilities have been eating the cost of [CE].
The problem is productivity requirements and the lack of administrative support. At times, additional staff is required to make up for CI's lost productivity.
Many clinician participants also voiced concerns about a loss of productivity during students’ CEEs and how this impacted perceived costs to the facility:
It takes a lot of time to take students. How can we make it work financially? It's one thing to be busy, but we can't lose money.
When we take a student, everyone else in the department has to take on more patients. What can schools do to pay us back?
Acute care is always in transition. Productivity is very important and doesn't include [the time allotted to] teaching.
The heightened productivity demands and escalating costs of care have influenced staffing patterns, which impacts students, as well:
There is a move to hire per diem staff vesus full hire employees for more costeffective ways to handle employees’ salaries.
Outside hospital consultants are saying you have to do more with less, resulting in decreased hiring. Employers are splitting positions—eg, per diem or part-time PTs without benefits—for more cost-efficient ways of paying salaries.
The clinic is only able to take a limited number of students because [being a CI] is optional. Also, clinicians job share. Clinicians’ productivity is high and the ratio of students versus mentors is an issue.
As staffing and productivity pressures become intensified, PTs are often less likely to take on the added responsibility of mentoring a student, as reflected in these comments:
Stress of the clinical environment has led to decreased numbers of students. Also, staffing is unstable at times. There is a very fine balance—as length of clinical experiences increases, clinics will end up taking less students, because we don't want to burn out staff.
We really have to be careful of burn-out of instructors. [CE] is just going to become a burden and CIs will eventually stop teaching.
I don't give a CI more than 1 student a year…1 a year seems to work okay, it gives [the CIs] enough down time.
How can we accept more students without stressing out the staff and maintaining the quality of education to the student?
Strategies to Offset Some of the Perceived Costs of CE
Some PTs support the CE internship model, in which PT students become licensed at a point during a more long-term CEE. This may alleviate some of the adverse constraints of the regulatory environment by allowing services provided by PT interns to be reimbursed. In addition, the interns may benefit from an extended period of mentorship and guided learning. However, as 2 participants noted below, the internship model has challenges that may not make it universally accepted:
The year-long internship where the student is paid a low wage, unlicensed for the first few months, and then licensed (but still paid less), works well but it is hard to get administration to keep the budget line for that purpose.
Year-long internships: It would take 1 open position and we don't always have that; many clinics have only part-time staff.
When asked to suggest strategies to manage the current challenges associated with CE, clinicians often indicated an interest in developing stronger partnerships with PT education programs to provide a greater sharing of resources and support for professional development, as shown in the following statements:
There is a push for regional partnerships with closer relationships between the educational institution and medical facility so that they share resources …
I would like the opportunity to have a split teaching/clinical position, which would be a regular relationship, not a 1-time class presentation.
We need access to library/internet resources as a clinical partner. Ongoing access would be best.
What about in-services? Is this another way for programs to give back?
We would like reimbursement and/or tuition vouchers being shared between the schools.
Offer extra pay or extra title (even temporary appointment) to credentialed CIs just to make people feel better.
We should get CEUs [continuing education units] for being a CI. OT [occupational therapy] does this.
Additionally, clinical education faculty expressed the following thoughts about financial incentives to accept students for CEEs, since there is a perceived expense assumed by the clinical facility during CEEs:
Can the clinical site be reimbursed at some level, perhaps from tuition dollars students pay for clinical education credits? Student tuition money should go from the academic institution to the clinical facility, not to the CI.
Consider the tuition dollars that the schools get for clinical education. Can clinical facilities and academic programs contract as partners? You give us dollars and we'll give you clinical spots.
Expense. It takes a lot of time to take students. How can we make it work financially? It's one thing to be busy, but we can't lose money. Can there be sharing of tuition dollars? Students never take on their own case load, so we never make money. We just lose money in the beginning.
The original purpose of this study was to more clearly identify, through focus group discussions, how the partnership between clinical facilities and academic programs could be strengthened. These discussions highlighted multiple stresses on contemporary physical therapist practice that have impacted the provision of CE from an economic viewpoint. As it relates to these concerns about economics, clinical personnel perceived that hosting students on CEEs has an impact on productivity. Previous studies regarding PT students’ effects on productivity have been conducted.17–22 Much of this literature is based in acute care settings17–20 and needs to be updated to reflect the current reimbursement and regulatory environment. Many of these studies are from outside the US,17–19 making it difficult to ascertain if the results would be the same in contemporary US clinical facilities. Additionally, the parameters used to define productivity are not consistent between studies. Dillon et al20 studied the impact that PT students had on productivity in an acute care setting. These researchers used the number of patients seen, evaluations performed, and charges generated by the student and CI pair to determine productivity and found that CI-student pairs were more productive in all 3 of these parameters versus the productivity of the CI working alone. Some clinical facilities have used a multiple student-to-CI, or collaborative, model in an effort to efficiently and effectively support CE. Ladyshewsky19 studied an acute care facility in Canada to determine measures on productivity using a collaborative model and found that productivity measures in this model also increased.
The Medicare B guidelines that stipulate that only the services provided by a licensed PT can be billed has been in effect since 2001; however, enforcement of this policy has increased with the recent focus on the federal budget. Therefore, under Medicare guidelines15–16 it is difficult for teams of students and CIs to demonstrate greater than normal levels of productivity if their patient load includes several patients covered by Medicare. However, it does seem feasible that productivity may not suffer in this model if there is careful planning, because the student and CI must work as a team with a single patient. In fact, recent research in the occupational therapy literature supports the notion that productivity is not compromised during Level II placements, especially when students are assigned to CIs who have a history of adequate productivity.23
A study by Moore et al21 explored productivity during CEEs at 3 military clinical sites using a teaching model in which student cohorts were supervised by 2 to 3 CIs. Their findings indicated that their sites maintained their productivity levels while students were on site. However, the researchers acknowledged that they eliminated data regarding productivity when their student interns were not “functioning efficiently due to development learning early in the internship.”(p32) Not including all the data regarding productivity during the full internship limits the applicability of their findings because the time leading up to students’ optimal function still has an impact on the clinical facility.
Lekkas et al22 performed a systematic review of the literature that explored data regarding various models of the delivery of CE. Their analysis of the literature indicated that productivity increased or remained the same, regardless of the CE model of delivery. The literature related to students and their effects on clinic productivity needs to be updated to reflect the current reimbursement and regulatory environment in the US and should include evidence regarding productivity to represent all the disciplines of physical therapist practice. It would also be beneficial to have some standardization regarding the parameters used to define “productivity” so that the results could be easily applied to multiple settings.
The productivity and administrative demands on clinicians can't be ignored as PT education programs consider how to integrate CE in contemporary practice. The focus group participants noted that they had to consider PT “burn-out” when assigning students to CIs. The demand on CIs to be productive throughout students’ CEEs contributes to this feeling of “burn-out.” APTA's Physical Therapist Clinical Performance Instrument24 is the assessment tool that is most commonly used by academic programs to assess students’ clinical performance. This tool stipulates that an “entry-level” rating requires the student to be “capable of maintaining 100% of a fulltime physical therapist's caseload in a cost-effective manner.”24 It should be noted that this tool does not require a student to manage a full caseload. Rather, the CI needs to make an assessment about the student's capability of handling a full caseload. Literature in medicine25 and physical therapy26 indicates that increasing the number of patient encounters seen by students does not necessarily enhance student learning.25 High patient volumes and fast-paced workloads, without time for reflection, are also not beneficial for student learning in the clinic.26 If PTs felt less compelled to schedule students at full caseload, they might be able to manage Medicare patients with greater ease by allowing students alternative learning opportunities when PTs are managing their Medicare patients.
Clinicians in these focus groups clearly articulated the challenges related to student CEEs, and although they appreciated the benefits of having students on site, this appears to be tempered by productivity, cost concerns, and challenges surrounding staffing and personnel. More research is needed to identify the benefits of having students at clinical facilities and how this may offset the perceived economic challenges associated with hosting CEEs. As noted by Applebaum et al,27 if a clinical facility hires a student after he or she has finished a CEE there, the facility may recognize a significant cost savings in recruitment expense. Hosting students for CEEs may improve the exchange between clinical practice and academic knowledge and research, thereby elevating the level of clinical practice. A qualitative study using information from Canadian PTs supports the premise that having students at clinical facilities empowered patients and brought fresh perspectives to CIs.28(p229)
Finally, the participants in this study, just as those in a study by Currens and Bithell,29 expressed a need to have their role as clinical education faculty valued in a meaningful way. Participants offered strategies to “compensate” the clinical facility for hosting students as a means to mitigate some of the economic and staffing challenges related to CE. These suggestions included a range of ideas such as monetary compensation, CE opportunities, awarding CE units for being a CI, and offering PTs joint appointments between the academic and clinical settings. Some states are starting to award CE units for CIs who supervise students on CEEs; however, this is not standard within the US. Additionally, some PT education programs have offered tuition vouchers, payment, and/or CE incentives. All of these suggestions need to be explored further, as there are implications about how these factors might affect the quality of the CEE, the cost to the student, and the cost to the PT education program.
The literature indicates that clinical educators have powerful influences on the students that they supervise, which will ultimately impact those students’ professional behaviors and values.30,31 For this reason, students need to have CEEs to prepare them for their professional role, and it is essential that clinical facilities provide students with this opportunity so that the physical therapy profession has a viable, skilled workforce. For this to occur, however, it must be recognized that this process requires a partnership between PT education programs and clinical facilities. Based on the economic forces that have been identified in this study, PT education programs and clinical facilities need to explore, in a systematic manner, the costs and benefits associated with CE, the impact of CE on staff productivity and morale, and how alternative models of CE might be implemented given constraints in third-party payers and staffing patterns. One participant noted the importance for PT education programs and clinical facilities to be partners in this effort by saying, “Partnership—are we really partners? If so, both parties have to be equal and equally committed.”
This study represents views of a limited number of PTs who are from New England. Their experiences might differ from that of PTs in other areas of the country. The data and interpretation might not be generalized to other areas of the country where local clinical and reimbursement practices are different. Also, some of the focus groups were not within the optimal recommendations for focus group numbers of 5 to 12.9 Seventeen of this study's 33 focus groups consisted of 6–12 participants. As stated previously, the numbers of participants was not available prior to discussion groups due to weather conditions and work demands. The investigators decided that information gleaned from all groups was meaningful and, therefore, did not exclude analysis of discussions based on the number of participants in a group. It must be acknowledged, however, that small group size might have limited more robust discussions, and large group size might have limited individual participation.
The investigators developed the focus group format, conducted the focus groups, and also analyzed the data. Although measures were taken, such as discussion of bias and discussion with an outside consultant throughout the process, it must be recognized that personal biases may have influenced the process and the outcomes.
Due to limited time, logistics, and financial resources, focus group discussions were not audio recorded. This may have had a negative impact on data analysis. Best efforts were initiated to capture the information using recorder sheets, designated manual recorders, and member checking of recorder sheets.
Third-party reimbursement structures, constraints on students’ ability to have handson experiences with patients insured by Medicare, staffing patterns, perceived costs associated with supporting CE, and staff “burn-out” were cited as factors that influence decisions about accepting students for CEEs. Updated research is needed to determine the actual economic impact to physical therapy clinical sites when hosting students for CEEs versus the perceived challenges. Additionally, research is needed to identify the tangible benefits to clinical sites and patients of hosting students on CEEs. Furthermore, CIs and CCCEs have expressed the need for greater support and recognition in their role as clinical educators, but it is not entirely clear if there are common ideas about what kinds of support and recognition would be widely accepted. This is another opportunity for greater research. The ability of clinical facilities to accept students for CEEs, and the conditions that they require for these CEEs, has implications on the cost of these programs to PT education programs and students. Clinical facilities and PT education programs need to work together and come to an agreement about how there can be a greater partnership in assuming the responsibility for CE to ensure that it remains sustainable.
The authors would like to acknowledge the contributions of members of the New England Consortium of Academic Coordinators of Clinical Education to this research.
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