Healthcare providers are being asked to redesign their care delivery systems to confront two intertwined pressures: new consumer expectations about timely care, and an acute shortage of physicians spanning nearly all specialties.

Navigating these twin challenges creates a particularly thorny dilemma for graduate medical education (GME) programs. Health systems that would otherwise engage in the professional development of physicians through residencies and fellowships are grappling with a decline in physician availability for providers acting as preceptors in such programs. That seems to leave them with an intractable decision: meet today’s patient demand with the resources available now, or invest in their future physician networks by training tomorrow’s providers.

Fortunately, it’s not an either-or proposition. With careful planning and a solid operational platform, the modern health system can successfully operate GME programs without compromising access to care.

Finding the Balance

When properly configured, GME programs can contribute to both growing the future medical staff and expanding appropriate access for patients. This requires GME programs to be thoughtful about integrating strong patient access operations that are aligned with the broader health system’s goals but tailored to the educational setting.

The ambulatory clinic experience is foundational to primary care residency training. Continuity clinics serve as the primary environment in which residents learn to provide longitudinal, coordinated care within team-based and evolving care models. This formative period imprints practice patterns daily through clinical exposure, shaping how physicians deliver care long after graduation. As a result, the structure and efficiency of clinic operations are not merely logistical concerns, but critical determinants of how future primary care physicians learn to practice.

By implementing the following purpose-driven policies and workflows, GME programs can find the sweet spot between improving patient access while promoting a robust learning environment for their residents:

1. Reconcile Clinical Work Effort: Maintaining accurate provider work effort in the clinical, research, and academic setting is critical to program the right volume of clinical effort appropriately. Perform a quarterly review of each provider’s assigned clinical and academic FTE. Their clinical availability to see patients (via a scheduling template) should be audited to ensure it matches the intended effort.
2. Establish Preceptor Target Ratios: When serving as a preceptor, the program should have clear guidelines around the ratio of precepting physicians and residents. When the ratio is as low as 1:1, the preceptor may still be required to see patients independently while supporting the resident (and maintaining accreditation requirements). Additional considerations should be given to the mix of PGY levels of the residents, which may enable a ratio as high as 4:1 with more senior residents.
3. Appropriately Enable Residents’ Practice: In a teaching clinic, a resident can render moderate to low-level encounters without the direct supervision of their faculty member under the CMS primary care exception (PCE) as long as specific provisions are met. Utilizing the PCE in a teaching clinic can create capacity for expanded patient access and provide valuable learning experiences for physician learners.
4. Optimize Template Design: Preceptors and residents should have a curated template that is built on the same best-practice specialty-specific design of the non-GME practices. Ensure that visit types are consolidated and appointment lengths are stackable. Purposefully program the mix of appointment types at different patient arrival times to improve patient flow and availability of the preceptor for cases that are likely to be more complex. Finally, create a consistent template design that ensures ongoing availability (seasonally adjusted) to foster continuity for patients and residents.
5. Measure and Adjust for No-Shows: As in all practices, residency clinics will experience a reliable volume of no-shows and late cancellations from patients. Monitor this rate closely over time, and implement an overbooking strategy to maintain patient volumes. The strategy should align with continuity goals but still allow for some flexibility between residents for low-level patient care needs.
6. Embrace a Care Team Model: Encourage preceptors and residents to fully integrate nonphysician colleagues to the extent of their license or clinical role, to support patient flow in the residency clinic and instill best-practice use of allied health colleagues. Incorporate daily huddles between preceptors, residents, and other clinicians to identify high-need patients and pre-plan for potential patient handoffs or escalation points.
7. Augment with Clinically Dedicated Providers: Many GME programs, especially in primary care, attempt to incorporate all physicians as part of the academic program, allocating academic FTE time toward precepting or other activities. However, many programs also fall short of reaching a steady-state clinical FTE that matches patient demand. These programs must evaluate the role of full-time clinically aligned providers working in collaboration with the GME program. These providers do not necessarily need to be in distinct clinical spaces or locations and often include advanced clinicians, such as NPs and PAs.

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