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Operation Community Preceptor: Reflections on the Importance and Need of Pediatricians in Medical Training

By Mitzi Scotten, MD, FAAP

With Reflections By Mallory McGinnis (School of Medicine 2015), Andrew Demo (School of Medicine 2015) and Peter Carter, MD, FAAP

PREFACE:  At the onset of this article, I feel compelled to be fully transparent in my motives for initially contacting the Kansas chapter of the AAP and asking for a platform to discuss the issue of community pediatrician involvement in medical education. This began as a purely selfish attempt to garner community support and make my job as pediatric medical student director a little easier.

Seven years ago I accepted the directorship of the pediatric medical student rotation at the University of Kansas. In my first year, I noted the substantial differences in the clerkship from the time I had experienced it over 15 years prior and one notable change was decreasing exposure to pediatrics from eight to six weeks. This change prompted a shift in which areas students rotate and caused a time pressure to learn about the field. One notable and important addition to come out of the change was the one week experience in a community setting.

I have no doubt that as pediatricians you will agree that allowing students to experience the care of children in the office setting is critical to their understanding of our field since the majority of medical interactions occur outside of the academic setting. This one week, however, has become the bane of my existence as director. And let me be very clear that this is not because of the value of the week on learning. Actually it is quite the opposite, as I learned very early on interviewing students coming back from their week off campus in the community setting. Students throughout the last seven years universally report a much clearer understanding of what real pediatric practice is and relate amazing learning opportunities provided by enthusiastic and passionate community providers.

The perpetual struggle continues due to a critical shortage of rotation sites and sets the stage for what has become a larger issue, both here in Kansas and across the country. In just crunching the numbers every six weeks there remains an epic scheduling dilemma on where to place over 150 students for one week in only a handful of sites. I have come to dread the regular call or visit to my office from our clerkship coordinator whose famous line “we don’t have enough spaces for community week next rotation” now garners just a heavy sigh and a wave of my hand and the new standard response of  “just make it work somehow”.

So as this appeal for community involvement began in a somewhat self-serving manner, I decided that simply voicing my needs or frustrations would not be nearly as moving as perhaps hearing from the learners themselves.

I began by sending out an invitation to students in their fourth year of medical school and chose those who have decided to become pediatricians.  I also sought feedback from a very special former student who graduated from the KU program and is now a practicing pediatrician in the very community office he rotated through in his third year rotation. I asked the question, “Why is it important to have students rotate in community pediatric settings?”

As you read on, I think you will see that the focus of this endeavor shifted from the needs I have to complete medical student schedules to the deeper issue of how imperative it is to train future physicians using community preceptor wisdom. More importantly, it has transformed to become a forum for learners to share their voices.

Reflections by Mallory McGinnis, School of Medicine 2015

Everything about my week with my community preceptor cemented my decision to go into pediatrics. I was fortunate enough to be able to spend my pediatric rotation community week with the same preceptor I saw once a month during the first and second years of medical school.  I experienced continuity of care in its truest form.  The community week offers a perspective on pediatric care that can’t be had in the hospital. My preceptor exposed me to true “bread and butter” pediatrics and to general pediatrics in the community.  I joined her on rounds in community hospitals and participated in anticipatory guidance with patients and their families. I was also able to glean some of the ins and outs of running a busy and thriving practice.  I’m interested in general pediatrics and preventative care; that is exactly what my preceptor does.  Having this experience gave me the exposure to community pediatrics that I desired.  I wanted to see what life could be like for me as a general pediatrician.

My preceptor is loved and adored by her patients and their families. It motivated me to become the best doctor I can in order to have some of those same trusting and respected relationships. She demonstrated leadership and poise while running her practice all the while providing excellent patient care and education. I’ve told many of my own friends and family that I would love to be just like her. As child-like as that may sound, it shows a dream that I plan to make come true someday soon. I grew to love her patients, staff and the way she practiced medicine. I could see myself doing what she does.  I could see where I would fit in the medical community and where I wanted to be as a physician. 

Reflections by Andrew Demo, School of Medicine 2015

My community week during my third year pediatrics rotation represents my favorite and most important week of medical school thus far. The timing of my community week could not have been better. I have known that I wanted to become a pediatrician since working as a medical assistant at a pediatrics office prior to entering medical school. However, I had really enjoyed my Ob-Gyn rotation and a low census the first two weeks of my pediatrics rotation suddenly had me second-guessing a future in pediatrics. My community week quickly erased these thoughts and confirmed my desire to become a pediatrician.

There are several reasons why the pediatric community week was a vital part of my third year training. I was fortunate enough to spend a week with Dr. Chris Koster at Pediatric and Adolescent Medicine in Lawrence, Kansas. One of the most important aspects of the community week is the opportunity to work with a physician away from the academic hospital setting. First and foremost, working away from the academic hospital allowed for one-on-one training with Dr. Koster. Working directly with a practicing physician is not always possible in an academic setting where residents are a crucial aspect of patient care. This opportunity allowed for a very hands-on experience with patients and their families. I was able to round on in-patients and newborns at Lawrence Memorial Hospital in the morning, see patients during the day at the office, and even stuck around for a night call. Secondly, it was crucial to have the chance to learn from a physician not directly affiliated with KU Med. Dr. Koster did his residency at Children’s Mercy Hospital and likely has developed different algorithms of treatment than those of residents and physicians at KU. This allowed me to see various modalities of treatment and will help me foster my own methods of treatment moving forward. Finally, as a student who will likely go into general pediatrics, it was important for me to see how an office in the community was ran. After all, my community week might serve as my only glimpse of how an office not affiliated with a teaching hospital operates before I apply for my first job. This will allow me to more accurately assess the strengths and weaknesses of an office that I may potentially join.

While this week was certainly beneficial for me as a student, I believe that it is also beneficial for the preceptor. Preceptors are allowed to showcase their skills and knowledge to future physicians. In doing so, they are refreshing themselves on medical concepts, differential diagnoses, and treatment criteria. If community physicians are concerned that students will slow down their busy practice, I would offer that they follow Dr. Koster’s formula for precepting students. He allows students to assess a patient that would otherwise be waiting to be seen anyways while he sees a patient with a sooner appointment. A time limit is given based on the presenting illness and then a concise presentation is given before seeing the patient together. This presentation helped prime Dr. Koster on pertinent history and exam findings before even walking into the room. I believe that the moments when we did have lengthier discussions about particular patients were educational for both of us and beneficial for patients and families.

I will always remember my community week as my favorite week of medical school and the week that confirmed my career choice. I look forward to my future in pediatrics and I am excited to eventually host my own community weeks for medical students when I am a practicing physician. I believe that serving as a community preceptor will help foster more well-rounded medical students, attract more students into the field of pediatrics, and make established pediatricians even better doctors. 

Reflections by Peter Carter, MD, FAAP

We are all very busy, right?  The stream of patients may seem endless some days.  Trying to keep up with the constant changes with insurances, electronic charting, and coding alone can drive us all crazy.  We squeeze in time for our families, and maybe, just maybe, a little personal time for a quiet mental vacation.  Why in the world would a busy community pediatrician want to take on the extra work of precepting a medical student?  Well, providing this service to an eager learner might actually lead to a connection to a future colleague, new knowledge, and even unexpected joy.

Creating relationships with future doctors through teaching students in clinic is a priority for me. This stems from several rich experiences during community and rural rotations I had as a medical student.  I graduated residency a year ago, and now have the privilege of working in an office that regularly hosts medical students.  Interestingly, I was once a medical student on a community pediatrics rotation at the very office where I now work.  I was drawn back to work with this group because of the bonds we formed during and after the rotation.  Watching the doctors prioritize being active students of medicine while also mentoring future physicians encouraged me. 

As a preceptor now, it is rewarding to create relationships with bright, eager students.  It is fun to see them find success after being forced outside of a comfort zone.  The community setting can offer an intimate and unique learning environment.  While getting to know the students on a more personal level, ethics conversations, clinical exam teaching, and discussions about future goals all happen naturally.  One-on-one case-based medical conversations are routine.  Small procedural opportunities abound for the learner.  These shared experiences with students help forge bonds that last. 

For years, medicine has based much of its education on the motto, “See one, do one, teach one.”  As pediatricians, we have an obligation to give back and teach, just as we have been taught.  As a bonus, steady questions from inquisitive students force preceptors to not only teach, but to continue learning.  Learning alongside students is one of the greatest joys of teaching, and it actively demonstrates lifelong learning to the next generation of doctors.

As physicians, it is our duty to help train our future colleagues.  All physicians go into medicine to help people.  Imagine the exponential impact just one community doctor can have on patients across the state, nation, or world by spending even just a little time training students who will go on to help others.  Working with students is a way to give thanks to your medical school.   It is a way to keep learning.  It is a way to meet a future partner for your practice.  It is a way to further enjoy each day by sharing your passion with the next generation.  I encourage all to take the plunge of hosting a medical student.

CLOSING THOUGHTS:

The issue of finding community preceptor sites for medical students is not unique to Kansas or to Pediatrics. A survey of American Medical Colleges in 2013 found that 80% of respondents voiced that they were either moderately or very concerned about the number of clinical sites they had in which to train learners. This trend also included learners from schools of Osteopathy, Nurse Practitioners and Physician’s Assistants. To summarize, while the number of students entering medical professions is steadily growing, the number of clinical sites to procure their training is staying stagnant, if not shrinking, considering the increase in class size across most institutions.

The specialty with the greatest need for more community sites across all training institutions  was in the field of Pediatrics and perhaps more concerning was the perception from schools that recruitment of Pediatric sites appeared to be getting harder in just the last two years.

In looking at the difficulties medical schools face in community recruitment, it becomes clear that the changing climate of medical practice has a large impetus for the difficulty in finding Pediatric sites. Major barriers to training students exist and involve the increased requirements for training community preceptors, security and legal issues that come with having student learners in the office and finally the subject of how to handle the issue of student access to electronic health records.

Another important but sometimes less comfortable discussion centers on the subject of community physician compensation for training medical students and in 2013 the large majority of medical schools used non-monetary means to pay their preceptors. With only 15% of medical schools reporting that they pay per student, there are discussions among educators that this will likely need to be changed in light of increasing pressure on physicians for productivity and the inevitable truth that increased learners in the office does not equal increased patient volume.

In closing, the issue of a community preceptor shortage in my job as pediatric director remains.  I was very lucky recently to connect with the community preceptor who guided me in my fourth year of medical school, Jon Jantz. I was the first student to rotate in his office in Newton about 20 years ago and I visited with the student who spent a month with him this year. I told her that I still remembered how Dr. Jantz had taken time to help me perfect my skills in cardiac auscultation and that several unique and ingenious tricks he had for the pediatric exam were still a part of my daily routine. The legacy in teaching the art of medicine resides in all of us. Mentoring learners remains at the heart of our practice and there is a desperate need for experts to guide the hands of novices in order to sustain our noble profession.

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