Author response: Incorporating students into clinic may be associated with both improved clinical productivity and educational value

We thank Dr. Roy for the comments on our article.¹ As noted, the most striking result of our study was the demonstration of an increase in relative value units (RVU) for preceptors when students were present in clinic. We were similarly surprised at the results, particularly since many neurologists at our institution shared a similar anecdotal perception that students impede productivity. There are few studies on this topic, although similarly students did not appear to affect emergency medicine resident financial productivity (RVU).²

We agree that productivity in relation to preceptor time is an important question. We are currently performing a second analysis to evaluate whether there is increased work after clinic for preceptors when a student is present in clinic.

Each clinic session involved a 4-hour time window. Clinical templates may vary based on the call for “add-on” slots and the acuity needs of their patients at a particular point in time. The template within the Johns Hopkins University neurology department generally slots follow-up patients for 30 minutes and 1 hour for new patients, resulting in a total of 6–8 patients per session. To attempt control for variability in daily clinic schedules (no-show rates, scheduling), preceptors were compared to themselves as controls. Productivity data in this study are limited to academic outpatient clinics and further investigations need to be performed regarding this relationship in an inpatient setting and in nonacademic environments. Of note, our clerkship students are exposed to private practice neurologists working in an ambulatory setting as part of the curriculum, but we did not have access to financial data for private practices to include them in the productivity analysis. When students were afforded the opportunity to provide value-added care and clinical exposure, they were able to have a more positive experience, allowing the preceptor the potential opportunity to see another patient or accomplish other work. However, we were unable to operationalize a method to collect and evaluate these data. As part of the clerkship, students and faculty are given detailed instructions and an inservice from our institution and the clerkship directors regarding student roles, responsibilities, and electronic medical record documentation capabilities. Standard and formalized instructions may have also helped to optimize students' roles as active participants on the clinical team and therefore the results of our study may not be generalizable to other settings.

We share concerns regarding physician burnout. However, involving medical students as a resource in clinic may help to address this by improving preceptor financial productivity, rather than worsen it. Furthermore, new Centers for Medicare and Medicaid Services 2018 criteria allowing student documentation to be used by preceptors provides exciting new pathways to optimizing the productivity potential of having students in clinic.³