Annie Rutter, MD, leads a discussion at a recent Preceptor Expansion Oversight Committee meeting

Initiative creates efficiencies and incentives
for preceptors

An interview with Preceptor Expansion Initiative chair, Annie Rutter, MD

By Mary Theobald, MBA, Vice President, Society of Teachers of Family Medicine

Mary Theobald: Tell us a little about yourself.
Annie Rutter: My name is Annie Rutter and I’m a family doc and I work in upstate New York where I’m the clerkship director for family medicine. That’s what I do as my day job. I’ve also been working with STFM on a couple of different initiatives — most recently with the Preceptor Expansion Initiative.

What’s the Preceptor Expansion Initiative?
So, this is an interdisciplinary approach to increase the pool of community-based preceptors. When we look at where most physicians practice after they graduate from residency, it’s in community settings. Right now, most of our medical education takes place in tertiary medical centers. We don’t have enough sites for students to train in community settings. So this initiative was taken on by multiple organizations, with the Society of Teachers of Family Medicine as the leader, to gain insight and to increase the number of physicians, nurse practitioners, and physician assistants in the community providing ambulatory education.

Why is there a shortage of community-based preceptors?
There are a lot of demands put on community physicians day to day. Sometimes, they’re not able to — or they don’t feel like they’re able to — take on students. This initiative will help them get rewarded for their work and also help them realize that this is work they can do.

There are also more medical schools — both MD and DO — in the United States and in the Caribbean and other parts of the world that are using the United States physicians as community faculty. And then certainly the demand increases when you add in other health professions who rely on community-based preceptors to teach the skills they need in an ambulatory setting.

What about the fact that an increasing number of community physicians are employed rather than solo practitioners?
Yeah, I mean that’s part of the hypothesis. There’s certainly a trend across the United States for more and more community-based and private practices to be part of bigger hospital or health care systems — to be employed. That comes with competing demands, created by systems or just the health care system more broadly. Where solo practitioners were making the decisions about whether or not they could or wanted to take a student, that decision is now sometimes taken out of their hands and raised up to the systems level. And when compensation is based on productivity, and there’s a perception that a student slows you down, then it’s certainly viewed as a burden to teach. That can be a huge barrier to getting students into community settings.

You’ve noted that clinical practices have a lot on their plates. Isn’t taking on a student going to add more to that already full plate?
If we train our students well before they get into the clinical setting, they can be a huge asset to a practice. Students can do a lot more than what many think they can do. Students can help with quality improvement projects and other practice-based initiatives. With the new CMS documentation changes, students can document patient visits. The preceptor, who of course has to see the patient and repeat the pertinent parts of the physical and the history, can confirm what the student wrote. The tedious task of re-typing doesn’t have to take place any more.

I think many of us, because of how we were trained, think students need to work one-on-one with a doctor and that students need to see every patient that comes in the door. If a student only sees several patients in a day and does the full visit from start to finish, including all the follow-up — the documentation, all of those pieces — they’ll learn what it’s like to take care of patients. Students aren’t as efficient as trained attending faculty physicians, so they’re not expected to do that same workload.

The reality is that students get a lot out of varied experiences in a practice — spending time with different types of providers, like pharmacists, medical assistants, case managers, nurse practitioners, physician assistants, all sorts of folks who are part of the care team. There’s value in learning from all health care team members.

Will the Preceptor Expansion Initiative help students be better prepared for clinical rotations?
Yeah, so there are a couple of things that this project is specifically focusing on. One of them is standardized onboarding of students, and this takes on a couple of facets. One is the logistics of onboarding: Does the student have a login to your EMR? Does the student have all of the proper HIPAA and other training and paperwork so he can contribute and begin learning right away?

The second piece of that onboarding is making sure the preceptor knows what the student has already learned, such as documentation skills, physical exam skills, history taking, and maybe even specific procedures. So, again, when student comes in on day one, the preceptor can utilize the student’s skills for improved and efficient patient care. And so those two pieces, the logistics and the clinical preparation, will help ease the transition of students into clinical settings.

I would say the other thing the Preceptor Expansion Initiative is working on is figuring out efficient workflows for when there are multiple learners in an environment. So, for example, if a practice was able to host a medical student and a pharmacy student, the practice could use the workflow models to get ideas on how to incorporate both types of students — who have different skill sets — into one clinical practice setting to provide value for the patients, the preceptor, and the students.

What are some of the positive things you hear from preceptors?
Some of the most positive feedback I get is related to giving back to the profession. A lot of preceptors say, “You know, I take students because someone took me and taught me how to do this.” They enjoy getting to know the students and sharing their wisdom — not just clinical wisdom, which is important, but also mentorship. Things like how to decide where to go for residency, work life balance, etcetera. Preceptors can share what it’s like working in private practice or working for a hospital system or doing procedures in the office. I think sharing this knowledge is one of the things preceptors really enjoy. The other thing so many preceptors tell me is that students teach them a lot.

What if a physician wants to precept, but no one has ever asked?
So there’s a lot of different ways to get involved. One of the first ways is to talk to your state chapter. Many of the Academy chapters can connect preceptors with medical schools. Or, if you have a medical school in your community, reach out directly to the Department of Family Medicine or to their office of medical education.

What if someone wants to precept and there are policies within their practice or system that won’t allow them to do that? Any suggestions for advocating for change?
I think one way is to have a good relationship with your administration, whether that’s your practice manager or a larger hospital systems director, and to talk to them directly. Systems need physicians, so hopefully they’ll want to keep you happy. Another avenue is to connect with other providers who might be interested in teaching. Band together and talk to your administration. And still another way might be go ahead and contact a medical school, because some of the folks there may be able to build a bridge with the administration at your health system to negotiate how this might work and to dispel myths.

Some people think a commitment means they need to take a medical student every day for the entire academic year. Many schools are able to negotiate it so a preceptor works with students part of the time — maybe at certain times of the year or when the demand is great. There are a lot of different models out there. It’s important to explore those options before closing the door.

Is there anything else you think we should talk about?
I sometimes hear that family docs don’t teach because they’re not sure they’d be a good teacher. Faculty development is a requirement for medical schools, and that includes community-based faculty. Schools work with community-based faculty to get them prepared to have students in their offices by teaching them what is expected and also providing tips on effective teaching. Community based physicians are extremely smart. They’re taking care of patients, they’re working hard every day, and they have a lot of wisdom to share with students about the day-to-day clinical presentations of patients.