Protocol for the 2023 CERA Clerkship Director Survey.

Introduction: CERA, the Council of Academic Family Medicine Educational Research Alliance, is a unique collaboration between multiple family medicine organizations to conduct omnibus surveys of distinct groups within family medicine. CERA's vision is to support excellence in family medicine educational research and improve research skills in family medicine. This paper describes the methods of the 2023 Clerkship Directory Survey and presents the demographic results of survey respondents. Methods: CERA's call for proposals for the annual Clerkship Directory Survey opened from January 2023 to February 2023. Five topics were selected, and authors of the selected proposals had a mentor assigned to their project. The survey was sent to Clerkship Directors via SurveyMonkey (Momentive, Inc) on May 30, 2023 and responses were collected through June 30, 2023. χ2 tests were used for descriptive analysis. Results: The survey was initially sent to 179 potential respondents but after receiving updated clerkship information, the final pool size was 169 (163 United States, 16 Canada). Ninety-six clerkship directors completed the survey, with a response rate of 56.80% (96/169). The demographic data of potential clerkship director respondents were compared with the demographic data of actual respondents. There were no significant difference in demographic data including location, gender, race/ethnicity and underrepresented in medicine status. Discussion: This paper describes the methods of the 2023 CERA Clerkship Directory Survey and shows that survey respondents are representative of clerkship directors. Authors of the five accepted survey topics are responsible for publishing their study findings.

More Than Half of Family Medicine Clerkships Do Not Address Systemic Racism: A CERA Study.

BACKGROUND AND OBJECTIVES: The influence of racism in medicine is increasingly acknowledged, and the negative effect of systemic racism on individual and population health is well established. Yet, little is known about how or whether medical students are being educated on this topic. This study investigated the presence and features of curricula related to systemic racism in North American family medicine clerkships. METHODS: We conducted a survey of North American family medicine clerkship directors as part of the 2021 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey. RESULTS: The survey response rate was 49% (78/160). Almost all clerkship directors agreed (n=68; 97.1%) that teaching about racism at all levels of medical education was appropriate. Yet, 60% (n=42) of family medicine clerkship directors reported no formalized curriculum for teaching about racism or bias. Teaching about systemic racism was more likely to be present in the family medicine clerkship at institutions where clerkship directors reported that faculty receive 5 or more hours of training in racism and bias, as compared to institutions where faculty receive 4 or fewer hours of training in racism/bias (odds ratio 2.82, 95% CI 1.05-8.04, P=.045). Programs reported using racism in medicine curricula based in cultural competency (20%); structural competency (10%); both cultural and structural competency (31%); and neither or uncertain (40%). Clerkship directors reported high faculty, student, and institutional engagement in addressing systemic racism. We did not find an association between underrepresented in medicine director identity and racism curricula. CONCLUSIONS: In more than half of family medicine clerkships, systemic racism is not addressed, despite interest from students and institutional support. A higher number of hours of faculty training time on the topic of racism was associated with having a systemic racism module in the clerkship curriculum, but we lacked data to identify a causal relationship. Investments in faculty development to teach systemic racism, including discussion of structural competency, are needed.

The Impact of Family Medicine Interest Groups and Student-Run Free Clinics on Primary Care Career Choice: A Narrative Synthesis.

BACKGROUND AND OBJECTIVES: Student-directed activities such as family medicine interest groups (FMIG) and student-run free clinics (SRFC) have been examined to discover their impact on entry into family medicine and primary care. The objective of this review was to synthesize study results to better incorporate and optimize these activities to support family medicine and primary care choice. METHODS: We conducted a comprehensive literature search using PubMed, Scopus, and CINAHL to identify all English-language research articles on FMIG and SRFC. We examined how participation relates to entry into family medicine and primary care specialties. Exclusion criteria were nonresearch articles, review articles, and research conducted outside the United States, Canada, Australia, and New Zealand. We used a 16-point quality rubric to evaluate 18 (11 FMIG, seven SRFC) articles that met our criteria. RESULTS: Of the nine articles that examined whether FMIG participation impacted entry into family medicine, five papers noted a positive relationship, one paper noted unclear correlation, and three papers noted that FMIG did not impact entry into family medicine. Of the seven articles about SRFC, only one showed a positive relationship between SRFC activity and entry into primary care. CONCLUSIONS: Larger-scale and higher quality studies are necessary to determine the impact of FMIG and SRFC on entry into family medicine and primary care. However, available evidence supports that FMIG participation is positively associated with family medicine career choice. In contrast, SRFC participation is not clearly associated with primary care career choice.

Medical School Characteristics, Policies, and Practices That Support Primary Care Specialty Choice: A Scoping Review of 5 Decades of Research.

BACKGROUND AND OBJECTIVES: The United States, like many other nations, faces a chronic shortage of primary care physicians. The purpose of this scoping review was to synthesize literature describing evidence-based institutional practices and interventions that support medical students' choices of primary care specialties, published in the United States, Canada, Australia, and New Zealand. METHODS: We surveyed peer-reviewed, published research. An experienced medical librarian conducted searches of multiple databases. Articles were selected for inclusion based on explicit criteria. We charted articles by topic, methodology, year of publication, journal, country of origin, and presence or absence of funding. We then scored included articles for quality. Finally, we defined and described six common stages of development of institutional interventions. RESULTS: We reviewed 8,083 articles and identified 199 articles meeting inclusion criteria and 41 related articles. As a group, studies were of low quality, but improved over time. Most were quantitative studies conducted in the United States. Many studies utilized one of four common methodologic approaches: retrospective surveys, studies of programs or curricula, large-scale multi-institution comparisons, and single-institution exemplars. Most studies developed groundwork or examined effectiveness or impact, with few studies of planning or piloting. Few studies examined state or regional workforce outcomes. CONCLUSIONS: Research examining medical school interventions and institutional practices to support primary care specialty choice would benefit from stronger theoretical grounding, greater investment in planning and piloting, consistent use of language, more qualitative methods, and innovative approaches. Robust funding mechanisms are needed to advance these goals.

The Influence of Role Modeling and Mentorship on Primary Care Career Choice: What Can Be Gleaned From 30 Years of Research?

BACKGROUND AND OBJECTIVES: Role modeling and mentoring are key aspects of identity formation in medical school and likely influence student specialty choice. No reviews have examined the ways that mentorship relationships impact primary care career choice. METHODS: We conducted a systematic literature search to identify articles describing the influence of role models and mentorship on primary care interest, intention, or choice. A content analysis of the included articles determined which articles focused on mentorship versus role modeling and the definitions of each. We coded articles as groundwork, effectiveness, or impact depending on the methodology and outcomes of each study. RESULTS: Searches yielded 362 articles, of which 30 met inclusion criteria. Three offered definitions of role modeling, and one compared and contrasted definitions of mentoring; 17 articles laid groundwork that indicated that role modeling and mentorship are important factors in career choice and specifically in primary care. Thirteen articles reported the effectiveness and impact of role modeling and mentoring in influencing intent to enter primary care or actual career choice. Primary care and non-primary care physicians influenced student interest, intent, and choice of primary care careers; this influence could be positive or negative. CONCLUSIONS: Role modeling and mentorship influence primary care career choice. Very few articles defined the studied relationships. More work on the impact of mentorship and role modeling on career choice is needed.

Family Medicine Residents' Experience During Early Phases of the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Residents have been thrust onto the front lines of the US medical response to COVID-19. This study aimed to quantify and describe the experiences of family medicine residents nationally during the early phases of the pandemic. Specific areas of interest included training received and the residents' personal sense of safety. The purpose of this study was to look for differences among residents based on geographic location. METHOD: This May 2020 survey was conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA) of a random sample of 5,000 resident members of the American Academy of Family Physicians (AAFP). RESULTS: The overall response rate for the survey was 5.66% (283/5,000). More than 40% of residents reported having felt in moderate to significant personal danger during the COVID-19 pandemic. Fewer than 20% had been tested for COVID-19 themselves. Among all respondents, 176 (65.7%) of the residents had provided direct patient care for COVID-19-positive patients. Most had been trained on personal protective equipment and the medical aspects of COVID-19, but 16.2% reported no training on how to care for COVID-19 patients. Minority residents, and residents in larger urban areas were less likely to receive timely training. CONCLUSIONS: The COVID-19 pandemic has had a major impact on family medicine residents' medical education and their sense of safety. Regional variations in residents' educational experiences during the pandemic exist. Training prior to COVID-19 exposure was not universal. In our sample, minority residents were less likely to receive timely training than White residents.

Use of Patient Identifiers at the University of Washington School of Medicine: Building Institutional Consensus to Reduce Bias and Stigma.

BACKGROUND AND OBJECTIVES: Patient identifiers are used in the opening lines of case presentations and written documentation in health care and medical education settings. These identifiers can reflect physicians' implicit biases, which are known to impact patient care. Yet, no clear recommendations for the use of patient identifiers to reduce bias and stigma in patient care and medical education learning environments currently exist. We describe a process and outcomes for articulating such recommendations. METHODS: The University of Washington School of Medicine convened a group of diverse stakeholders to create patient identifier recommendations for use in the undergraduate medical education program. After a literature review, 22 recommendations for the use of patient identifiers were articulated. These underwent public comment periods reaching 11,150 potential respondents across our 5-state institution. Feedback from 437 respondents informed modifications to the recommendations. We used consensus methodology with three rounds of surveys and an expert group of 27 stakeholders to adopt recommendations with an a priori threshold of 90% agreeing the recommendation should be used. RESULTS: We adopted 12 recommendations for patient identifiers for age, gender/sex, race/ethnicity, sexual orientation, ability, size, and stigma; nine in round one, three in round two, and none in the third round. DISCUSSION: Our institution vetted these patient identifier recommendations via public comment and consensus methodology. Next steps include implementation across the undergraduate medical education program, including classroom and clinical settings. Other institutions could consider similar processes as key steps to reduce bias and stigma in their medical education programs.

Impact of a Targeted Rural and Underserved Track on Medical Student Match Into Family Medicine and Other Needed Workforce Specialties.

BACKGROUND AND OBJECTIVES: There is a shortage of physicians in rural communities in the United States. More than other types of primary care physicians, family physicians are the foundation for care in rural areas.1 There are also critical shortages of other specialties such as general surgery, pediatrics, internal medicine, and psychiatry in rural America.2-7 This study assessed student participation in the University of Washington School of Medicine's (UWSOM) Targeted Rural Underserved Track (TRUST) program as a predictor for family medicine (FM) and needed workforce specialty residency match. METHODS: The study group was 156 medical students from 2009-2014; 102 were accepted to the TRUST program compared to a control group of 54 who were not accepted into the TRUST program but did matriculate to UWSOM. Student characteristics for the two groups were compared using t tests. Logistic regression analysis determined whether acceptance in TRUST predicted the outcomes measures of FM residency match or residency match into a needed rural physician workforce specialty; t tests compared match rates to family medicine for TRUST applicants and graduates, UWSOM graduates, and US allopathic seniors. RESULTS: TRUST program graduates had the same FM residency match rate and match rate in needed workforce specialties as the control group. The FM match rate for TRUST graduates was 29.1% compared to UWSOM at 16.9% and US seniors at 8.7% (P<.001). CONCLUSIONS: Although match rates in FM and needed workforce specialties were not different in accepted versus not accepted groups, all TRUST applicants had an FM match rate that approaches 30%, which is higher than the general UWSOM class and the United States. In order to help reach the goal of 25% of medical students matching into FM by 2030, medical schools should consider having a rural program and using rural-focused admissions widely.

Faculty Perceptions of Formative Feedback from Medical Students.

Phenomenon: Feedback given by medical students to their teachers during a clerkship has the potential to improve learning by communicating students' needs and providing faculty with information on how to adjust their teaching. Aligning student learning needs and faculty teaching approach could result in increased student understanding and skill development before a clerkship's end. However, little is known about faculty perceptions of formative feedback from medical students and how faculty might respond to such feedback. Approach: In this qualitative study, semistructured interviews of 24 third-year clerkship faculty were conducted to explore faculty opinions about receiving formative feedback from students. Transcripts of these interviews were reviewed, and content analysis was performed. Findings: Faculty endorsed the idea of obtaining formative feedback from medical students. However, probing revealed factors that would significantly influence their receptivity and response to the feedback provided, including (a) who would be giving the feedback, (b) what content was included in the feedback, (c) how the feedback was framed, and (d) why the feedback was given. Although participants endorsed the concept of receiving formative feedback from medical students, their accounts of how they might respond to it presented a mixed picture of receptivity, acceptance, and response. Insights: These findings have practical implications. If formative feedback from medical students to faculty is to be encouraged, institutions need to find ways of creating a feedback culture in which more dialogic models become "the norm" and work with faculty to increase their receptivity to and acceptance of student feedback. This is essential for students to feel safe and be safe from retribution when providing insights into how faculty can better meet their learning needs.

Association of Family Medicine Interest at Matriculation to Medical School and FMIG Participation With Eventual Practice as a Family Physician.

BACKGROUND AND OBJECTIVES: An adequate family medicine workforce is needed to improve health and health care outcomes in the United States, yet few medical students in the US become family physicians. Indicators of family medicine interest upon medical school matriculation exist. Family medicine interest groups (FMIGs) may influence student choice. This study examines the association of FMIG participation with various matriculation interest indicators to predict which students go on to become family physicians. METHODS: The American Medical Association Masterfile was used to identify the practice specialty of 601 graduates of the University of Washington School of Medicine who matriculated between 2003 and 2007. Graduates' scores on the Family Medicine Interest Survey (FMIS) and whether a student listed family medicine as their top choice upon matriculation along with FMIG participation and demographic characteristics were used in a binary logistic regression model to predict eventual practice. The model output was used to calculate odds ratios and predicted probabilities of family medicine practice given initial family medicine interest and FMIG participation. RESULTS: FMIG participation was associated with higher odds ratios and increased predicted probability of becoming a family physician regardless of initial interest although the magnitude of the difference varied. FMIG participants who listed family medicine as their top specialty had a 68% predicted probability of entering family medicine compared to 8% probability if they did not list family medicine first and did not participate in FMIG. FMIG participation was associated with odds ratios between 3.27-4.19 for entering family medicine regardless of FMIS score. CONCLUSIONS: Among University of Washington students with family medicine as their top specialty choice upon matriculation, FMIG participation was associated with higher odds of entering the specialty. The same was true, although to a lesser degree, for students who had a high score on the FMIS.

Community Preceptor Perspectives on Recruitment and Retention: The CoPPRR Study.

BACKGROUND AND OBJECTIVES: Medical schools are increasingly challenged to recruit and retain community-based preceptors. Physicians experience various incentives and deterrents to teaching medical students while providing patient care. Self-determination theory (SDT) posits people act in response to internal and external motivations and suggests autonomy, competence, and relatedness are basic psychological needs for well-being and integrity. The applicability of SDT to explain why physicians become or remain a preceptor is uncertain. This study explores physicians' motivations for precepting medical students within the framework of SDT. METHODS: Focus groups were conducted at seven institutions chosen to represent national diversity using a semistructured interview guide based on SDT. Community-based family physicians discussed benefits and barriers to precepting. Interviews were recorded, transcribed, and coded using open codes. Thematic analysis was performed utilizing the conceptual framework of SDT emphasizing the domains of autonomy, competence, and relatedness. RESULTS: Feeling competent about their medical practice and teaching skills, reporting connectedness to the institution and students, and having autonomy over their teaching increased preceptor motivation to teach. Concerns about clinical workload demands, negative teaching experiences, and institutional bureaucracy decreased motivation. CONCLUSIONS: Preceptors choose to become and remain preceptors based on a combination of intrinsic motivating factors and effective external motivators. SDT appears to be a useful framework for assessing and responding to the needs of community-based family medicine preceptors and may be a useful guide for medical educators and policy makers seeking to identify and implement effective strategies to recruit and retain community preceptors to work with medical students.

Graduating Medical Student Perspectives on Factors Influencing Specialty Choice An AAFP National Survey.

BACKGROUND AND OBJECTIVES: Fewer than 10% of US medical school graduates enter family medicine residencies each year. Little is known about the perceptions and attitudes of senior medical students as they make final decisions about specialty choice, especially those that support a decision to pursue family medicine. The American Academy of Family Physicians (AAFP) administered a national survey to US seniors in 2015 to explore these factors. METHODS: US seniors who were AAFP members (N=11,998) were invited to complete a survey exploring attitudes toward family medicine and experiences that influenced interest and choice of family medicine (FM) or other specialties. This was offered after students submitted their National Residency Matching Program rank list but before match. For those matching in family medicine, additional questions explored mentorship experience. Factors significantly predicting intent to match in family medicine, mentor attributes significantly influencing student attitudes, and family medicine interest group (FMIG) participation were identified via regression. RESULTS: The survey response rate was 15.1%. Student perceptions of the respect of FM (OR=0.82), the future of FM (OR=2.04), and FMIG involvement (OR=1.75) predicted choosing FM, as did AAFP student membership (OR=2.13-2.44) and AAFP National Conference of Family Medicine Residents and Students attendance (OR=9.77). For students entering FM, having supportive mentors outside of FM and being dedicated to FM positively influenced their attitudes toward FM and their FMIG participation. CONCLUSION: National programs, FMIGs, mentorship, and medical school support of family medicine play a role in student selection of family medicine.

The Persistence of Specialty Disrespect: Student Perspectives.

PURPOSE: One aspect of the hidden curriculum of medicine is specialty disrespect (SD)-an expressed lack of respect among medical specialties that occurs at all levels of training and across geographic, demographic, and professional boundaries, with quantifiable impacts on student well-being and career decision making. This study sought to identify medical students' perceptions of and responses to SD in the learning environment. METHODS: We conducted quantitative and content analysis of an annual survey collected between 2008 and 2012 from 702 third- and fourth-year students at the University of Washington School of Medicine. We describe the frequency of reported SD, its self-rated impact on student specialty choice, and major descriptive categories. RESULTS: Nearly 80% of respondents reported experiencing SD in the previous year. A moderate or strong impact on specialty choice was reported by 25.9% of respondents. In our sample, students matching into family medicine, obstetrics/gynecology, and emergency medicine were most likely to report exposure. Content analysis identified two new concepts not previously reported. Internecine strife describes students distancing themselves from both disrespecting and disrespected specialties, while legitimacy questions the validity of the targeted specialty. CONCLUSIONS: SD is a consistent and ubiquitous part of clinical training that pushes students away from both disrespecting and disrespected specialties. These results emphasize the need for solutions aimed at minimizing disrespect and mitigating its effects upon students.

Validation and Comparison of a Brief Instrument vs a Single-Item Screen to Predict Entry to Family Medicine at Matriculation to Medical School.

BACKGROUND AND OBJECTIVES: A strong US primary care workforce is necessary to meet health care needs, yet fewer than 9% of allopathic medical students choose family medicine each year. No validated instrument exists to identify students likely to enter family medicine upon medical school matriculation. METHODS: A subset of a larger survey at the University of Washington School of Medicine (UWSOM) was used to create the Family Medicine Interest Survey (FMIS), a 15-item instrument to predict eventual practice in family medicine for a 2003-2007 matriculating cohort. A single-item screen asking about top specialty choice was administered at UWSOM for the same cohort and for a 2006-2012 matriculating cohort of students at Oregon Health & Science University (OHSU). Test performance measures including D (discrimination) and Cronbach α were calculated. Logistic regression determined whether FMIS score or reporting family medicine as the top specialty choice predicted family medicine practice for 601 UWSOM graduates or family medicine residency match for 744 OHSU graduates. RESULTS: The FMIS is reliable (Cronbach α=0.76). Both tests significantly predicted the probability of entering family medicine. Listing family medicine as the preferred specialty choice yielded a 47% predicted probability for UWSOM graduates entering family medicine. OHSU graduates listing family medicine first had an eightfold odds of matching to family medicine residencies. Combining the two instruments for UWSOM graduates showed a dose-response curve for predicted probability of entering family medicine with increasing levels of interest. CONCLUSION: Each screening tool can predict students more likely to enter family medicine upon matriculation.