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    So many medical students, so few clerkship sites

    Hands-on clinical experience is essential to producing future physicians. But some schools have been struggling to find enough clerkship sites and preceptors. Now, COVID-19 has only worsened their worries. We look at the problem — and possible solutions.

    Two medical students confer in a room

    For Catherine Houle, MD, training medical students during their clinical rotations at West River Health Services in New England, North Dakota, isn’t just part of her job. It’s a moral imperative.

    “I’m involved because that’s what you do. Someone taught me. So now I’ve got to teach, too,” she says.

    Houle and other practitioners who take the time to teach are central to the medical school model in which future physicians learn from experienced providers during clinical clerkships. These hands-on experiences — generally lasting four to eight weeks — are where students practice physical exams, decision-making, patient communication, and other essential skills.

    But in recent years, finding such instructors and clerkship sites has grown tough for some medical schools — and the global pandemic has only complicated matters.

    Over the past decade, much of clinical education has shifted from inpatient to outpatient settings. That means schools can’t rely as much on the full-time faculty who typically supervise trainees in teaching hospitals. Instead, they need additional preceptors such as those in community practices — people who teach largely because they love doing it and usually receive little or no payment.

    As demand has grown, so has schools’ concern about shortages of sites willing to host students and qualified preceptors able to mentor them.

    “[This] is a national problem,” says Marc Basson, MD, PhD, MBA, senior associate dean for medicine and research at the University of North Dakota School of Medicine and Health Sciences.

    Basson is not alone in his assessment. According to a new AAMC (Association of American Medical Colleges) report, 84% of medical school deans were concerned about the number of clerkship sites even before the pandemic. More than 70% of surveyed deans worried about having enough qualified specialty preceptors, and the response jumped to 87% for primary care preceptors.

    "Every school is preparing for the possibility that they will experience challenges moving forward. Unpredictability is the name of the game with COVID-19.”

    Katherine McOwen
    AAMC senior director of educational affairs

    During the pandemic, schools in hard-hit regions have faced additional challenges in locating sites, and those who haven’t struggled are looking ahead.

    "Every school is preparing for the possibility that they will experience challenges moving forward,” says Katherine McOwen, AAMC senior director of educational affairs. “Unpredictability is the name of the game with COVID-19.”

    Meanwhile, educators continue to work hard to identify possible solutions. “This problem cannot go unsolved,” notes AAMC Chief Medical Education Officer Alison Whelan, MD. “Core clerkships are a required part of education.”

    So, how are medical schools going to provide this essential training to tomorrow’s doctors?

    Unpacking the issue

    Those involved say several factors fuel the struggle to find sites and preceptors. These include:

    Consolidation of facilities. “In the last 10 to 20 years, there’s been a [movement toward] larger practices and conglomerates,” says Mary Ann Forciea, MD, a clinical professor of geriatrics at the Perelman School of Medicine at the University of Pennsylvania.

    “The trend curtails the physician’s ability to say, ‘I’m going to donate 25% of my time in this four-hour session to teaching,’” notes Forciea, who helped draft recommendations on the clerkship issue to the Health Resources and Services Administration at the U.S. Department of Health and Human Services, which is tasked in part with fostering a skilled health workforce. In fact, doctors might have to meet billing targets that make teaching a near impossibility. “It’s no longer really the decision of the physician,” says Forciea.

    Financial worries caused by COVID-19 have only heightened this aspect of the problem, McOwen notes. “People are laying off or furloughing staff. They are making decisions for their institution’s survival.”

    Growing medical school enrollment. In 2006, the AAMC called for medical schools to increase first-year enrollment by 30% to alleviate anticipated physician shortages. Schools responded. Between 2002 and 2019, enrollment in U.S. medical schools grew by 33%. When combined with DO-granting institutions, total enrollment was 52% higher in 2019 than in 2002.

    Rising demand for clinical sites for other health professions students. It’s not just would-be physicians who need clinical placements. Physician assistants, nurses, and students in other health professions are increasingly looking for hands-on training, too. Experts note that this reflects a shift in health education from lecture-based learning to more experiential opportunities to better develop hands-on skills, real-world problem-solving, and interprofessional teamwork.

    “We are increasingly looking for more time in the curriculum in which students are at clinical sites,” Basson says. “They all need to get trained somewhere” and that can lead to shortages.

    Competition from offshore schools. Another piece of the puzzle is competition for slots from offshore medical schools that pay to place their students.

    Whelan explains that many offshore medical schools in the Caribbean can’t offer core clinical experiences where they're located, so they instead rely on training sites within the United States. “[This] is an area of high concern to many U.S. medical schools,” she says.

    Although most U.S. medical schools don't pay community physicians or clinics to train clerkship students, the AAMC survey of deans found that 44% of respondents felt moderate to severe pressure to do so.

    Potential solutions

    Experts struggling with the issue have been working to craft potential solutions, and schools are trying out various approaches. Some options include:

    Developing new sites. Some medical schools are looking farther afield for possible clerkship sites, such as helping establish ones in community-based health centers. The AAMC survey indicated that 74% of schools had expanded their radius when searching for sites before the pandemic.

    This approach has worked in North Dakota, says Basson, as staffing rural hospitals is notoriously difficult. “Some of the hospitals in the state are interested in having us send students because that’s a recruitment tool," he explains.

    Forciea points to two other ways schools are trying to increase the number of clerkship sites: reaching out to alumni and providing educational support to clerkship sites that help make training students easier.

    Deploying technology. Simulation and telehealth technologies can help by offering alternative and remote access to educational experiences. The pandemic has shown that some remote learning — watching a physician perform a procedure via webcam, for example — can work well.

    Still, experts note that online options are not a complete substitute for hands-on learning. “Sometimes you have to be standing with someone who’s experienced to show you,” says Houle.

    Increasing collaboration. As competition grows for clinical placement sites, collaboration across health professions becomes imperative, say experts. “We try to coordinate rather than compete” with nursing and physician assistant programs, Basson says. His school might suggest that a proctor work with both a nursing student and a medical student simultaneously, for example. That’s positive, he adds, because interdisciplinary training also bolsters collaborative, team-based learning.

    In New York, during the height of the pandemic there, medical schools collaborated as well. “They all got together and tried to help each other find sites rather than competing,” says McOwen.

    Offering tax incentives. Several states have passed bills that offer tax credits to physician preceptors who meet certain criteria. In Maryland, for example, a qualifying physician could receive a tax credit of $1,000 for each student up to a maximum of $10,000. Other states taking this approach include Hawaii, Ohio, and Georgia.

    Lightening the load. In 2016, the Society of Teachers of Family Medicine (STFM) held a summit to address shortages of training sites, and two of the five tactics it crafted focused on lightening the burden associated with preceptorship. One was to advocate that the Centers for Medicare & Medicaid Services (CMS) change requirements that curtailed students’ ability to document patient visits. Members were delighted when the CMS adopted revisions in 2018, notes STFM Chief of Strategy and Innovation Mary Theobald, MBA.

    The other recommendation was to develop standardized onboarding processes for students. “Medical students can be a helpful part of the workflow,” says Theobald, but she notes that they have to be integrated — and quickly. Among the materials the group created to further this goal were pre-clerkship training modules and a primer for students describing ways to hit the ground running.

    During the pandemic, one way that some schools have been helping to place students in training sites is by providing personal protective equipment (PPE) for them rather than asking sites to do so.

    Awarding CME credits to preceptors. Providing preceptors with continuing medical education (CME) credits for teaching prep is another strategy for enticing physicians to do the work. For example, the American Board of Family Medicine offers up to 50% of the credits required for certification to those who teach medical students. Other groups have taken similar approaches.

    Saying thanks. No matter how personally fulfilling teaching might be, it’s an added responsibility that preceptors pile on top of already busy days. So, Basson emphasizes the need to show appreciation. “We give preceptors rewards after 5, 10, 15 years of service. It might be a pen, a plaque, a sweatshirt,” he explains. It’s just “a simple way of saying thank you that turns out to be really important.”

    Providing other privileges and perks. Forciea says that some schools are extending other perks, such as digital library privileges and access to journals that usually would be reserved for faculty members. Some schools also offer specialized conferences for preceptors, she adds. Plus, “a lot of schools have experimented with titles that show a teaching role that can be put on business cards and advertisements for the practice,” she explains.

    The road ahead

    As they look forward, experts worry that COVID-19 issues — such as the need to conserve PPE and limit the number of people in clinics — will continue to exacerbate existing clerkship concerns.

    “The pandemic has increased concerns about sites, and its effects will continue after it ends. For one, there’s the financial issue. When a community hospital or clinic closes, everything that goes along with it stops, including the clinical instruction that happens there,” says McOwen.

    “There will not be a single solution to the problem of sites because it is complex and multifactorial,” says Whelan. “But to train an effective future health care work force, academic medicine must commit to finding solutions.”

    Basson emphasizes the need to attract and retain dedicated preceptors. “I’m grateful for the loyalty of our preceptors who are willing to stick with us," he says. "We work very hard at maintaining that.”

    “To train an effective future health care work force, academic medicine must commit to finding solutions.”

    Alison Whelan, MD
    AAMC chief medical education officer

    And those who do the work note that they also clearly benefit from it. Working with future doctors keeps mentoring physicians thinking critically about how to provide the best care possible. “Teaching residents and students makes you a better clinician,” Houle says. “They’re going to ask ‘why,’ and you have to be on your toes.”

    Houle encourages other physicians to consider becoming preceptors. “I wouldn’t want to do this job if I couldn’t do the teaching,” she says. “I can’t emphasize how rewarding this is when I watch the light bulb come on and see a student realize something. It’s hard but it’s fun.”