The American Board of Family Medicine recently released the results of its 2020 National Family Medicine Graduate Survey. This is an annual survey of family physicians three years out of residency. The 2020 data included responses to a new question: "Do you currently work in a practice or for an organization where you completed a clerkship or another part of your training during medical school?" Nearly 1 in 5, 19%, responded yes. This data suggests that the undergraduate medical experience influences the selection of future practice settings of family physicians.
However, medical schools continue to struggle to find enough clinical training sites for their medical students. A 2013 survey by the Association of American Medical Colleges found that 47% of allopathic family medicine clerkship directors were having difficulty finding core clinical training sites. A 2019 AAMC survey of deans at U.S. M.D.-granting schools illustrates that the problem persists. A majority of respondents expressed concern about the number of clinical training sites (84%) and the supply of qualified primary-care preceptors (86%).
The shortage of clinical training sites is multifactorial. One contributing factor is likely the increasing number of physicians who are employed by health systems. In 2020, 50.2% of physicians were employed, up from 47.4% in 2018 and 41.8% in 2012. Primary care is especially affected by this trend, as 49.6% of general internists, 58.3% of family physicians and 57.6% of pediatricians are employed. Younger physicians are more likely than older physicians to be employed.
The majority of employed physicians have a "physician scorecard," which is intended to track their adherence to both quality metrics and performance benchmarks—most notably their accumulated work relative value units (wRVUs)—that directly influence their total earned compensation. A physician scorecard can also track patient experience satisfaction scores, specialty referral patterns, and Medicare hierarchical categorical coding and risk adjustment factor scores.
At our medical school, employed physicians are telling primary-care clerkship coordinators that they cannot possibly pay attention to these issues to preserve or enhance their earned compensation AND precept/teach medical students. We have resorted to placing first- and second-year medical students, during their half-day longitudinal clinical experience, with specialty physicians, which undermines their primary-care learning objectives.
Why put this issue front and center? Because if we don't confront this growing clinical teaching challenge, we will not be able to model family medicine and mentor students in a way that will help them make a career choice to meet the growing national need for a robust, expanded, well-trained primary-care workforce. The number of medical students is increasing at the same time that the bandwidth to teach is decreasing, resulting in a problem that can't be ignored. Efforts by organizations such as the Society of Teachers of Family Medicine to better prepare students to add value to practices during their clinical rotations have to be supplemented with teaching incentives from health systems.
The results of the ABFM survey demonstrate that undergraduate primary-care ambulatory precepting/teaching is a viable pipeline for future employment.
We need to engage in meaningful dialogue with health insurers, hospital systems, and other large corporate physician employer groups to help them understand that policies to support undergraduate medical student teaching are a win-win-win arrangement for our national primary-care workforce goals, our students, and employer organizations. Whether it be wRVU credits to permit a reduced patient workload on precepting days or other adjustments to acknowledge the value of precepting/teaching to the organization, accommodations need to be integrated into the culture and financial structure.
A national survey of or a focus group with large physician and advanced practice clinician employer groups is a necessary step toward understanding the depth and breadth of this issue as a prelude to meaningful change.