Recruiting Community Faculty

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Recruiting

Community

Faculty

Michael C. Sharp, MD

ABSTRACT. The success of community-based resident

education depends on a partnership between a residency

program and a variety of individuals, physician and

non-physician, in the community. The process of recruiting

community faculty in the education of pediatric residents

begins with selection of learning objectives. Next,

char-acteristics of effective teachers and teaching sites should

be listed so that appropriate faculty may be identified

and recruited. A residency program’s existing physician

network of both referring physicians and graduates of

the residency is a good beginning point for making

con-tacts. Selection of specific educational goals, objectives,

and activities will lead to identification of potential

non-physician participants. Understanding why community

colleagues might want to become part of the training

program leads to techniques for contacting and recruiting

them. Pediatrics 1996;98:1268-1272; community faculty,

recruiting, resident education.

WHAT ARE THE PRELIMINARY EDUCATIONAL

GOALS?

It is important for pediatric residency programs to establish some preliminary goals for their communi-ty-based curricula. These initial goals, which will help clarify what kind of community faculty the program needs, will form a base on which the spe-cific aspects of the community activities can be jointly agreed on with the community faculty. “Pre-liminary” is an important point; the goals of the training program can only be preliminary, because community faculty must be involved in helping de-termine the final goals. Community faculty must not only understand the goals of the learning experi-ences, they must be committed to them, including colleagues in the definition of goals ensures that outcome. It is important also to include community faculty, because they may have helpful suggestions for specific methods to use in achieving the goals. Moreover, they may be able to identify financial resources to help support the ongoing costs of the program and educational resources that will prepare residents for community experiences.

A possible outline of goals for an outreach pro-gram might include increasing a resident’s:

1. Capacity to care for common acute and chronic illnesses of childhood;

2. Understanding of and ability to collaborate with community resources; and

3. Understanding of and ability to collaborate with families.

These three goals are not meant to be comprehen-sive; a residency program might want to add other goals. One might be providing residents with expe-riences to improve their skills in:

1. Organizational leadership;

2. Individual and community-based health promotion;

3. Understanding of and ability to foster social sup-port networks, access-to-care programs, or both; and

4. Use of community-based information systems.

Training residents in community settings provides an excellent opportunity to nurture values such as commitment to service, humility, honesty, and car-ing.

WHO SHOULD TEACH RESIDENTS?

Pediatric Practices

Most program directors are drawn to community sites because such sites are likely to provide residents with opportunities to increase their capacity to treat common acute and chronic illnesses of childhood. Community sites excel particularly in their capacity to provide residents with ongoing relationships with families and with exposure to both excellent role models and a large volume of patients, all at a lower cost than at tertiary care facilities.1’2 When shifting to a community emphasis, most residencies are likely to begin by recruiting community-based pediatricians to teach their residents. Programs wifi naturally have concerns about issues of quality, and, in fact, the program director has a responsibility to assure high-quality sites. Here are some criteria the program might want to consider before making an initial con-tact:

Preceptor

1. Enthusiasm for the practice of pediatrics; 2. Community connectedness;

3. Board certification; and

4. Willingness to incorporate preceptorship into the practice.

From the Office of Community Medical Education, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. PEDIATRICS (ISSN 0031 4005). Copyright © 1996 by the American Acad-emy of Pediatrics.

Office or Clinic Setting

1. 2. 3.

Openness of other staff to having residents; Physical layout; and

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Population Served

I. Diversity;

2. Adequate number; 3. Distance to travel; and 4. Housing availability, if needed

The ultimate test of the quality of the site will be resident reaction to it. Issues around program eval-uation are discussed later, but I should point out here that monitoring the experience of residents and de-veloping a mechanism to provide feedback to the community preceptor is vital to assuring quality. The program will need to be prepared to drop a precep-tor who does not seem to be providing a good expe-rience. We have found that this situation is rare, and that it rarely has to do with the knowledge or tech-nical expertise of the practitioner. Much more corn-monly, an unwillingness to devote the necessary time or an inability to cooperate on achieving learn-ing objectives is the problem, one that is likely to relate to stresses on the physician other than the presence of residents.

Some residency programs will decide that devel-oping relationships with private pediatric offices will be the only basis for their community programs. Others may decide that part of the developing resi-dent’s capacity to care for children with common diseases includes the care of children in settings such as public health departments and rural and migrant health clinics. Residency programs may also want to provide their residents with opportunities to appre-ciate the roles of nonphysicians in the delivery of health services better. If so, they may put some em-phasis on recruiting sites that have midlevel practi-tioners. Many, if not all, residency programs are likely to have an obligation to produce pediatricians who have the special skills required to work effec-tively in managed care organizations, and thus, they may seek to recruit those sites as well.

The obvious place to begin when making a list of possible sites for resident education is with pediatric practices that are related in some way to the resi-dency program. This network is likely to include not only providers who refer patients into the health center in which the residency is located, but also graduates of the training program who are located at some distance from the program. These contacts will probably have additional suggestions for possible training sites, as might the American Academy of Pediatrics chapter. If the training program has a fac-ulty of specialists, it will be a good source of sugges-tions as well.

Other Community Faculty

Community colleagues other than physicians might be best suited to help the residency program achieve some of its other learning goals. For exam-ple, to increase resident understanding of and ability to collaborate with community resources, a large variety of professionals and agencies might be re-cruited. Examples include day care providers, public and private schools, early interventionists, police and courts, allied health professionals, psychologists, dentists, nurses, child protective service workers,

home health agencies, homeless shelters, and pro-grams dealing with pregnancy prevention and do-rnestic violence.

One goal, understanding and increasing a resi-dent’s ability to collaborate with families, suggests the need to recruit families. Good sources of families would include the local ARC (previously referred to as the Association for Retarded Children), the local United Cerebral Palsy program, schools for children with special needs (hearing and vision impaired), local early intervention programs, and again, the specialists in the training program who work closely and for long periods with children with special needs, particularly those with chronic illnesses. Pe-diatric residents must be able to understand the problems of and to respect families with newborns, single parents, and addictions and those living with poverty or violence. Getting into their shoes through community experiences offers a learning opportu-nity for the resident to participate in the care of their health more skillfully.

A residency program might observe that there is an increasing need to prepare residents to practice within managed care systems. This observation itself may have many implications for community-based training programs, but an obvious one is the trend toward increased emphasis on interdisciplinary co-ordination within health care delivery systems. There have been recommendations that the physi-cian of the future will need more skills in organiza-tional leadership. To that end, one goal of a training program might be to develop other academic faculty, such as business schools or schools of public health, to help design educational programs. Community participants might include managed care or hospital administrators or individuals at the management level of public or private health agencies.

Health behavior and health education programs in schools of public health and departments of psychol-ogy or perhaps sociology may have desirable ada-demic faculty for a program to increase in residents the ability to promote individual and community-based health. Community partners could include public health departments, child advocacy groups, and city, local, or state officials, elected or appointed. Increasing evidence of the impact of social support networks on the health of individuals3 suggests the need for pediatricians to be better informed on how those networks operate and on how physicians can support their development. The important Commu-nity Access to Child Health program of the American Academy of Pediatrics4 is a wonderful opportunity for resident participation, and local Community Ac-cess to Child Health programs are obvious resources in an educational program designed to increase the capacity to initiate and promote access-to-care pro-grams.

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developing clinical reasoning and information man-agement skills in both the residents and the commu-nity preceptors.

A residency training program might decide that it wants to promote in its residents some core values it considers essential to the practice of medicine. These values might include commitment to service, hon-esty, humility, and caring. Some readers may ques-tion the likeithood of changing a resident’s values. Unquestionably, the core values a resident brings to the program are more determining of what values the individual carries into a professional career than are experiences during the training program. On the other hand, training programs exhibit and reinforce values at every turn. Thus, there is reason to believe intuitively that these programs themselves are highly influential in determining how a resident practices.

To facilitate development and exploration of activ-ities to promote the values residents are expected to acquire in a residency program, these values should be explicit and well articulated. In addition, having these values clearly defined allows the program to measure their development in the residents. I am aware of only one training program, in orthopedics, that documents resident growth in this dimension (Frank Wilson, orthopedic housestaff manual, Uni-versity of North Carolina Hospitals, 1996).

Let us assume that one goal of a residency pro-gram is to nurture caring capacity and behavior. First, it might explore what kinds of behaviors dem-onstrate caring, eg writing a personal note asking how a family is doing after discharge or going out of the way to make a phone call to a patient’s grand-parents. The residency director might decide that such behaviors were dependent on a resident’s ap-preciation for the role of the grandparents or for the family’s life outside the medical care environment. Therefore, the director might give residents more exposure to the home environment, not from the perspective of the health care provider but, rather, from the perspective of the family. For example, the resident might have an experience as a respite care provider.

Few studies document the effects of experiential learning on the development of values so that the pro-gram director is likely to need a great deal of tolerance for uncertainty in developing such programs, but some fine models and resources for experiential learning do exist, such as Health of the Public, Pew Service Learn-ing, Network of Community-Oriented Educational In-stitutions for Health Sciences, Center for Experiential Learning, the Kellogg-sponsored Community-Based Public Health Initiative, and the Institute for Family-Centered Care.

WHY DO COMMUNITY PEDIATRICIANS WANT TO

BE PRECEPTORS?

Successfully recruiting pediatricians depends to some extent on an understanding of why they might want to be involved.5 In my experience, the most powerful motivator is the community physician’s strong belief in the importance of the educational program. Such belief and commitment results in

en-thusiasm, initiative, and extra work, work far in ex-cess of what could be justified by any concrete re-wards that can be offered. Also, community pediatricians might feel particularly eager to partic-ipate because they view the community education program as validating their own values, opinions, and activities. Community medical education initia-tives are emerging at the majority of schools of medicine in this country, and the need for willing community participation is great. Developing, un-derstanding, and nurturing community partnerships is a crucial challenge in the rush to adapt to current pressures to change the physician work force. My guess is that the continued eager participation of our community-based physician colleagues will depend on continuing expressions by the residency program and other educational program directors of respect for and willingness to hear the opinions of commu-nity faculty. In my view, including community pediatricians in refining learning objectives is more likely to assure their continued enthusiastic participation than any other single aspect of this relationship.

At the same time, even if the program takes time to listen to the views of its community colleagues on the relative importance of various aspects of the training program, some other expressions of gratitude seem appropriate. Incentives that have been used include pay, but pay is troublesome because of the difficulty in finding the financial resources and because it changes the nature of the relationship between the residency and the practitioner. The financial impli-cations of training residents in private practices have been explored, and it seems clear that taking resi-dents into practices for continuity experiences in-volves no financial sacrifice.2 Other teaching and learning experiences (for example, with medical stu-dents or for shorter periods of contact) may not be as revenue neutral.6’7 Some private pediatricians may only want to participate if pay is available, although experience in this regard around the county is var-ied. What does seem certain is that this issue should be discussed before placing residents in a practice.

Other incentives that training programs have used include faculty appointments, access to information systems, access to continuing education opportuni-ties, and certificates in the practice waiting room declaring the practice a teaching site. Some pro-grams, with the necessary permissions, have sent press releases about the teaching activity of the prac-tices to local newspapers. Programs are developing locum tenens opportunities for community physi-cians, including having community physicians spend half-days or weeks at academic health centers working with specialists or developing their teaching skills.

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to comment on how they would recommend the case be handled.

WHY NONPHYSICIAN COMMUNITY

PARTICIPANTS WANT TO TEACH RESIDENTS

Incentives for nonphysician community partici-pants seem to have much more to do with educa-tional objectives than with pay or rewards. Many community professionals have seen problems cre-ated by pediatricians who either do not know how to collaborate around the care of children or do not appreciate the importance of collaboration. Most of the relationships that we have developed with our nonphysician community faculty are fueled by the desire of such colleagues to influence the attitudes and thinking of future pediatricians by spending time with them in their formative stages.

Initial Contact

HOW DOES ONE RECRUIT?

Initial contacts with potential faculty can begin as soon as objectives are defined and other groundwork has been completed. How the initial contact is made is often determined by the time frame of recruitment and the number of preceptors to be recruited. At the University of North Carolina, we had to recruit 165 community-based primary care providers to partici-pate in a medical student program. Because we had

a relatively short period to find these physicians, we

employed two medical students to help us. After they were coached on how to describe course goals and content, they worked closely with the staff of the nine statewide area health education centers and regional primary care education offices. They also talked with existing preceptors. Through this net-work, they identified community generalist pediatri-cians who were likely to be good candidates for course preceptors. The students talked directly with these physicians to explain the course and to discuss their potential role in student learning. Printed ma-terial describing the course was sent to those who requested it. The necessary preceptors were recruited in 6 weeks.

A number of years ago, we also had to find about

15 practices to help us with another medical student program. We picked North Carolina practices that were known to us either because they included grad-uates of our residency program or because they were a steady source of referrals to our medical center. In this instance, we sent each of them an individualized letter with an outline of the educational program and asked whether they would be interested in partici-pating. They were given a postcard to return to us, and the course director made personal phone calls to those who expressed interest. Thirteen of the

prac-tices returned the postcard, and we recruited every one of them.

Negotiation Around Mutual Goals

In our educational programs, we share written learning objectives with our community faculty. When we have sent residents into private practices to develop their clinical skills, these general objectives

have been accepted with little comment. We have

expected our community colleagues to spend time

with our residents, agreeing to specific learning ob-jectives at the very beginning of the week or month of their relationship. Our community physicians have had to remind us that it is difficult to find time to do this, and we have had to modify some of our expectations in this regard. We have included resi-dents, as well, in helping refine our educational ob-jectives and methods, and they continue to let us know that getting feedback on their performance from their community preceptors is very important to them. This subject continues to recur in commu-nications with preceptors; we continue to stress how important it is for them to lay out objectives and to give feedback, and they continue to point out how difficult it is to incorporate these activities into their other responsibilities. Practical tactics for efficiently incorporating residents into the patient and work flow of a busy practice continue to be an issue of mutual interest, concern, and study.

When the learning objectives have been primarily concerned with professional collaboration or under-standing and working with families, we have often arrived at objectives different from the ones that we began with, because we have discovered that our community colleagues have goals for these experi-ences that are often different or at least significantly modified from our initial ones. In most instances, the final educational program has been considerably more complex, comprehensive, and effective, in our judgment, than the one with which we began.8

SUMMARY

Recruiting community faculty in the education of pediatric residents begins by selecting learning ob-jectives. Including residents when listing character-istics of effective teachers and teaching sites before the process of identifying them is likely to be helpful.

A program’s existing physician network of both

re-ferring physicians and graduates of the residency is a good place to begin to make contacts. This network will likely have additional recommendations for pos-sible faculty. Selecting specific educational goals, ob-jectives, and activities leads to identification of po-tential nonphysician colleagues in these educational programs. Understanding why community partici-pants, both physicians and nonphysicians, might want to become part of the training program leads to techniques for contacting and recruiting them. An ongoing process-discussing the nature of the learn-ing objectives, evaluating their achievement, and re-negotiating them-is the basis for a partnership that will grow and develop over time.

MODELS AND RESOURCES FOR EXPERIENTIAL

LEARNING

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Wiscon-sin Aye, Suite 405, Bethesda, MD 20814, phone: (301) 652-0281, fax: (301) 652-0186; Community-Based Public Health Initiative, W. K. Kellogg Foundation, I Michigan Ave E, Battle Creek, MI 49017-4058, phone: (616) 968-1611, fax: (616) 968-0413; and Pew Service Learning, the Pew Charitable Trusts, the Pew Health

Pro-fessions Commissions, Center for the Health Professions,

Univer-sity of California, San Francisco, 1388 Sutter St. Suite 805, San Francisco, CA 94109, phone: (415) 476-8781.

ACKNOWLEDGMENTS

I am deeply endebted to the following individuals for help in the development of the concepts and flow of this manuscript:

Lynn Blanchard, PhD, S. Claire Lorch, MSW, Shirley Geissinger, PhD, and Katherine Savage.

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Pediatrics. 1993;91 :1089-1093

2. Sargent JR. Osborn LM. Resident training in community pediatricians’

offices: not a financial drain. Am JDis Child. 1990;144:1356-1359

3. Evans RG, Barer ML, Marmor TR, eds. Why Are Some People Healthy and Others Not? The Determinants of Health of Populations. New York, NY: Aldine de Gruyter, Inc; 1994

4. American Academy of Pediatrics. Community Access to Child Health (CATCH). Elk Grove Village, IL: American Academy of Pediatrics; 1995 5. Langlois JP. Support of community preceptors: what do they need? Fam

Med. 1995;27:641-645

6. Kirz HL, Larsen C. Costs and benefits of medical student training to a health maintenance organization. JAMA. 1986;256:734-739

7. Pawlson LG, Watkins R, Donaldson M. The cost of medical student

instruction in the practice setting. JFam Pract. 1980;10:847-852 8. Lorch SC. A social worker’s role in training residents in community

settings. In: DeWitt T, Roberts K, eds. Pediatric Education in Community Settings. A Manual. Arlington, VA: National Center for Education in Maternal and Child Health; 1996:124-125

1996;98;1268

Pediatrics

Michael C. Sharp