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Identifying Solutions to Ambulatory Faculty Recruitment, Retention, and Remuneration in Graduate Medical Education: An AAIM Position Paper

Published:November 09, 2019DOI:https://doi.org/10.1016/j.amjmed.2019.11.001

      Keywords

      Perspectives Viewpoints
      • Graduate medical education (GME) directors should target their efforts on faculty development and salary support/payment for teaching as highly valued incentives for ambulatory resident teaching.
      • GME programs from Title VII and Teaching Health Centers are potential solutions for ambulatory faculty recruitment and retention at both university-based and community-based institutions.
      • Because faculty produce income from their clinical and teaching efforts with residents, an educational relative value unit structure provides an equitable method to reward GME teaching faculty.

      Background

      With implementation of the Affordable Care Act and core requirements from the Accreditation Council for Graduate Medical Education, directors of graduate medical education (GME) programs must create robust ambulatory teaching environments for residents. Success requires effective recruitment, remuneration, and retention of high-quality ambulatory faculty. The recent AAIM Perspectives article
      • Fazio SB
      • Shaheen A
      • Amin A
      Tackling the problem of ambulatory faculty recruitment in undergraduate medical education: an AAIM Position Paper.
      and the 2017 Alliance for Academic Internal Medicine (AAIM)/Society of General Internal Medicine (SGIM) position paper
      • Fazio SB
      • Chheda S
      • Hingle S
      • et al.
      The challenges of teaching ambulatory internal medicine: faculty recruitment, retention, and development: an AAIM/SGIM position paper.
      provided several recommendations to support and engage ambulatory faculty. Yet literature identifies multiple challenges in recruiting and retaining ambulatory clinician educators,
      • Meyers FJ
      • Weinberger SE
      • Fitzgibbons JP
      • Glassroth J
      • Duffy FD
      • Clayton CP
      Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force.
      • Bowen JL
      • Salerno SM
      • Chamberlain JK
      • Eckstrom E
      • Chen HL
      • Brandenburg S
      Changing habits of practice. Transforming internal medicine residency education in ambulatory settings.
      • Weinberger SE
      • Smith LG
      • Collier VU
      Education Committee of the American College of Physicians
      Redesigning training for internal medicine.
      • Kumar A
      • Kallen DJ
      • Mathew T
      Volunteer faculty: what rewards or incentives do they prefer?.
      • Denton GD
      • Grifin R
      • Cazabon P
      • et al.
      Recruiting primary care physicians to teach medical students in the ambulatory setting: a model of protected time, allocated money, and faculty development.
      with 40% of program directors
      • Willett LL
      • Estrada CA
      • Adams M
      • et al.
      Challenges with continuity clinic and core faculty accreditation requirements.
      and 54% of department chairs
      • Fazio SB
      • Shaheen A
      • Amin A
      Tackling the problem of ambulatory faculty recruitment in undergraduate medical education: an AAIM Position Paper.
      acknowledging difficulty. The myriad barriers and pressures in ambulatory GME teaching has elevated this issue to a high priority for the AAIM community. In this cross-sectional study, AAIM investigates current barriers for ambulatory educators to teach residents and identify pragmatic, high-value strategies to incentivize faculty participation in resident ambulatory teaching. The intent of this AAIM position paper is to increase communication and establish groundwork for best practices to recruit, retain, and reward high-quality ambulatory faculty.

      Methods

      Survey Instrument

      From January 2016 to May 2017, a subcommittee convened monthly to discuss GME faculty needs and develop a needs-assessment survey on faculty teaching in GME ambulatory education. After extensive literature review and several Delphi processes, the final survey consisted of 14 questions in a mix of multiple-choice, 5-point Likert scale, and open-text questions on the following topics: types of existing ambulatory medicine rotations, barriers to ambulatory GME teaching, and institutional strategies for ambulatory faculty teaching of residents (Appendix, available online). The survey platform was the web-based QuestionPro 20.9 (Survey Analytics LLC, San Francisco, Calif), which was programmed and maintained by AAIM staff. Five subcommittee members pilot-tested the survey online to ensure validity. The survey underwent a final review for functionality, content, and validity.
      From August to November 2017, requests for survey participation were posted every 2 weeks on the discussion forums of SGIM, the Association of Program Directors in Internal Medicine (APDIM), the Association of Professors of Medicine (APM), and AAIM ambulatory faculty retention, recruitment, and remuneration (RR&R) online communities. Survey participation was anonymous and voluntary through an embedded URL, with no incentives provided. The University of Oklahoma Institutional Review Board granted exemption from human subjects research (IRB #669439).

      Data Analysis

      Prior to removing respondent metadata from the survey dataset, IP address and geographic region of respondents were compared with individual survey responses to ensure no duplicate responses. Respondents reporting “no” as core ambulatory resident educators exited the survey. Data cleaning and summary descriptive statistical analysis were conducted in Stata 14.2 SE.
      • Stata SE
      Stata Statistical Software: Release 14.
      Data from university-based respondents were compared with community-based respondents for variables regarding barriers and strategies. Group-based tests for statistical significance were conducted using Pearson's chi-squared or Fisher's exact test (for anticipated cell sizes below 5). Because the survey was anonymous and survey population was an approximation, data were not statistically weighted to adjust for nonresponse. Three authors thematically analyzed open-text responses on existing ambulatory rotations, institutional barriers, and strategies.

      Results

      The total number of possible respondents was 7630 based on membership of the 4 solicited academic groups (APDIM-4261, APM-258, RR&R Focus Group-111, SGIM-3471). Overlap existed between memberships in AAIM, SGIM, and the RR&R focus group; thus, the total number of respondents is less than the potential total. Only one survey response was allowed per participant.

      Demographics of Respondents and Institutional Ambulatory Education

      A total of 217 individuals responded to the survey; 65.4% were from university-based institutions, 15.7% community-based, 11.5% equally at community-based and inpatient settings, and 7.4% others (eg, Veterans Affairs ambulatory care and community federally qualified health centers). Respondents were primarily core ambulatory resident educators in assistant professorships and served as assistant/associate program directors in administration (Table 1). Geographic representation was mostly from the Northeast (40.1%), followed by Midwest (22.6%), Southeast (20.7%), West (11.5%), and Southwest (5.1%).
      Table 1Respondent Demographics per Institutional Type
      Respondent DemographicsInstitution Types
      University-Based (%)(n = 142)All Others (%)(n = 75)P Value
      Pearson chi-squared test used; Fisher's exact test used when anticipated cell sizes are 5 or less.
      Program Administrator2.86.7.281
      Instructor4.92.7.722
      Assistant Professor46.524.0.001
      Associate Professor30.337.3.292
      Professor13.421.3.130
      Other
      Other respondent demographics, ie, Core Faculty, Attending Physician, Associate/Assistant Program Director.
      2.18.0.067
      Respondents who were educational administrators serve as:
       Medical Director9.42.8.396
       Residency Clinic Director28.915.3.182
       Residency Program Director14.136.1.003
       Chief of General Medicine6.34.21.000
       Assistant/Associate Program Director35.931.91.000
       Designated Institutional Officer4.2.140
       Core faculty29.727.8.775
       Dean/Associate Dean3.91.41.000
       Other Educational Leadership Role
      Other educational leadership roles i.e. concurrent clerkship director, course director, director of ambulatory education, director of primary care track, director of clinical education, director of quality improvement, vice chair of education
      21.18.3.157
      low asterisk Pearson chi-squared test used; Fisher's exact test used when anticipated cell sizes are 5 or less.
      ϯ Other respondent demographics, ie, Core Faculty, Attending Physician, Associate/Assistant Program Director.
      Other educational leadership roles i.e. concurrent clerkship director, course director, director of ambulatory education, director of primary care track, director of clinical education, director of quality improvement, vice chair of education
      The predominant rotation to teach general medicine ambulatory education for university-based residency programs (n = 128) was a longitudinal primary care track/program (57.8%, P = .001), while for community-based residency programs (n = 72) it was primary care electives (43.7%, P = .142). Rotation distributions for primary care electives, longitudinal subspecialty clinics, and specialized community-based clinics were not statistically significant between university-based and community-based programs (Table 2).
      Table 2Distribution of Educational Rotations for Primary Care/General Internal Medicine per Institution Type
      % Distribution of Primary Care/General Medicine RotationsUniversity-Based (n = 128)Community-Based (n = 72)P Value
      Pearson chi-squared test used; Fisher's exact test used when anticipated cell sizes are 5 or less.
      Longitudinal outpatient subspecialty clinics56.356.0.962
      Specialized outpatient community-based clinics (eg, prison clinics, homeless clinics, mobile clinics, county health department, AHEC clinics)38.034.71.000
      Primary care elective43.758.7.142
      Formal primary care track or program57.830.7.001
      Other
      Other, ie, ambulatory block rotations of subspecialty clinics, longitudinal continuity clinics, longitudinal ambulatory weeks in x + y model, 1-year ambulatory long blocks, acute care clinics, women's health elective, geriatrics clinics, home-based primary care rotation. Note: Multiple responses allowed; percentage will exceed 100%.
      24.722.71.000
      AHEC = Area Health Education Center.
      low asterisk Pearson chi-squared test used; Fisher's exact test used when anticipated cell sizes are 5 or less.
      ϯ Other, ie, ambulatory block rotations of subspecialty clinics, longitudinal continuity clinics, longitudinal ambulatory weeks in x + y model, 1-year ambulatory long blocks, acute care clinics, women's health elective, geriatrics clinics, home-based primary care rotation.Note: Multiple responses allowed; percentage will exceed 100%.

      Barriers to Ambulatory Resident Teaching

      Of the 217 participants, 93.5% completed the section on barriers to ambulatory training (68.0% university-based, 32.0% community-based). The most common barriers shared by university-based and community-based ambulatory faculty (percent agreeing and strongly agreeing) were inadequate financial support (67.5%), lack of clinic space (63.3%), restraints in clinic time (47.9%), and reduction in clinical productivity (43.2%) (Figure 1).
      Figure 1
      Figure 1Percent of respondents who perceived each barrier to residency ambulatory education per educator type.
      In subgroup analyses, 4 specific barriers were significantly higher among community-based institutions than university-based institutions: lack of skilled community-based faculty educators (P = .002), lack of faculty interest (P < .001) and increase in clinic time (P = .004), and clinical work (P = .032) with teaching residents. The barrier on housing learners at distant educational sites was unique to community-based programs. Other barriers were not significantly different across program types (Figure 1).

      Strategies to Incentivize Ambulatory Faculty Teaching

      Of the 217 participants, 97.7% completed the section on strategies to incentivize ambulatory training (66% university-based, 34% community-based). The top incentives employed by both institution types were teaching awards/recognition (63.2%), faculty development in ambulatory teaching (54.3%), established ambulatory curricula (52.4%), dedicated space for learners (51.4%), and access to institutional resources/facilities (46.7%) (Figure 2). About 41% required mandates from chairs/division chiefs for faculty teaching of residents in the ambulatory setting. Financial incentives were less frequently employed as a strategy in university-based institutions (10%-28%) compared with community-based institutions (12.5%-43%). Heterogeneity existed in how salary support, relative value units (RVUs), and productivity were applied to faculty incentives. One-third of respondents reported a salary support system for outpatient teaching (eg, salary adjustment or lump sum payment per learner or session). Educational RVUs (eRVUs) were used by 10.9% of institutions, although respondents in open text commented that clinical RVUs from staffing resident clinic patients served as an incentive separate from eRVUs. Others noted that their eRVUs applied only to work with students, not residents. Infrequently utilized strategies included Continuing Medical Education (CME) credit for teaching activities, discounted/free parking, and discounted conference registration.
      Figure 2
      Figure 2Percent of respondents who reported these strategies utilized to incentive each physician type.
      Subgroup analyses revealed 2 specific strategies utilized significantly more among community-based institutions than university-based institutions: use of salary support for teaching (P = .026) and close partnership with community physicians (P = .005). Other employed strategies were not significantly different across program types (Figure 2).
      Regarding perceived value, respondents across all programs ranked the most valuable incentives for ambulatory faculty recruitment and retention to be adequate number of teaching clinicians (77.7%), qualified teaching clinicians (72.4%), salary support for teaching (69.3%), dedicated clinic space for learners (65.7%), faculty development in ambulatory teaching skills (57.6%), established ambulatory core curricula (50.2%), schedule adjustment to lower patient volume (45.6%), and eRVU system (44.8%). Least valuable strategies involved ambulatory teaching mandates from chairs/division chiefs (18%), access to institutional resources/facilities (17%), CME credit for teaching activities (17%), discounted/free parking (17%), and free/discounted CME tuition (16%) (Figure 3).
      Figure 3
      Figure 3Percent of respondents who perceived these strategies as highly valuable to incentive each physician type.
      In subgroup analyses, salary support for teaching was the most valuable incentive for both university-based faculty (86.9%) and community-based faculty (91.7%) (P = .362). Community-based educators perceived discounted/free parking (P = .015), discounted conference registration (P = .024), and free/discounted tuition to institutional CME (P = .052) significantly less valuable than university-affiliated educators (Figure 3).

      Discussion

      This position paper adds supporting evidence to the recommendations of the 2015 AAIM white paper,
      • Denton GD
      • Lo MC
      • Brandenburg S
      • et al.
      Solutions to common problems in training learners in general internal medicine ambulatory settings.
      the 2017 AAIM-SGIM position paper,
      • Fazio SB
      • Chheda S
      • Hingle S
      • et al.
      The challenges of teaching ambulatory internal medicine: faculty recruitment, retention, and development: an AAIM/SGIM position paper.
      and the 2019 AAIM Perspectives on ambulatory faculty recruitment and engagement,
      • Fazio SB
      • Shaheen A
      • Amin A
      Tackling the problem of ambulatory faculty recruitment in undergraduate medical education: an AAIM Position Paper.
      particularly on financial compensation, protected time, and faculty development. The strengths of this study include its large-scale national dissemination to key ambulatory academic groups and generalizability to various ambulatory faculty stakeholders. By stratifying barriers and incentives to different faculty types, our study helps to tailor strategies for GME directors to engage their ambulatory clinicians to teach.
      A clear difference exists in the struggles of community-based ambulatory educators to teach residents, compared with university-based faculty. With the lack of skilled faculty to teach, GME directors of community-based programs must focus efforts on faculty development and mentorship programs to attract practicing clinicians to teach ambulatory medicine. Our survey respondents support faculty development as one of the highest valued strategies for ambulatory teaching. The significant faculty inertia to teach and the increased clinical workload make salary support/payment and close partnership with community physicians important incentives to recruit community-based ambulatory faculty to teach residents. These same challenges may explain the differential distribution of ambulatory medicine rotations by institution type. Community-based institutions favor primary care electives, while university-based institutions can significantly provide longitudinal primary care tracks/programs. Nonetheless, both institution types rely heavily on longitudinal subspecialty clinics to teach residents ambulatory medicine.
      Unsurprisingly, the most commonly shared barrier from the survey was inadequate financial support for teaching in the ambulatory setting. This clarifies the findings of salary support/payment for teaching as the most valuable strategy to recruit ambulatory faculty. Financial support likely factors into other common barriers, including inadequate space and time for teaching and reduction in faculty productivity. Solving the challenges of funding for ambulatory teaching requires considerable advocacy for GME funding reform because the majority of GME funding is concentrated in the inpatient environment.

      Medicare Payment Advisory Commission (MedPAC). Report to Congress: aligning incentives in Medicare. Available at: http://www.medpac.gov/docs/default-source/congressional-testimony/20100623_EandC_Testimony_AligningIncentivesinMedicare.pdf?sfvrsn=0. Accessed November 19, 2019.

      This imbalance has galvanized SGIM and the Society of Teachers of Family Medicine to propose major reforms to the educational payment policy with increased accountability and transparency to ambulatory education. Specific federal programs, such as the Title VII Health Professions Primary Care Training and Enhancement Grants and the Veterans Access, Choice, and Accountability Act, are critical for building the educational infrastructure of primary care by providing financial support of new primary care training programs, resources for ambulatory faculty recruitment, and expansion into new faculty development programs for ambulatory teaching clinicians.
      • Phillips Jr, RL
      • Turner BJ
      The next phase of Title VII funding for training primary care physicians for America's health care needs.
      • Reynolds PP
      Title VII innovations in American medical and dental education: responding to 21st century priorities for the health of the American public.
      • Klink KA
      • Joice SE
      • McDevitt SK
      Impact of the Affordable Care Act on grant-supported primary care faculty development.
      Congress under the Affordable Care Act 2010 created the Teaching Health Center (THC) GME program to increase community-based primary care residencies and address the primary care workforce shortage. GME programs from Title VII and THCs represent potential solutions for the recruitment and retention of ambulatory faculty at both university-based and community-based institutions by addressing issues with financial support, clinic space, time for teaching, and creating incentives for the dual mission of ambulatory care and resident primary care education.
      • Chen C
      • Chen F
      • Mullan F
      Teaching health centers: a new paradigm in graduate medical education.
      • Regenstein M
      • Snyder JE
      • Jewers MM
      • Nocella K
      • Mullan F
      Comprehensive revenue and expense data collection methodology for teaching health centers: a model for accountable graduate medical education financing.
      • Lipkin M
      • Zabar SR
      • Kalet AL
      • et al.
      Two decades of Title VII support of a primary care residency: process and outcomes.
      The outreach of THCs and expansion of Title VII could include partnerships between community-based and academic health centers.
      • Rieselbach RE
      • Crouse BJ
      • Neuhausen K
      • Nasca TJ
      • Frohna JG
      Academic medicine: a key partner in strengthening the primary care infrastructure via teaching health centers.
      The survey findings suggest that such partnerships remain an untapped resource for GME ambulatory education. Both university-based and community-based respondents report longitudinal community-based Area Health Education Center clinics as the least utilized rotation to teach residents ambulatory medicine.
      The literature on specific salary support structures is limited, and monetary structures such as eRVUs and salary lump payments are infrequently utilized incentives in GME ambulatory teaching. Medical schools have adopted mission-based funding as a means to compensate the time faculty dedicated to medical education. Certain departments use eRVUs as a framework to compensate for educational work to residents and medical students.
      • Kairouz VF
      • Raad D
      • Fudyma J
      • Curtis AB
      • Schunemann HJ
      Assessment of faculty productivity in academic departments of medicine in the United States: a national survey.
      • Rouan GW
      • Wones RG
      • Tsevat J
      • Galla JH
      • Dorfmeister JW
      • Luke RG
      Rewarding teaching faculty with a reimbursement plan.
      • Regan L
      • Jung J
      • Kelen GD
      Educational value units: a mission-based approach to assigning and monitoring faculty teaching activities in an academic medical department.
      Department chairs have utilized eRVUs to incentivize both clinical and nonclinical teaching.
      • Kairouz VF
      • Raad D
      • Fudyma J
      • Curtis AB
      • Schunemann HJ
      Assessment of faculty productivity in academic departments of medicine in the United States: a national survey.
      ,
      • Rouan GW
      • Wones RG
      • Tsevat J
      • Galla JH
      • Dorfmeister JW
      • Luke RG
      Rewarding teaching faculty with a reimbursement plan.
      ,
      • Osborn LM
      • Sostok M
      • Castellano PZ
      • Blount W
      • Branch Jr, WT
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      • Stites S
      • Vansaghi L
      • Pingleton S
      • Cox G
      • Paolo A
      Aligning compensation with education: design and implementation of the Educational Value Unit (EVU) system in an academic internal medicine department.
      • Yeh MM
      • Cahill DF
      Quantifying physician teaching productivity using clinical relative value units.
      Implementation of eRVUs, however, remains mixed due to limited funds for medical education. University of Queensland Ochsner Clinical School had to restructure its tuition funds and faculty compensation plan to allocate monies to faculty ambulatory teaching.
      • Denton GD
      • Grifin R
      • Cazabon P
      • et al.
      Recruiting primary care physicians to teach medical students in the ambulatory setting: a model of protected time, allocated money, and faculty development.
      University of Kansas successfully overhauled its eRVUs to align with clinical productivity.
      • Stites S
      • Steffen P
      • Turner S
      • Pingleton S
      Aligning clinical compensation with clinical productivity: design and implementation of the financial value unit (FVU) system in an academic department of internal medicine.
      A meta-analysis
      • Akl EA
      • Meerpohl JJ
      • Raad D
      • et al.
      Effects of assessing the productivity of faculty in academic medical centres: a systematic review.
      of compensation strategies found that most compensation schemes, including eRVUs for teaching sessions, improve research and clinical productivity. GME programs generate revenue for the clinical work of residents and from Medicare subsidies. Because faculty produce income from their clinical and teaching efforts with residents, an eRVU structure provides an equitable method to reward GME teaching faculty. Yet, discordance still exists between educational directors and department chairs on the value of eRVUs in ambulatory faculty recruitment, with 62% of clerkship directors vs 35% of chairs in favor per the recent AAIM paper.
      • Fazio SB
      • Shaheen A
      • Amin A
      Tackling the problem of ambulatory faculty recruitment in undergraduate medical education: an AAIM Position Paper.
      Determining the right compensation model to incentivize ambulatory teaching and provide appropriate oversight of residents remains elusive and an area in need of collaborative research among academic leaders. The survey suggests a significant ability of community-based institutions to provide financial support for ambulatory clinicians to teach residents, compared with university-based institutions. This disparity may reflect the need of traditionally nonteaching institutions to provide financial incentives to entice traditionally nonteaching physicians to teach residents; sustainability remains a concern. Physicians in university-based institutions have a contractual obligation to teach learners as part of a department's tripartite mission. Teaching is an essential role and expectation of any academic-based faculty.
      Survey respondents of both institution types reported the need to use nonfinancial strategies to incentivize resident ambulatory educators due to limited institutional financial resources for medical education. Providing faculty development, teaching awards, structured ambulatory curricula, and dedicated clinic space for teaching are commonly used strategies and provide highly valued intangible incentives. These findings support the cost-neutral incentives recommended by the 2017 SGIM-AAIM position paper
      • Fazio SB
      • Chheda S
      • Hingle S
      • et al.
      The challenges of teaching ambulatory internal medicine: faculty recruitment, retention, and development: an AAIM/SGIM position paper.
      and the 2019 AAIM paper.
      • Fazio SB
      • Shaheen A
      • Amin A
      Tackling the problem of ambulatory faculty recruitment in undergraduate medical education: an AAIM Position Paper.
      High-value strategies from our survey further substantiate the proposals by AAIM-SGIM
      • Fazio SB
      • Chheda S
      • Hingle S
      • et al.
      The challenges of teaching ambulatory internal medicine: faculty recruitment, retention, and development: an AAIM/SGIM position paper.
      ,
      • Denton GD
      • Lo MC
      • Brandenburg S
      • et al.
      Solutions to common problems in training learners in general internal medicine ambulatory settings.
      and the American College of Physicians
      • Weinberger SE
      • Smith LG
      • Collier VU
      Education Committee of the American College of Physicians
      Redesigning training for internal medicine.
      for a core faculty model of master educators with salary support and institutional resources to teach in the ambulatory setting, lead medical educational programs, and mentor junior clinical faculty in ambulatory teaching. Interestingly, GME directors may wish to limit such intangible incentives as discounts in CME activities, conference registration, and parking because they hold less value for ambulatory faculty to teach, especially community-based clinicians.
      The literature remains sparse on specific incentives and rewards employed for and valued by ambulatory clinicians to teach residents. Existing studies mostly target clerkship directors for ambulatory teaching of medical students. Table 3 details the employed strategies for GME ambulatory teaching from the literature review while proposing other potential incentives for each barrier per the study.
      Table 3Employed and Proposed Strategies for GME Faculty Ambulatory Teaching per Barrier
      BarrierInstitutional TypeEmployed Strategies (from Literature)Potential Solutions and Incentives
      Inadequate financial supportSharedEducational RVU
      • Osborn LM
      • Sostok M
      • Castellano PZ
      • Blount W
      • Branch Jr, WT
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      ,
      • Yeh MM
      • Cahill DF
      Quantifying physician teaching productivity using clinical relative value units.


      Title VII programs
      • Phillips Jr, RL
      • Turner BJ
      The next phase of Title VII funding for training primary care physicians for America's health care needs.
      ,
      • Reynolds PP
      Title VII innovations in American medical and dental education: responding to 21st century priorities for the health of the American public.


      Teaching Health Centers
      • Chen C
      • Chen F
      • Mullan F
      Teaching health centers: a new paradigm in graduate medical education.
      ,
      • Regenstein M
      • Snyder JE
      • Jewers MM
      • Nocella K
      • Mullan F
      Comprehensive revenue and expense data collection methodology for teaching health centers: a model for accountable graduate medical education financing.
      ,
      • Rieselbach RE
      • Crouse BJ
      • Neuhausen K
      • Nasca TJ
      • Frohna JG
      Academic medicine: a key partner in strengthening the primary care infrastructure via teaching health centers.
      ,
      • Petterson SM
      • Liaw WR
      • Tran C
      • Bazemore AW
      Estimating the residency expansion required to avoid projected primary care physician shortages by 2035.
      ,
      • Regenstein M
      • Nocella K
      • Jewers MM
      • Mullan F
      The Cost of Residency Training in Teaching Health Centers.


      Salary incentives for teaching
      • Osborn LM
      • Sostok M
      • Castellano PZ
      • Blount W
      • Branch Jr, WT
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      ,
      • Ceriani PJ
      Compensating and providing incentives for academic physicians: balancing earning, clinical, research, teaching, and administrative responsibilities.
      Major GME reform

      Title VII programs

      Teaching Health Centers

      Educational RVU
      • Fazio SB
      • Shaheen A
      • Amin A
      Tackling the problem of ambulatory faculty recruitment in undergraduate medical education: an AAIM Position Paper.


      Routinely scheduled communication between program directors and department chairs
      • Fazio SB
      • Shaheen A
      • Amin A
      Tackling the problem of ambulatory faculty recruitment in undergraduate medical education: an AAIM Position Paper.


      Contract-hour payments
      • Denton GD
      • Grifin R
      • Cazabon P
      • et al.
      Recruiting primary care physicians to teach medical students in the ambulatory setting: a model of protected time, allocated money, and faculty development.


      Clinic schedule adjustments, ie, clinic block-outs for teaching
      • Denton GD
      • Grifin R
      • Cazabon P
      • et al.
      Recruiting primary care physicians to teach medical students in the ambulatory setting: a model of protected time, allocated money, and faculty development.


      Medical scribes while teaching
      • Pozdnyakova A
      • Laiteerapong N
      • Volerman A
      • et al.
      Impact of Medical Scribes on Physician and Patient Satisfaction in Primary Care.
      • Mishra P
      • Kiang JC
      • Grant RW
      Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience.
      • Hafer J
      • Wu X
      • Lin S
      Impact of Scribes on Medical Student Education: A Mixed-Methods Pilot Study.
      • Ou E
      • Mulcare M
      • Clark S
      • Sharma R
      Implementation of Scribes in an Academic Emergency Department: The Resident Perspective.


      Offsets to clinical billing losses, eg, use of extenders, departmental teaching incentive pool
      Inadequate spaceSharedTeaching Health Centers

      Increase primary care residency positions
      • Akl EA
      • Meerpohl JJ
      • Raad D
      • et al.
      Effects of assessing the productivity of faculty in academic medical centres: a systematic review.
      Inadequate time for teachingSharedEducational RVU

      Faculty development
      • Osborn LM
      • Sostok M
      • Castellano PZ
      • Blount W
      • Branch Jr, WT
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      ,
      • Bowen JL
      • Clark JM
      • Houston TK
      • et al.
      A national collaboration to disseminate skills for outpatient teaching in internal medicine: program description and preliminary evaluation.
      Reduction in faculty productivitySharedEducational RVU

      Salary incentives for teaching

      Teaching mission in promotion criteria
      • Osborn LM
      • Sostok M
      • Castellano PZ
      • Blount W
      • Branch Jr, WT
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      ,
      • Bowen JL
      • Clark JM
      • Houston TK
      • et al.
      A national collaboration to disseminate skills for outpatient teaching in internal medicine: program description and preliminary evaluation.
      Learners reduce clinic access for patientsSharedTeaching mission in promotion criteriaUse of extenders for urgent/overflow visits
      • Fazio SB
      • Chheda S
      • Hingle S
      • et al.
      The challenges of teaching ambulatory internal medicine: faculty recruitment, retention, and development: an AAIM/SGIM position paper.
      Learners adding too much time to the clinicCommunity-basedEducational RVU

      Teaching mission in promotion criteria
      Medical scribes while teaching

      Clinic schedule adjustments, ie, clinic block-outs for teaching
      Learners add too much work to the clinicCommunity-basedEducational RVU

      Salary support for teaching

      Teaching mission in promotion criteria

      Teaching awards
      • Osborn LM
      • Sostok M
      • Castellano PZ
      • Blount W
      • Branch Jr, WT
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      ,
      • Bowen JL
      • Clark JM
      • Houston TK
      • et al.
      A national collaboration to disseminate skills for outpatient teaching in internal medicine: program description and preliminary evaluation.
      Educational RVU

      Contract-hour payment methods

      Medical scribes while teaching
      Lack of skill in ambulatory teachingCommunity-basedAcademic faculty mentorship of community physicians
      • Osborn LM
      • Sostok M
      • Castellano PZ
      • Blount W
      • Branch Jr, WT
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      ,
      • Pololi L
      • Knight S.
      Mentoring faculty in academic medicine. A new paradigm?.
      ,
      • Sambunjak D
      • Straus SE
      • Marusic A
      Mentoring in academic medicine: a systematic review.


      Faculty development
      Ambulatory Clinician Educator tracks/programs during residency training

      Workplace faculty development programs
      • Fazio SB
      • Chheda S
      • Hingle S
      • et al.
      The challenges of teaching ambulatory internal medicine: faculty recruitment, retention, and development: an AAIM/SGIM position paper.


      Recruitment outreach of alumni
      • Fazio SB
      • Shaheen A
      • Amin A
      Tackling the problem of ambulatory faculty recruitment in undergraduate medical education: an AAIM Position Paper.
      ,
      • Osborn LM
      • Sostok M
      • Castellano PZ
      • Blount W
      • Branch Jr, WT
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      ,
      • Lesky LG
      • Hershman WY
      Practical approaches to a major educational challenge. Training students in the ambulatory setting.
      ,
      • Koehler TJ
      • Goodfellow J
      • Davis AT
      • vanSchagen JE
      • Schuh L
      Physician Retention in the Same State as Residency Training: Data From 1 Michigan GME Institution.


      Core faculty model of master educator
      • Fazio SB
      • Chheda S
      • Hingle S
      • et al.
      The challenges of teaching ambulatory internal medicine: faculty recruitment, retention, and development: an AAIM/SGIM position paper.
      ,
      • Weinberger SE
      • Smith LG
      • Collier VU
      Education Committee of the American College of Physicians
      Redesigning training for internal medicine.
      ,
      • Denton GD
      • Lo MC
      • Brandenburg S
      • et al.
      Solutions to common problems in training learners in general internal medicine ambulatory settings.
      ,
      • Yeh MM
      • Cahill DF
      Quantifying physician teaching productivity using clinical relative value units.
      Clinicians not interested in ambulatory teachingCommunity-basedEducational RVU

      Recruitment outreach of alumni

      Academic faculty mentorship of community physicians

      Faculty development

      Clinical faculty appointment
      • Osborn LM
      • Sostok M
      • Castellano PZ
      • Blount W
      • Branch Jr, WT
      Recruiting and retaining clinician-educators. Lessons learned from three programs.


      Salary support for teaching

      Teaching awards
      Educational RVU

      Contract-hour payment methods

      Workplace faculty development programs

      Recruitment outreach to alumni

      Core faculty model of master educators

      Specialized teaching clinics catered to faculty's niche
      • Fazio SB
      • Chheda S
      • Hingle S
      • et al.
      The challenges of teaching ambulatory internal medicine: faculty recruitment, retention, and development: an AAIM/SGIM position paper.


      Institutional support and resources for faculty scholarly activities
      • Fazio SB
      • Shaheen A
      • Amin A
      Tackling the problem of ambulatory faculty recruitment in undergraduate medical education: an AAIM Position Paper.


      Ambulatory Clinician Educator tracks/programs during residency training
      Certain limitations exist in this study. First, the survey had an over-representation of university-affiliated faculty and respondents from the Northeast region, which introduces the possibility of selection bias. Second, despite wide dissemination of the survey, many institutions failed to participate. Respondents may not be representative of the entire population of ambulatory faculty. Third, the survey instrument is not externally validated. However, experienced educators vetted each survey item prior to dissemination. The 2016 Clerkship Directors in Internal Medicine Annual Survey also employed variations of these survey questions to investigate medical student ambulatory teaching. Finally, this study did not explore the factors behind the barriers or the outcomes of the utilized strategies. The authors are unable to determine which strategies translated to success in engaging ambulatory faculty to teach. For example, survey respondents valued faculty development programs highly for incentivizing ambulatory clinicians; further studies need to determine the specific faculty development elements to effectively recruit ambulatory clinicians to teach.

      Conclusion

      This position paper serves as a blueprint of viable and valuable strategies for institutional and GME directors to guide their recruitment and remuneration of different ambulatory teaching faculty. Future studies must investigate the effectiveness of such strategies in incentivizing ambulatory faculty to teach our residents. Efforts by academic organizations must work on establishing guidelines for best practices to recruit, retain, and reward ambulatory faculty to teach learners in the outpatient setting. This paper lays the groundwork for such efforts.

      Acknowledgments

      The authors wish to thank Bich-Thy Ngo, MD for all her efforts in and oversight of the Institutional Review Board process at the University of Oklahoma.

      Supplementary materials

      Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j.amjmed.2019.11.001.

      Appendix. Supplementary materials

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