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The American Journal of Managed Care April 2019
Time to Fecal Immunochemical Test Completion for Colorectal Cancer
Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
From the Editorial Board: Kavita K. Patel, MD, MS
Kavita K. Patel, MD, MS
Comment on Generalizability of GLP-1 RA CVOTs in US T2D Population
Maureen J. Lage, PhD
Authors’ Reply to “Comment on Generalizability of GLP-1 RA CVOTs in US T2D Population”
Eric T. Wittbrodt, PharmD, MPH; James M. Eudicone, MS, MBA; Kelly F. Bell, PharmD, MSPhr; Devin M. Enhoffer, PharmD; Keith Latham, PharmD; and Jennifer B. Green, MD
Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences
Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH
The Health and Well-being of an ACO Population
Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Marcia Lowry, MS; Sachin Rauri, MS; Juliana O. Tillema, MPA; Jeanette Y. Ziegenfuss, PhD; Nicolaas P. Pronk, PhD, MA; and Susan M. Knudson, MA
Effect of Changing COPD Triple-Therapy Inhaler Combinations on COPD Symptoms
Nick Ladziak, PharmD, BCACP, CDE; and Nicole Paolini Albanese, PharmD, BCACP, CDE
Deaths Among Opioid Users: Impact of Potential Inappropriate Prescribing Practices
Jayani Jayawardhana, PhD; Amanda J. Abraham, PhD; and Matthew Perri, PhD
Do Health Systems Respond to the Quality of Their Competitors?
Daniel J. Crespin, PhD; Jon B. Christianson, PhD; Jeffrey S. McCullough, PhD; and Michael D. Finch, PhD
Currently Reading
Impact of Clinical Training on Recruiting Graduating Health Professionals
Sheri A. Keitz, MD, PhD; David C. Aron, MD; Judy L. Brannen, MD; John M. Byrne, DO; Grant W. Cannon, MD; Christopher T. Clarke, PhD; Stuart C. Gilman, MD; Debbie L. Hettler, OD, MPH; Catherine P. Kaminetzky, MD, MPH; Robert A. Zeiss, PhD; David S. Bernett, BA; Annie B. Wicker, BS; and T. Michael Kashner, PhD, JD
Continuity of Outpatient Care and Avoidable Hospitalization: A Systematic Review
Yu-Hsiang Kao, PhD; Wei-Ting Lin, PhD; Wan-Hsuan Chen, MPH; Shiao-Chi Wu, PhD; and Tung-Sung Tseng, DrPH

Impact of Clinical Training on Recruiting Graduating Health Professionals

Sheri A. Keitz, MD, PhD; David C. Aron, MD; Judy L. Brannen, MD; John M. Byrne, DO; Grant W. Cannon, MD; Christopher T. Clarke, PhD; Stuart C. Gilman, MD; Debbie L. Hettler, OD, MPH; Catherine P. Kaminetzky, MD, MPH; Robert A. Zeiss, PhD; David S. Bernett, BA; Annie B. Wicker, BS; and T. Michael Kashner, PhD, JD
A business case is made for medical centers to offer high-quality clinical training experiences to recruit graduating health professionals.

Objectives: Recruiting professional staff is an important business reason for hospitals allowing health trainees to engage in supervised patient care. Whereas prior studies have focused on educational institutions, this study focuses on teaching hospitals and whether trainees’ clinical experiences affect their willingness to work (ie, recruitability) for the type of healthcare center where they trained.

Study Design: A pre–post, observational study based on Learners’ Perceptions Survey data in which respondents served as their own controls.

Methods: Convenience sample of 15,207 physician, 11,844 nursing, and 13,012 associated health trainees who rotated through 1 of 169 US Department of Veterans Affairs (VA) medical centers between July 1, 2014, and June 30, 2017. Generalized estimating equations computed how clinical, learning, working, and cultural experiences influenced pre–post differences in willingness to consider VA for future employment.

Results: VA recruitability increased dramatically from 55% pretraining to 75% post training (adjusted odds ratio [OR], 2.1; 95% CI, 2.0-2.1; P <.001) in all 3 cohorts: physician (from 39% to 59%; OR, 1.6; 95% CI, 1.5-1.6; P <.001), nursing (from 61% to 84%; OR, 2.5; 95% CI, 2.4-2.6; P <.001), and associated health trainees (from 68% to 87%; OR, 2.7; 95% CI, 2.6-2.9; P <.001). For all trainees, changes in recruitability (P <.001) were associated with how trainees rated their clinical learning environment, personal experiences, and culture of psychological safety. Satisfaction ratings with faculty and preceptors (P <.001) were associated with positive changes in recruitability among nursing and associated health students but not physician residents, whereas nursing students who gave higher ratings for interprofessional team culture became less recruitable.

Conclusions: Academic medical centers can attract their health trainees for future employment if they provide positive clinical, working, learning, and cultural experiences.

Am J Manag Care. 2019;25(4):e111-e118
Takeaway Points

This multisite, multiyear study found that health trainees were likely to consider future employment at medical centers where they received supervised clinical training, but only when trainees were satisfied with:
  • The clinical learning environment.
  • Their personal experiences.
  • The institutional culture.
As healthcare systems consider investments in clinical education, they desire evidence to support whether healthcare training provides a return on investment. Evidence exists that successful recruitment and retention of healthcare professionals is associated with higher employee satisfaction,1 which in turn is related to improved patient satisfaction2 and quality of care.3 However, there is a paucity of evidence quantifying any association between training and willingness of trainees to work in the systems where they trained. The Department of Veterans Affairs (VA) healthcare system, with long-standing investments in healthcare training, provides a model to study this association that is applicable to broader settings. The foundation for this model is based on evidence that clinical training experiences and program factors have been shown4-9 (also J.M.B. et al, unpublished data, 2017) to be related in the VA.

In the United States, healthcare trainees’ career choices regarding location and specialty are not strategically aligned with healthcare needs, especially in primary care, rural areas, and underserved populations that include veterans.10 Traditional models to explain location and specialty choices among physicians have emphasized trainee attitudes and sociodemographic and environmental factors.11 Previous studies have focused on predictors including debt load, earning potential,12 lifestyle, and specialty prestige.13 The location of physician training programs has also been reported as a driver of career choice, as residents often elect to stay in the geographic areas where they trained,14 including in small towns,15 underserved areas,16 and rural settings.17 Furthermore, rural hospitals with residency programs were more successful at recruiting and retaining physicians than rural hospitals without residency programs.18,19 Few studies have examined career location and practice choices among nonphysician health professionals, critically including those in nursing and associated health (AH) disciplines (see Table 1 [part A and part B] for definition of AH).

We examine 2 questions pertaining to whether a training experience is sufficient to critically affect career choices across healthcare disciplines. Did the clinical learning experiences of physician, nursing, and AH profession trainees influence their consideration about future employment in VA? If yes, what were the salient factors that led to those changes in perceptions?



The study took place in 169 VA facilities in which health professions students, interns, residents, fellows, and other trainees rotate as part of an education curriculum under affiliation agreements (38 USC 7302) between VA and 135 allopathic medical schools, 30 osteopathic medical schools, and more than 1800 colleges and universities.

Data and Design

This was a pre–post intervention study in which subjects served as their own controls. Observational data came from a convenience sample of trainees who had concluded their rotation through a VA medical center between July 1, 2014, and June 30, 2016, and who agreed to take the survey, entered a designated website, and completed the survey. Overall, 85% of respondents who entered the website completed the survey. All VA trainees were invited to enter the website and complete the survey through emails and direct contacts by VA program officers at the time the trainee exited from VA.

At the end of their rotation, respondents were administered the Learners’ Perceptions Survey (LPS),20 an anonymous, voluntary, online survey. Here, respondents were asked about their perceptions of VA covering 3 time periods: prerotation, during their clinical rotation, and immediately after their rotation. The 1-survey administration design allows us to match pre–post perceptions without having to identify trainees, who are considered to be vulnerable human subjects.

Since 2000, VA’s Office of Academic Affiliations has administered the LPS under the Office of Management and Budget’s Information Collection Authorization (#2900-0691, VA form #10-0439) within a confidential Data Accounting System.21 LPS response data used for this study show high levels of content validity, test–retest reliability, scalability, internal consistency, and discriminant and congruent construct validity.5,22,23 LPS physician respondents are comparable with residents (excluding pediatrics and obstetrics/gynecology [OB/GYN]) in US accredited graduate medical education programs in 20134 and 2015 with respect to gender, specialty, international graduate status, and postgraduate year (PGY) (J.M.B. et al, unpublished data, 2017).


Our purpose is to measure the change in a trainee’s willingness to consider VA for future employment following their VA training experience, here referred to as recruitability. Pretraining perception is determined by asking, “Before this VA clinical training experience, how likely were you to consider a future employment opportunity at a VA medical facility?” and posttraining perception by asking, “As a result of this VA clinical training experience, how likely would you be to consider a future employment opportunity at a VA medical facility?” on 5-point ordinal scales with response choices of very unlikely, somewhat unlikely, had not thought about it, somewhat likely, and very likely.

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