Preceptorships on Idle: An Analysis of Pre-Doctoral Osteopathic Education

By Ron Russ, DO, FACOFP

ABSTRACT: The traditional model of pre-doctoral osteopathic medical education is undergoing a tremendous transformation. With the projected increase in students and a decline in preceptor resources and availability, we must seek alternative methods of training to maintain survivability. These include compensation for preceptors, focusing on educational quality over service-oriented rotations, and future osteopathic medical colleges having the forethought to plan where their students will rotate for the third and fourth years of training. If our educational challenges are not addressed now, we will need hundreds of new preceptors in each specialty to fill our future students’ needs.

The traditional models of osteopathic medical student teaching begin with the first two years of training taking place at a college of osteopathic medicine (COM) where academic faculty facilitate learning experiences for the students, using mostly lectures and small group activities. During years three and four, the students spend time with physician preceptors, either on hospital-based rotations or in the private office setting. Most of this third- and fourth-year instruction is performed on a voluntary basis, with the community preceptor receiving no financial compensation, but earning continuing medical education credit and faculty privileges from the osteopathic medical colleges.

As our health care system has changed over the years and as the medical colleges train students who have had more case-based learning and early clinical exposure, the demands placed on preceptors have increased. Not only are there more paperwork requirements such as affiliation agreements, educational agreements, course objectives, and pre- and post-rotational examinations, there are more stringent time requirements as well. There is an expectation of greater educational value for these preceptor rotations.

All the while the physician preceptor continues to balance these new demands of an active educator, with the challenges of personal/family requirements, greater patient volumes and declining reimbursement. As time progresses we are seeing more and more preceptors declining osteopathic medical students for rotations, citing reasons such as lack of financial compensation, being “overworked and stressed out”, and having exclusive agreements with other medical colleges and health systems. The purpose of this article is to examine the history, current trends, and possible future solutions to the challenges facing osteopathic preceptorship in the context of declining numbers of attending physicians willing to precept and increasing numbers of osteopathic medical students who need to be trained.

Past
Since the advent of osteopathic medicine in 1874, osteopathic physician trainees have learned most of their clinical skills through work with a precepting physician in the geographic region of their training institution. Dr. A.T. Still, the founder of osteopathy, was “apprenticed” as a physician and served in the U.S. Army during the Civil War, precepting other physician trainees on the battlefield. This was the accepted method of training students in the early days of osteopathic medicine. Some of this apprentice-based practice has continued today.

As stated in the Flexner report of 1910, “the student…will then possess two sets of facts: one in a way indirectly obtained, through microscopic or other study of excretions, secretions, tissues, etc.; the other set procured directly at the bedside. He must learn the art of combining them; he must see them together as the total picture of the situation with which he is called on to deal.”1 At the time of this report osteopathic medicine was considered an “alternative medicine” field, with only four osteopathic medical colleges in operation: Kirskville College of Osteopathic Medicine (1892), Des Moines University College of Osteopathic Medicine (1898), Philadelphia College of Osteopathic Medicine (1898), and Midwestern University Chicago College of Osteopathic Medicine (1900). These schools, as with many allopathic institutions, were in danger of closing as a result of the report’s findings.

At the time, the newly formed American Osteopathic Association (AOA) was able to bring the osteopathic medical school teaching into compliance with Flexner's recommendations. As a result, osteopathic medical schools changed the balance of their teaching to an evidence-based, scientific knowledge base. The convergence of classroom and hospital training in osteopathic instruction demonstrated the sweeping effect the Flexner report had, not only in the closure of inadequate schools, but also in the standardization of the curricula of surviving schools. This includes the use of precepting physicians
to complete the medical student training.

With the establishment and growth of osteopathic medical colleges throughout the last century, the clinical and practical training model has undergone many changes and modifications. Accompanying the curricular changes has been the trend toward opening schools that are independently functioning and privately funded. Only six of the current 28 osteopathic medical school campuses are public institutions, and these all originated between 1969 and 1976. (Figure 1 ) The public schools have specific limitations and governance regulations as dictated by the state in which they exist, such as class size restrictions and accountability to their respective parent university.

To the public COM’s benefit, they have the access and resources of a larger academic center with dedicated teaching faculty and research facilities. The private COMs generally do not have such limitations placed on them by their state government or sponsoring institution, and have the ability to change class size, tuition, or curricula based on a more flexible administrative model. However, these colleges lack the resources of a more stable academic center and are forced to either build training facilities or utilize those already established in their clinical and academic communities. As discussed later in this paper, herein lies one of the problems that COMs will face as class size increases and there is a new demand for preceptors.

Present
For the 2007-2008 academic year, the Commission on Osteopathic College Accreditation (COCA) approved first-year class size totals 4,290 students (3,409 [79 percent] private; 881 [21 percent] public).2 Assuming a 96 percent graduation rate, which has remained constant over the past six years, there will be 4,118 new osteopathic physicians graduating in 2011.2 For the years 2009-2011 the third- and fourth-year student physicians will be on clinical rotations with preceptors in the hospital or private office setting.

To truly understand the impact these students will have, assume this scenario: every one of the 4,118 third-year medical students must complete one month in a family medicine office and that the preceptor will only have one student at a time. This means that if a preceptor had a student every month of the year, there would be a need for 343 osteopathic family medicine preceptors. A more likely time course is that a preceptor only has a student 10, eight, or six months of the year. This means the need would be 412, 517, or 686 preceptors respectively. Currently there are only 450 registered preceptors in the ACOFP directory.3

This scenario does not include preceptors that may take more than one student at a time, or those preceptors who are not registered with the ACOFP. It also does not take into account those offices with multiple preceptors who only take one student at a time nor does it include those physicians who only have students for one to two months of the year. It does not have provisions for fourth-year students, who at the same time are trying to fulfill a second month rotation of family medicine or obtain a rotation for residency selection. The example is not meant to be an in-depth review of preceptor usage, but serves as a cursory example to demonstrate that we already have a lean preceptor base, upon which we expect to place more demands in the future.

One large demand is the initiative by the osteopathic medical colleges to increase enrollment and graduate more physicians. Results of the 2007 AACOM Survey of Osteopathic College Growth Plans and Issues reveals that first-year enrollment is projected to increase to 5,277 from the current 4,290 by the 2012-2013 academic year, an increase of 987 students (22 percent).2

Using the example in the previous paragraph, these 5,277 third-year osteopathic medical students will need 440, 527, 660, and 880 preceptors for the 12, 10, 8, and 6 month training cycles, respectively.

Current trends in registered ACOFP preceptors will not likely change significantly enough by this time frame to effectively keep pace with the new demand. All 13 of the COMs reporting planned growth acknowledged this issue and indicated that they would either “definitely” or “probably” attempt to increase clinical affiliations.2 Even among the COMs that did not plan growth, 50 percent commented that they had concerns regarding the availability of clinical training sites for their existing student pool.2

The increase in COM enrollment is largely in response to multiple studies that predict a shortage of practicing physicians by the year 2020. The Department of Health and Human Services predicts a shortfall of 55,000 physicians by this time, largely in the areas that deal with the aged and underserved populations.8 Since 2002, there have been 15 state studies of current or future physician workforce need.

In nearly all of these studies, the same populations were most likely to be affected, the aged and underserved, and each state recognized the problems in population geography and need. A 2004 study done in California predicts that there will be a 15.9 percent shortage in physician supply in the year 2015.9 With 60 percent of the current physicians practicing in only 5 of 58 counties, the California Board of Regents has approved the establishment of a new allopathic medical school at the University of California at Riverside. Florida predicts a 124 percent growth of the aged population by 2030 and has approved the opening of two new medical colleges. Texas has seen a 50 percent increase in population with a static medical school graduation rate.9 The Governor of Texas has approved legislation for a new allopathic school at Texas Tech.

Osteopathically, there are five new medical colleges that are waiting to graduate their first class of physicians. The Andrew Taylor Still University - School of Osteopathic Medicine in Arizona, Lincoln Memorial University - DeBusk College of Osteopathic Medicine in Tennessee, and Touro College of Osteopathic Medicine in New York will each graduate their first class in 2009.

Students at the Rocky Vista University College of Osteopathic Medicine in Colorado will matriculate in 2010, and those at the Pacific Northwest University of Health Sciences – College of Osteopathic Medicine in Washington will matriculate in 2011. It is exciting to see more medical schools, both osteopathic and allopathic, but until these physicians graduate from residencies and begin to serve as preceptors, there still looms a shortage of facilitators and clinical rotation sites.

A second demand is the tightening business of running a medical practice. It has become more difficult to find a solo practicing physician who has not joined a larger physician group or institution-based practice for contracting and negotiating purposes.4 These physicians often feel that they do not have extra time during the day to spend overseeing and teaching medical students. They have to see more patients in the same or less time period to make the same reimbursement as in previous years.

With proposed Medicare cuts over the next few years, many physicians will be redefining how they manage their time throughout the day.4 Faced with a choice of seeing four to five extra patients per day for reimbursement or teaching medical students, the choice for most will be monetarily-based. The “extra” one to two minutes between patient encounters is a great teachable moment in which the preceptors can pass on “pearls” of education for the learner. With these precious minutes growing scarce, there is no leeway for teaching moments and therefore a lost opportunity; the learner loses a valuable educational opportunity and the educator loses his/her teaching skills.

Current Centers for Medicare and Medicaid Services (CMS) guidelines provide reimbursement for resident physicians in the office.4 As compared to medical students, residents are more experienced trainees and are able to see patients with greater speed and skill, potentially leading preceptors to favor taking resident physicians for rotations over medical students. Questions are raised, such as, how long before CMS or COCA require reimbursement for medical students on rotations, and what financial impacts will this have on the COMs? The fear is that these additional costs will be transferred to the students themselves, which places them further in debt, and more likely to focus future efforts on financial gain rather than fostering education.

Future
What can we do to ensure the training of our osteopathic medical students? As outlined in the previous paragraphs, increasing numbers of trainees, increasing paperwork demands by COCA and the COMs, and a decrease in preceptor reimbursement are just some of the challenges osteopathic medical education will face in the years to come. How we prepare for these challenges and how we adapt to the dynamic guidelines imposed is crucial for the sustainability of our osteopathic training programs. The first stage of change must begin with the medical colleges themselves.

There are some novel medical school curricula currently in place, such as a three-year Primary Care Scholars Pathway at the Lake Erie College of Osteopathic Medicine (LECOM), and the early clinical exposures for second-year medical students at Andrew Taylor Still University School of Osteopathic Medicine in Arizona (ATSU-SOMA). These programs are giving early exposure to medical students in real-world clinical examples of situations that they will encounter in their future careers in a time-efficient manner. The three-year program at LECOM condenses the first two years of academic based learning into 20 months and saves those students one year of student loans and school costs (currently $53,700 for one year).5

This also allows the graduate to enter into an income generating practice one year earlier than traditional curricula would normally allow. The ATSU-SOMA program releases second-year medical students into clinical rotations, rather than concentrating on classroom and lecture based teaching during this year. The goal is to produce osteopathic physicians that understand current practice dynamics and can adapt to future changes in healthcare.

Both schools are trying to cater to the millennial generation of learners who question why they should sit in a classroom and be taught from a power point lecture or small group, when they can be out in the clinical setting experiencing the topic, then on their own time use various forms of technology to enrich their learning. These novel methods of how we think about learning may translate in the future to other specialties. For example, orthopedic-interested trainees may take only one to two years of anatomy and physiology training before starting a residency in orthopedic surgery.

Why should an “orthopedic-focused student” go through and pay for, four years of medical school training, learning cardiology, gynecology, and pediatrics, when this person may never utilize these skills again in providing patient care. These two pathways are just two examples of how the academic world might adapt to address current challenges and demands.

With these curricular changes, the osteopathic medical colleges must identify and maintain training site affiliations which meet the needs of their student population. This includes hospital-based and office-based rotations. The colleges need to be sensitive to the preceptor and hospital needs through financial compensation and Osteopathic Postdoctoral Training Institution (OPTI) accreditation. After all, the changes being developed place more demand on the preceptors in breadth and depth of instruction.

What is happening increasingly is that allopathic medical colleges have developed contractual relationships with preceptors and hospitals which preclude or limit outside students, particularly osteopathic students, from rotations.2 What has developed in some instances, is an area-wide competition, severely biased towards the allopathic institutions, due to their ability to monetarily compensate preceptors for their teaching time. The response from rotations is that they are sorry for not being able to accommodate an osteopathic student due to the contractual obligations with their allopathic medical school. One response from an anonymous COM Dean gives perspective2:

“Competition for rotations (despite a large number of major teaching sites) looms for those places where MD and DO students coexist. In places where allopathic schools are refusing DO students for rotations, our options are limited. Intrusion of offshore medical schools into our training areas is also occurring with high payments for rotations to preceptors or hospitals. Our current model relies heavily on volunteer faculty who are loyal to our quality manner of education. We are concerned that future costs to pay these individuals will usurp strategic plans for other purposes. In addition, the intrusion of other DO schools into our existing established rotation consortium compromises our ability to manage the learning environment for effective faculty-student ratios.”
- Anonymous

To be competitive, COMs must compensate physicians for their teaching time in a reasonable and mutually equitable manner. The manner that currently exists is to give the physician faculty status at the COM and access to the educational resources the COM has to offer. It also allows for level 1-B continuing medical education (CME) credits for each hour the student rotates, and in some instances, a discount towards earning level 1-A CME credits for licensure requirements.

While these are valued by some preceptors, most physicians see these benefits as non-essential. The faculty status at the COM allows little input into the first and second years of training. The educational resource access was crucial in the past, but with the explosion of electronic media and wireless connectivity currently, most physicians do not use COM portals to view medical informatics.

The CME credits are useful, but currently the highest nationwide requirement for Category 1-B credits is 150 hours of Category 1 or 2 credit per three-year cycle.6 This means that one medical student, rotating for one full month, five days a week in the preceptor’s office (160 1-B hours), would satisfy the Category 1 (1-B) CME requirements for the entire three year cycle. Would additional CME benefit be of value once he/she has taken one student for one month?

The Centers for Medicare and Medicaid Services adopted a policy in 2005 requiring that teaching hospitals must use GME funds to pay “all or substantially all” of the costs, including community based supervisors, for teaching residents.7 This applies only to resident physician trainers, but the policy shift has initiated dialogue among medical student preceptors as to whether they should be compensated also for their teaching time. Some have even stopped accepting medical students for rotations unless they are compensated monetarily for their time.7

COMs need to be engaged in these discussions, as they rely heavily on volunteer preceptor faculty and could not financially afford a situation where third- and fourth-year training sites demand reimbursement to take their trainees. If this should happen it would place excellent statewide training consortiums at risk, such as those in Ohio and Michigan, to use funding for preceptor payment instead of educational programming.

The second level of change must take place at the rotational level. As hospitals get overwhelmed by students requesting rotations, they look to place them with any preceptor they can find who is accepting students for the months needed. Osteopathic Graduate Medical Education (GME) departments are afraid to turn away students for rotations as this may hinder residency recruitment efforts in the future.

Residency programs and program directors will now accept twice as many students for rotations as they want to “audition” them for residency. This dilutes the experience for every trainee. The focus of the experience is shifted from what can be offered to the student for his/her education. What should take place is the GME department, in conjunction with the preceptors and undergraduate medical education office, deciding on the volume of medical trainees they can accommodate and what rotations they can offer.

Rotations should be reviewed and analyzed annually to determine how to provide the highest quality educational experience, and what can be done to share resources to make rotations better. The American Association of Medical Colleges (AAMC) has published a position statement that studies addressing the relationship between physician preparation (i.e., medical education and residency training) and the quality and outcomes of care should be conducted
and supported by public and private funding.10

Given the national concern with quality and outcomes, additional resources should be invested in research in this area. It should be perceived as an honor and privilege to have a medical student in the office or on hospital rotation with a preceptor, as this is an indicator that the preceptor is valued both by the hospital and by the medical education community. It is imperative that a sufficient number of preceptors be available who meet the high standards of quality to avoid “burnout” and an overloading of select rotations.

The third level of change must take place at the preceptor level. All preceptors who take trainees should have the time and resources to make the rotational month worthwhile for both the preceptor and the trainee. There should be sufficient faculty development provided for the preceptors in order to be able to institute this focus. There needs to be a clear educational focus, rather than maintaining a primarily service-oriented rotation.

While there is educational value in rounding on patients, performing history and physical examinations and writing SOAP notes, time must be allotted for one-on-one topic discussions and the sharing of clinical pearls. The first question a good preceptor should ask an osteopathic student is “what do you want to get out of this rotation?” This opens a discussion showing that the preceptor is genuinely interested and gives direction for the learning objectives. It allows the non-surgically interested student to say “I plan on doing family medicine, so I would like to focus my surgical month on learning not only how to scrub and assist intra-operatively, but on how to perform a good surgical H&P. I also would like to concentrate on what things I can do to ensure a better outcome for my patients if they require surgery.”

If necessary, the student can write their own learning objectives or adjust operating room service and outpatient time to fulfill their needs. Too often students start a rotation without ever having spoken with, or even met the attending physician, and are relied upon to do the “busy work”. Most of the pre- and post-surgical rounds are under the supervision of the surgical residents and the entire outcome of the rotation can hinge on the students’ experience with the resident physician. This type of rotational experience has, in many instances, influenced future career choices.

This level of change is the hardest to modify as it deals with attitudes and perceptions of individual physicians. While one physician may be in a salaried group practice with a reasonable workload, another may be a solo practitioner who sees medical students as slowing down his/her productivity.

Any offerings by the COM to help with the rotation or education of students can be seen as “another meeting” or “something else they want me to do now” rather than as an opportunity to have positive impact. The process must be standardized and the preceptor must be compensated by the COM with something tangible. Equitable compensation ideas discussed at past educational conferences include payment of national or specialty college dues, payment of licensure fees, textbooks for rotational use, or category 1-A CME credits.

Physicians must pursue these items anyway, and it requires no more meetings or time. It also provides the COM with accountability of the preceptor and something the COM can use to structure preceptor training. There can be a physician preceptor educational day, which must be attended in order to have medical students rotate with them. Whatever the compensation it must be sought after by the preceptor, and able to be enforced by the COM.

Conclusion
The osteopathic medical educational model has always been a preceptor-based, mostly volunteer system. The “see one, do one, teach one” model of education has been the standard followed for over a century. With the predicted physician shortage and the dominance of privately funded osteopathic medical schools, the focus of training is starting to shift, though heavy dependence on community and hospital physicians to educate and train students remains.

At the same time preceptors can barely keep up with their own practices, patient challenges, and declining reimbursements. As more COMs become operational there must be discussions that involve where students can be trained for clinical rotations. Using a family medicine model, there may be a shortage of 400+ preceptors by the year 2012. To keep this from happening, dialogue must be undertaken now between the COMs, preceptors, and the rotational site hospitals.

Physician preceptors are becoming more selective in whom they accept for rotations and a new COM may not be able to compete in an already established osteopathic or allopathic dominated area. It is likely that preceptors will demand reimbursement, in some way, shape, or form, for their continued training of medical students. The medical colleges should not pass the entire cost on to the students, but share in the educational cost burden.

Modifications to the current osteopathic model must occur at every level, or the system may not be able to sustain itself in the future. The medical colleges must recognize maintaining quality educational experiences as the top priority. The rotations sites must guarantee a commitment to improved services and dedication to the teaching of osteopathic trainees.

The preceptors need to place the student derived rotational objectives ahead of service to the rotation. All three components must function in a collaborative manner in order to ensure sustainability of the system. The osteopathic educational family as a whole should have the same belief as Michelangelo: “the greatest danger is not that our aim is too high and we miss, but that it is too low and we reach it.”

Dr. Russ is a 1998 graduate of the Ohio University College of Osteopathic Medicine, Athens, Ohio. He received his certification in family medicine in 2001, and is currently the Director of Medical Education and Family Medicine Residency Director at Cuyahoga Falls General Hospital in Cuyahoga Falls, Ohio.

References:

1. Flexner, Abraham, Medical Education in the United States and Canada; A report to the Carnegie Foundation for the Advancement of Teaching, The Carnegie Foundation for the Advancement of Teaching, Bulletin Number Four, 1910, pp. 109.
2. Levitan, Thomas Med., AACOM Projections for Growth Through 2012:Results of a 2007 Survey of US Colleges of Osteopathic Medicine, JAOA, Vol. 108,No. 3,2008, pp 116-120.
3. ACOFP Preceptor Directory, accessed 4/8/08.
4. Centers for Medicare and Medicaid Services, accessed 5/20/08.
5. Primary Care Scholars Pathway, accessed 5/27/08.
6. Rodgers, Delores BS, AOA Continuing Medical Education, JAOA, Vol. 108,No. 3, 2008, pp.141-156.
7. AAFP News Now, accessed 6/3/08.
8. Health Resources and Services Administration (HRSA), Physician Supply and Demand: Projections to 2020, October 2006.
9. Association of American Medical Colleges, Recent Studies and Reports on Physician Shortages in the U.S., August 2007.
10. Association of American Medical Colleges, AAMC Statement on the Physician Workforce, June 2006