Impact of Clinical Training on Recruiting Graduating Health Professionals

A business case is made for medical centers to offer high-quality clinical training experiences to recruit graduating health professionals.

ABSTRACT

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-e118Takeaway 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?

METHODS

Setting

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).

Outcomes

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.

Training Experiences

The LPS also asks respondents to rate their clinical training during their VA rotation on 6 satisfaction and 3 assessment domains. Satisfaction was rated on a 5-point scale for the 7-item clinical environment, 9-item working environment, 8-item physical environment, 7-item personal experience, 15-item learning environment, and 13-item clinical faculty and preceptors domains. To compute satisfaction domain scores, a value of 1 was assigned to responses of very dissatisfied, 2 to somewhat dissatisfied, 3 to neither satisfied nor dissatisfied, 4 to somewhat satisfied, and 5 to very satisfied. Domains were scored as Likert scales24 by taking the mean response across all items within each domain. This is appropriate because the items have been shown to constitute a single dimension.22,23

Assessment domains were computed based on how much respondents agreed or disagreed with a statement describing their training experiences. Items were scored by assigning a value of 1 to responses of strongly disagree, 2 to disagree, 3 to neither disagree nor agree, 4 to agree, and 5 to strongly agree. As with satisfaction, assessments were scored as the mean responses across n items for 2-item psychological safety, 16-item patient-centered care, and 9-item interprofessional team care domains.

Structural Factors

LPS responses were also used to assess other covariates. Facility-level factors include complexity as scored officially by VA on a 5-level scale based on number of beds, clinical services offered, number and diversity of trainees, and dollars of research support.25 VA also computes a rurality index as the ratio of a facility’s census of rural and highly rural patients to total patient census. At the respondent level, factors are the trainee’s gender, length of time in VA, academic program, and academic level. The mix of patients seen during their VA rotations is computed across 8 variables. These variables describe the percent of patients the respondent saw who were 65 years or older; female; with a chronic mental illness, a chronic medical illness, multiple medical illnesses, and alcohol/substance dependence; with low income/socioeconomic status; or lacking social/family support. To avoid confounding with professional discipline, patient mix factors were centered around the mean for all respondents with the same professional discipline, specialty, and academic level. Finally, as described elsewhere,8,22 associations were calibrated to reflect differences in how trainees apply thresholds when classifying the intensity of their satisfaction into 1 of the 5 response levels. This calibration index is computed by taking the respondent’s mean satisfaction rating for facility-level items (facility convenience, parking, and electronic health record) and subtracting the average of these mean ratings across all respondents at the respondent’s VA facility and reporting year.

Analyses

Recruitability, both before and after training, was measured on a 5-point ordinal scale and treated analytically as repeated measures, based on generalized estimating equations with a multinomial distribution and cumulative logit link function. The training effect was computed as an odds ratio by discipline based on estimates of the coefficient to an independent time indicator variable that equals 1 if post VA training and 0 if pre—VA training. Factors related to these associations were estimated using interaction terms calculated by multiplying a suspected mediator with the time indicator variable. Academic level (years of training) was centered to reflect a referent academic level that describes the level at which a trainee was most likely to be exposed to VA for the first time in that discipline (eg, third-year medical student, PGY1 physician resident, PGY4 resident in medicine subspecialty; see Table 2). Finally, the mean-centered patient mix and calibration index variables were included as control variables to reduce confounding in estimated associations between training experience and recruitability. For this exploratory study, a Wald χ2 test statistic is computed, and 95% CIs and P values provided, to indicate precision of effect size estimates, and not for hypothesis testing.

RESULTS

Sample

Table 1 describes characteristics of survey respondents; they represent a broad range of professional disciplines, subspecialties, academic levels, gender, mix of patients seen, facility location (rural or urban), complexity of care, and respondents’ perceptions of training experiences across 9 domains. The domains are presented in descending rank of satisfaction or agreement for all trainees. Overall, physician trainees tended to rate their clinical training experiences lower than their nursing or AH counterparts. Faculty/preceptors was the highest-rated and interprofessional team care was the lowest-rated domain across professions.

Overall Pre—Post Training Effect on Recruitability by Discipline

As shown in Table 2, VA trainees were 2.1 times more likely to consider VA employment after VA experiences, with recruitability increasing from 1.6-fold for physicians to 2.5-fold for nursing and 2.7-fold for AH trainees. The largest before—after differences were reported for blind and other rehabilitation therapy (4.5), speech pathology (4.3), and occupational (4.2) and physical (4.1) therapy. Podiatry residents were the only profession reporting no net increase in recruitability following VA training.

Impact of Clinical Experience and Program Factors on Recruitability

Table 3 reports how satisfaction and assessment ratings of the clinical experiences and program factors were associated with pre—post changes in recruitability for physician, nursing, and AH profession trainees. For all 3 groups, higher ratings for learning environment, personal experiences, and psychological safety were associated with larger changes in recruitability. Physician trainees were also influenced by how they rated their clinical environment, whereas nursing students and AH trainees were influenced by how they rated faculty/preceptors. In contrast, the presence of interprofessional team experiences and patient-centered care were unrelated to changes in recruitability. In fact, clinical environments emphasizing interprofessional team care were associated with smaller changes in recruitability for nursing students. Ratings of satisfaction with physical environment did not influence the impact of training on recruitability for any group. Among training program characteristics, training in more complex facilities had a slight advantage in increasing recruitability. Gender mattered only for AH, where female trainees were observed to be 1.2 times more likely to change perceptions about VA employment than were their male counterparts.

Prior to training, trainees at rural VA medical centers were only 59.6% (95% CI, 52.2%-67.9%; P <.001) as likely to consider VA employment as their urban counterparts. VA training narrowed this gap, but only for AH trainees. That is, AH trainees at rural VA medical centers were initially only 41.9% (95% CI, 33.8%-51.9%; P <.001) as likely to consider VA employment as their urban counterparts. After VA training, this increased by an adjusted factor of 1.77 (95% CI, 1.44-2.17; P <.001) to 74.1% (95% CI, 58.0%-94.6%; P <.001).

DISCUSSION

VA medical centers face many of the same challenges of staff recruitment and retention as academic medical centers in the private sector that engage in patient care, health profession education, and research. This study found that clinical trainees from all disciplines, except podiatry, were substantially more likely to consider VA for future professional employment after clinical training at a VA facility than before. This pre—post increase in recruitability was associated not only with structural factors, but also with their clinical training experiences. This is consistent with the theory that mere exposure to a teaching facility is not sufficient to induce trainees to change their perceptions about whether they will want to work there in the future. These data suggest that across disciplines, urban/rural settings, and facility complexities, trainees must give high ratings to their learning environment, personal experiences, and sense of psychological safety before their VA training experiences are expected to be associated with improved willingness to consider VA for future employment.

Our findings provide a business case to support VA’s long-standing affiliations with the nation’s academic institutions.26,27 VA Policy Memorandum Number 2, published January 30, 1946, codified relationships between VA facilities and medical schools that gave veterans the highest quality medical care and opportunities to further their education, raise the standard of medical practice in the United States, and mitigate the shortage of physicians after World War II.28,29 These data provide evidence that the network of academic partnerships increased healthcare trainee willingness to work in VA14 and are consistent with the policy behind the Veterans Access, Choice, and Accountability Act of 2014 [PL 113-146; 38 USC 7302(e) (1)-(2)], which expands the number of funded VA physician resident and fellow positions in primary care, mental health, and other specialties by 1500 over 10 years.30,31

Psychological safety is defined as a sense of safety in taking personal risks to discuss problems without fear of retribution. Our data suggest that psychological safety is associated with future employment choices across all trainee disciplines. Our finding is consistent with earlier reported positive associations between psychological safety and trainee satisfaction with the clinical learning environment,8 error reporting, team performance, personal work engagement and systems improvement,32-34 and mental health employees’ job satisfaction and turnover intentions.35 Collectively, these studies underscore the role that psychological safety plays in the quality of clinical training programs.

Personal experiences include job stress, fatigue, and capacity to balance personal and professional life. Our data showing that personal experience is important to future employment preferences of physician, nursing, and AH profession trainees are consistent with prior findings that controllable lifestyles influence specialty choices.36,37 While lifestyle factors have also been shown to be important to dental students,38 the literature does not offer insight into the effect of lifestyle or personal experiences on employment choice of other AH trainees.

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.

Limitations

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

CONCLUSIONS

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.

Acknowledgments

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: michael.kashner@va.gov.REFERENCES

1. Breaugh JA, Starke M. Research on employee recruitment: so many studies, so many remaining questions. J Manage. 2000;26(3):405-434. doi: 10.1177/014920630002600303.

2. Collins KS, Collins SK, McKinnies R, Jensen S. Employee satisfaction and employee retention: catalysts to patient satisfaction. Health Care Manag (Frederick). 2008;27(3):245-251. doi: 10.1097/01.HCM.0000318755.24332.4b.

3. Mohr DC, Young GJ, Meterko M, Stolzmann KL, White B. Job satisfaction of primary care team members and quality of care. Am J Med Qual. 2011;26(1):18-25. doi: 10.1177/1062860610373378.

4. Kashner TM, Hettler DL, Zeiss RA, et al. Has interprofessional education changed learning preferences? a national perspective. Health Serv Res. 2017;52(1):268-290. doi: 10.1111/1475-6773.12485.

5. Cannon GW, Keitz SA, Holland GJ, et al. Factors determining medical students’ and residents’ satisfaction during VA-based training: findings from the VA Learners’ Perceptions Survey. Acad Med. 2008;83(6):611-620. doi: 10.1097/ACM.0b013e3181722e97.

6. Kaminetzky CP, Keitz SA, Kashner TM, et al. Training satisfaction for subspecialty fellows in internal medicine: findings from the Veterans Affairs (VA) Learners’ Perceptions Survey. BMC Med Educ. 2011;11:21. doi: 10.1186/1472-6920-11-21.

7. Lam H-T, O’Toole TG, Arola PE, Kashner TM, Chang BK. Factors associated with the satisfaction of millennial generation dental residents. J Dent Educ. 2012;76(11):1416-1426.

8. Torralba KD, Loo LK, Byrne JM, et al. Does psychological safety impact the clinical learning environment for physician residents? results from the VA’s Learners’ Perceptions Survey. J Grad Med Educ. 2016;8(5):699-707. doi: 10.4300/JGME-D-15-00719.1.

9. Kashner TM, Henley SS, Golden RM, et al. Studying effects of ACGME duty hours limits on resident satisfaction: results from the VA Learners’ Perceptions Survey. Acad Med. 2010;85(7):1130-1139. doi: 10.1097/ACM.0b013e3181e1d7e3.

10. Phillips RL Jr, Dodoo MS, Petterson S, et al. Specialty and geographic distribution of the physician workforce: what influences medical student & resident choices? Washington, DC: The Robert Graham Center; 2009. graham-center.org/dam/rgc/documents/publications-reports/monographs-books/Specialty-geography-compressed.pdf. Accessed March 10, 2019.

11. Wolinsky FD. Why physicians choose different types of practice settings. Health Serv Res. 1982;17(4):399-419.

12. Sivey P, Scott A, Witt J, Joyce C, Humphreys J. Junior doctors’ preferences for specialty choice. J Health Econ. 2012;31(6):813-823. doi: 10.1016/j.jhealeco.2012.07.001.

13. Creed PA, Searle J, Rogers ME. Medical specialty prestige and lifestyle preferences for medical students. Soc Sci Med. 2010;71(6):1084-1088. doi: 10.1016/j.socscimed.2010.06.027.

14. Dorner FH, Burr RM, Tucker SL. The geographic relationships between physicians’ residency sites and the locations of their first practices. Acad Med. 1991;66(9):540-544.

15. Hancock C, Steinbach A, Nesbitt TS, Adler SR, Auerswald CL. Why doctors choose small towns: a developmental model of rural physician recruitment and retention. Soc Sci Med. 2009;69(9):1368-1376. doi: 10.1016/j.socscimed.2009.08.002.

16. Brazeau NK, Potts MJ, Hickner JM. The Upper Peninsula Program: a successful model for increasing primary care physicians in rural areas. Fam Med. 1990;22(5):350-355.

17. Crump WJ, Fricker RS, Ziegler C, Wiegman DL, Rowland ML. Rural track training based at a small regional campus: equivalency of training, residency choice, and practice location of graduates. Acad Med. 2013;88(8):1122-1128. doi: 10.1097/ACM.0b013e31829a3df0.

18. MacQueen IT, Maggard-Gibbons M, Capra G, et al. Recruiting rural healthcare providers today: a systematic review of training program success and determinants of geographic choices. J Gen Intern Med. 2018;33(2):191-199. doi: 10.1007/s11606-017-4210-z.

19. Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Med Teach. 2004;26(3):265-272. doi: 10.1080/0142159042000192055.

20. Keitz SA, Holland GJ, Melander EH, Bosworth HB, Pincus SH; VA Learners’ Perceptions Working Group. The Veterans Affairs Learners’ Perceptions Survey: the foundation for education quality improvement. Acad Med. 2003;78(9):910-917.

21. Kashner TM, Hinson RS, Holland GJ, et al. A data accounting system for clinical investigators. J Am Med Inform Assoc. 2007;14(4):394-396. doi: 10.1197/jamia.M2218.

22. Kashner TM, Clarke CT, Aron DC, et al. The 9-criteria evaluation framework for perceptions surveys: the case of VA’s Learners’ Perceptions Survey. Biostat Epidemiol. In press.

23. McKay T, Velasco ED, Perez EV, et al. Psychometric properties of VA’s Learners’ Perceptions Survey. Poster presented at: 13th Annual Association of American Medical Colleges’ Health Workforce Research Conference; May 4-5, 2017; Arlington, VA.

24. Likert R. A technique for the measurement of attitudes. Arch Psychol. 1932;22(140):1-55.

25. Peterson D. FY17 VHA Facility Complexity Model Overview. Veterans Health Administration Office of Productivity, Efficiency, and Staffing website. http://opes.vssc.med.va.gov/FacilityComplexityLevels/Pages/default.aspx. Published November 6, 2017. Accessed March 11, 2019.

26. The Report of the Blue Ribbon Panel on VA-Medical School Affiliations: Transforming an Historic Partnership for the 21st Century. Washington, DC: Veterans Health Administration, Office of Academic Affiliations; 2009. https://www.va.gov/oaa/archive/BRP-final-report.pdf. Accessed March 11, 2019.

27. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med. 2003;348(22):2218-2227. doi: 10.1056/NEJMsa021899.

28. Longo WE, Cheadle W, Fink A, et al. The role of the Veterans Affairs Medical Centers in patient care, surgical education, research and faculty development. Am J Surg. 2005;190(5):662-675. doi: 10.1016/j.amjsurg.2005.07.001.

29. The VA and academic medicine: partners in health care, training, and research. Association of American Medical Colleges website. aamc.org/download/383770/data/06262014.pdf. Accessed February 23, 2018.

30. Chang BK, Brannen JL. The Veterans Access, Choice, and Accountability Act of 2014: examining graduate medical education enhancement in the Department of Veterans Affairs. Acad Med. 2015;90(9):1196-1198. doi: 10.1097/ACM.0000000000000795.

31. Impact of the VACAA (Choice Act) on training at VA. VA Office of Academic Affiliations. va.gov/OAA/VACAA_Impact.asp. Updated June 29, 2018. Accessed March 10, 2019.

32. Derickson R, Fishman J, Osatuke K, Teclaw R, Ramsel D. Psychological safety and error reporting within Veterans Health Administration hospitals. J Patient Saf. 2015;11(1):60-66. doi: 10.1097/PTS.0000000000000082.

33. Carmeli A, Gittell JH. High-quality relationships, psychological safety, and learning from failure in work organizations. J Organ Behav. 2009;30(6):709-729. doi: 10.1002/job.565.

34. Yanchus NJ, Derickson R, Moore SC, Bologna D, Osatuke K. Communication and psychological safety in Veterans Health Administration work environments. J Health Organ Manag. 2014;28(6):754-776.

35. Yanchus NJ, Periard D, Moore SC, Carle AC, Osatuke K. Predictors of job satisfaction and turnover intention in VHA mental health employees: a comparison between psychiatrists, psychologists, social workers, and mental health nurses. Hum Serv Organ Manag Leadersh Gov. 2015;39(3):219-244. doi: 10.1080/23303131.2015.1014953.

36. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students [erratum in JAMA. 2003;290(20):2666]. JAMA. 2003;290(9):1173-1178. doi: 10.1001/jama.290.9.1173.

37. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two US medical schools, 1998-2004. Acad Med. 2005;80(9):809-814.

38. Gallagher J, Clarke W, Wilson N. Understanding the motivation: a qualitative study of dental students’ choice of professional career. Eur J Dent Educ. 2008;12(2):89-98. doi: 10.1111/j.1600-0579.2008.00506.x.

39. Beecroft PC, Santner S, Lacy ML, Kunzman L, Dorey F. New graduate nurses’ perceptions of mentoring: six-year programme evaluation. J Adv Nurs. 2006;55(6):736-747. doi: 10.1111/j.1365-2648.2006.03964.x.

40. Wright S, Wong A, Newill C. The impact of role models on medical students. J Gen Intern Med. 1997;12(1):53-56.

41. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700. doi: 10.1001/jama.2010.1506.

42. Byrne JM, Chang BK, Gilman SC, et al. The Learners’ Perceptions Survey-Primary Care: assessing resident perceptions of internal medicine continuity clinics and patient-centered care. J Grad Med Educ. 2013;5(4):587-593. doi: 10.4300/JGME-D-12-00233.1.

43. Jiang K, Liu D, McKay PF, Lee TW, Mitchell TR. When and how is job embeddedness predictive of turnover? a meta-analytic investigation. J Appl Psychol. 2012;97(5):1077-1096. doi: 10.1037/a0028610.

44. Kashner TM. Making causal inferences from observational databases? Am J Psychiatry. 2016;173(12):1161-1162. doi: 10.1176/appi.ajp.2016.16091091.

45. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166. doi: 10.1186/1472-6963-9-166.

46. Mohr DC, Bauer MS, Penfold RB. Changes in VA psychiatrists’ attitudes about work environment and turnover during mental health service enhancement. Psychiatr Serv. 2013;64(6):563-569. doi: 10.1176/appi.ps.201200337.