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The American Journal of Managed Care April 2019
Time to Fecal Immunochemical Test Completion for Colorectal Cancer
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Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH
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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
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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
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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.
The clinical faculty/preceptors domain includes faculty clinical skills, teaching ability, quality, being evidence-based, mentoring, serving as a role model, and accessibility and approachability. Our finding—that receptiveness to a career in VA was associated with how nursing and AH profession trainees rated their clinical faculty/preceptors—is consistent with the importance these programs place on learning through student interactions with faculty and preceptor role models.39 Our findings that physician preferences for future employment were unresponsive to faculty/preceptors are in contrast to those of other studies that showed that faculty and preceptors affected physician career specialty choices.40

These data failed to show a direct link between a trainee’s recruitability and VA experience with interprofessional team or patient-centered care. In fact, the presence of interprofessional team care for nursing students and patient-centered care for physician trainees had a negative influence on openness to consider VA for future employment. This is important. Both VA care models and academic institutions’ curricula emphasize patient-centered and interprofessional team care. For example, surgical team training in VA has been associated with improved mortality. Our findings are consistent with those of earlier studies that showed that physician trainees undervalue patient-centered and interprofessional team care compared with nonphysician trainees, even after changes in medical school and residency training curricula.41 On the other hand, they contrast with a finding that internal medicine residents rotating through VA primary care continuity clinics are more likely to value patient-centered and interprofessional team care than colleagues at non-VA continuity clinics.42 More studies are needed to understand the relationship between how trainees value patient-centered and interprofessional team care and their future employment choices.

Our finding that female AH trainees were more responsive to recruitability following training than male AH trainees is consistent with the psychology literature that suggests differential influences on job choices between women and men. One study showed that more on-the-job engagement is associated with decreased job turnover and that this association was stronger in female-dominated samples.43

These findings also shed light on the critical priority of enhancing recruitment of health professionals in rural areas. Overall, trainees in rural facilities began and ended their training with a poorer view of VA employment than their urban counterparts. However, rurality was a positive modifier for AH trainees, who demonstrated a 1.77-fold increase in recruitability (Table 3). This underscores the critical importance of establishing quality health professions training programs in rural settings. An important caveat is that an increase in recruitability does not necessarily imply increased willingness to work for VA in a rural versus urban setting.


This study has limitations. First, this is a convenience sample subject to selection biases. Despite adjusting estimates to account for mediating interactions and blinding participants to the study purpose, some selection biases will likely remain. In prior studies,4 (also J.M.B. et al, unpublished data, 2017) LPS respondents who were physician residents were comparable by gender, academic level, international status, and specialty with residents in all accredited, nonpediatric, and non-OB/GYN US residency programs. Second, our use of observational data will leave estimates of associations subject to confounding biases. However, randomized trials are not practical here.44 Mitigating this bias was a pre–post comparison in which subjects serve as their own controls, and final estimates are adjusted for respondent and facility factors and calculated by discipline. Third, both pre- and posttraining recruitability questions were administered in the same survey, introducing recall bias and possibly blurring differences to create downward biases on the estimates of associations between training and recruitability. Fourth, the data are not linked to actual employment decisions made by respondents. However, intentions to stay have been shown to be related to job search behavior, job performance, and, ultimately, actual turnover.35 Future studies should follow respondents and their actual employment decisions. Fifth, cross-profession comparisons may be biased by how healthcare professionals in different disciplines perceive satisfaction.45 To mitigate these biases, estimates were adjusted to reflect variation in response thresholds to account for how respondents approached classifying the intensity of their perceptions into 5-level ordered responses. Finally, variation in organizational factors may also affect the trainee’s employment choices. However, there is little evidence that VA reorganization in specialties such as psychiatry had meaningful impacts on employee satisfaction or perceptions of their work environment.46


To recruit professional staff from among their physician, nursing, and associated health trainees, academic medical centers are advised to invest in their training mission in order to improve trainee clinical, working, learning, and cultural experiences.


The authors express their sincere gratitude for the support from the Office of Academic Affiliations (OAA) (Jemma Ayvazian, DNP, ANP-BC, AOCNP, and Samuel S. King, MS, MDiv), OAA’s National Evaluation Workgroup (Sheri A. Keitz, MD, PhD, chair), OAA Data Management and Support Center in St. Louis, Missouri (Christopher T. Clarke, PhD; David Bernett, BA; Terry V. Kruzan; George E. McKay; and Laura Stefanowycz), and the network of Designated Education Officers and Associated Chiefs of Staff for Education at VA Medical Centers.

Author Affiliations: UMass Memorial Medical Center at the University of Massachusetts (SAK), Worcester, MA; Louis Stokes Cleveland DVA Medical Center (DCA), Cleveland, OH; School of Medicine and Weatherhead School of Management, Case Western Reserve University (DCA), Cleveland, OH; Virginia Commonwealth University (JLB), Richmond, VA; Jerry L. Pettis Memorial VA Medical Center (JMB), Loma Linda, CA; Loma Linda University Medical School (JMB, TMK), Loma Linda, CA; George E. Wahlen VA Medical Center (GWC), Salt Lake City, UT; School of Medicine, University of Utah (GWC), Salt Lake City, UT; Office of Academic Affiliations, Department of Veterans Affairs (CTC, SCG, DLH, RAZ, ABW, TMK), Washington, DC; Tibor Rubin VA Medical Center (SCG), Long Beach, CA; University of California, Irvine (SCG), Irvine, CA; Pennsylvania College of Optometry and College of Health Sciences, Salus University (DLH), Elkins Park, PA; VA Puget Sound Health Care System (CPK), Seattle, WA; University of Washington School of Medicine (CPK), Seattle, WA; Office of Academic Affiliations, VA Medical Center (DSB), St. Louis, MO; University of Texas Southwestern Medical Center (TMK), Dallas, TX.

Source of Funding: This study was supported by the Office of Academic Affiliations and IIR14-071 from Health Services Research and Development Service, Veterans Health Administration, Department of Veterans Affairs, Washington, DC. All statements and descriptions expressed herein are those of the authors and do not necessarily reflect the opinions or positions of the Department of Veterans Affairs or its affiliated institutions.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SAK, DCA, JLB, JMB, CTC, SCG, DLH, CPK, RAZ, TMK); acquisition of data (SAK, DCA, JMB, GWC, CTC, CPK, DSB, ABW, TMK); analysis and interpretation of data (SAK, DCA, JLB, JMB, GWC, SCG, DLH, CPK, RAZ, ABW, TMK); drafting of the manuscript (SAK, DCA, JLB, JMB, GWC, CPK, RAZ, TMK); critical revision of the manuscript for important intellectual content (SAK, DCA, JLB, JMB, GWC, SCG, DLH, CPK, RAZ, DSB, ABW, TMK); statistical analysis (TMK); and administrative, technical, or logistic support (JLB, CTC, DSB, ABW, TMK).

Address Correspondence to: T. Michael Kashner, PhD, JD, VA Loma Linda Healthcare System, Research Service (151), 11201 Benton St, Loma Linda, CA 92357. Email:

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