The Crisis of Clinical Education for Physicians in Training

A significant challenge for medical schools in the United States is the clinical education of medical students after the largely didactic, and typically two years of pre-clinical education occur. Current trends in healthcare and educational processes have had a direct impact on medical education including 3^rd year clerkship training. The number of allopathic medical students enrolled in the first year class has increased by 29% since the year 2002–2003, with over half of the growth occurring due to increases in class size of existing schools. This produces a cohort of over 21,000 allopathic medical students who require clinical education yearly. In 2016 over half of the MD schools surveyed mentioned the clinical training of students from other health care professional schools as a source of decreased availability of clerkship training spots for medical students, as compared to approximately 25% of schools reporting this in 2009.¹ In 2002–2003, there were 3,079 first-year osteopathic medical students. This number has increased in 2017–2018, in which 8,088 first-year students were enrolled.² Osteopathic growth is due to increases in class size as well as new school development. Combined osteopathic and allopathic first-year medical student enrollment has increased by 50% since 2002–2003, with almost 28,000 students per year entering medical school.

Although the number of osteopathic and allopathic medical students requiring clerkship spots has increased, there has not been a commensurate increase in the number of clerkship spots nor has there been an increase in clinical preceptors. There are several additional factors which compound this challenge. Many community-based hospitals have closed, or been acquired by larger organizations, decreasing the available hospital based rotations for students. Preceptors who have historically provided clinical education are retiring, and many preceptors are joining practices that limit medical students, or don’t permit students at all.

Another source of additional competition for clerkship spots not included above is offshore medical schools with for-profit models. They often purchase large blocks of clinical clerkship spots in U.S. hospital systems.³ When these partnerships are established with hospitals or health systems, there may be an ensuing shift of remaining clerkship availability toward outpatient sites. These typically require more sites in order to accomplish training. This has the resultant consequence of causing some medical schools to pursue new clinical or clerkship core sites, often extending outside of the desired geographic home region of the medical school.

Additionally, widespread occurrences of hospital and health system mergers have had a negative impact on current and potential clinical sites often due to a lack of experience with clinical education on the part of the parent acquiring body. There has also been a notable shift to increase ambulatory health care. This shift includes outpatient surgeries as well as pre- and postoperative care, and overall shorter hospital stays. This shift directly impacts educational opportunities and preceptor capacity.^{3, 4}

The transition of the physician workforce away from private or physician-owned practice settings to a hospital or health system employed scenario further contributes to preceptor shortages. The complexities of opening and maintaining a medical practice has been a driving force of this transition. There has also been a shift away from the concept or mentality of teaching the next generation as being a duty and privilege.³ With large system and industry driven concerns, the focus often becomes a concern that teaching students in clinical education results in a loss of productivity. This is frequently combined with an expectation of monetary reimbursement (or increased incentives where payment is already taking place) on the part of the hospital, health system, and even individual preceptors, clearly impacting retention and recruitment.

In addition to the roughly 28,000 medical students mentioned above in need of clinical training, other allied health professionals such as Physician Assistant students and Advanced Practice Nurse students, often compete for the same clinical experience in the same training spots.³ Some potential preceptors hesitate to participate due to concern for their ability to contribute to education while maintaining operational efficiency and high quality of care. One factor which makes precepting of students more challenging is the existence of so many different, non-communicating electronic health record systems. This is especially true during the first few months of clinical education, when the learner’s exposure to electronic medical records may be nil to minimal. Preceptors and health systems have to decide between taking the time to train a new learner on their EMR system, taking the time to review, edit and augment the students’ notes, or just not let the students document in the system. Even after training on one system, another office/hospital may have different systems with different complexities.

While these challenges did not develop overnight, and a simple, quick, fix-all solution has not yet been identified, there are some learning opportunities that may lessen the burden of the clinical education crisis. Although the use of simulation and virtual reality has been present for some time in medical education, their use has yet to be fully optimized. Simulation based education has in some models demonstrated advantages over the more traditional, but less available approach to clinical education. As it relates to certain skill sets such as advanced cardiac life support, laparoscopic surgery, cardiac auscultation, hemodialysis and central venous catheter insertions, and thoracentesis, simulation offers significant opportunity to create proficiency and improve safety when performing these procedures.⁵ In general, a preceptor is more likely to take learners in their clinic if the learner has already practiced or even demonstrated competency with basic procedures in a virtual setting or on a human patient simulator.

One suggested solution to address offshore schools purchasing and using needed clinical sites includes restricting approval for federal loan programs to medical schools who have met COCA or LCME accreditation standards. There is also support for adding the expectation or requirement that these institutions have accountability to graduate medical education (GME) reporting and contribution to development.³ One less exclusionary approach to the issue of competition for clinical education slots could be considering global educational exchange opportunities,⁴ and taking advantage of existing interprofessional education (IPE) opportunities rather than directly competing with other healthcare learners for training and preceptors.

The implementation of standardized preceptor development measures may help address concerns related to efficiency, productivity, and quality of care. While many teaching models exist in the clinical setting, the One Minute Preceptor (OMP) is a clinical teaching strategy that has shown measurable improvement in medical student skills, abilities, and knowledge base as well as teaching performance from the preceptors.⁶ Robust and consistent curriculum development by medical schools, creating preceptor manuals, consistent use of online modules for students, and self-directed learning strategies may prove useful as the preceptor’s energy can be focused on clinical training and facilitating the student’s learning. Improved preceptor recognition efforts, library access and support, and additional CME offerings can be helpful measures as well. Transitioning medical students to clerkship with consistent clinical readiness and recognized professionalism standards would lessen the burden on the preceptors.

While beyond the scope of this article, the topic of Graduate Medical Education must be addressed as it is an equally challenging issue influencing the future of the medical profession. Although not always the case, the transition of medical students from clinical education into residency would be a seamless continuum. With the implementation of a single GME accreditation system, an increasing number of medical students will be in direct competition for the available residency training spots. With the given transitions and changes surrounding the health care system, challenges facing GME parallel many of those in clinical education. In fact, major restructuring of the GME system may be in order to better coexist with healthcare transformation.⁷ The anticipated shortage of primary care physicians is another topic directly related to clinical education. The growth in non-primary care GME positions is much greater than primary care growth, and steps such as redirecting funding towards development of primary care positions have been mentioned as potential corrective measures.⁷ As nurse practitioners and physician assistants increasingly provide the health care once delivered solely by primary care physicians, then the primary care GME needs become less critical.⁸ A trend that concerns many medical students regarding post-residency opportunities and may ultimately influence the path they take during their clinical education experiences.⁹ This poses a challenge given the extent of the projected primary care physician shortage. Perhaps a focus during both clinical education and residency on primary care physicians serving as supervisors of interprofessional teams, and expert clinical educators could lessen the burden since these roles will always exist for primary care physicians.⁹ Using evidence of best practices and needs-analyses, models can be created to influence resident distribution in the US, creating allocation proposals of GME position growth and distribution. This can serve as an initial point of focus for decision makers when deliberating about post-graduate training of phsyicians.⁸

There is no easy solution for the many challenges facing clinical education for physicians in training, and what may work for one medical school may not work for another, depending on factors such as geographical region, class size, and the established preceptor network. Some of the burden may be lessened by requiring all medical schools to allocate part of their resources to preceptor development as well as planning for increased capacity. This is especially critical if the medical school is requesting an increase in class size from their accreditation bodies. Although this is done to some extent, heightening scrutiny on this process, as well as mandating evidence of clerkship capacity increases, can help medical schools thoughtfully increase their class size. A reduction in the number of U.S. based clinical training spots used for offshore schools may help some medical schools place students in clinical training environments especially if these institutions cannot compete with private, for profit entities who can afford to “purchase” clinical rotation spots. Giving preceptors well trained students who will enhance clinical services for patients, both in the office and hospital can also be addressed through additional and improved pre-clinical coursework focused on systems-based practice and patient-centered care. Additionally, a systematic approach to addressing the competitive challenges of clinical education training site distribution can create opportunities for national and international interprofessional collaborative clinical education. It is clear, that a multifaceted approach is needed to address the crisis of clinical education of our future physicians.