To What Extent Are Programs Recruiting Their Own Graduates as Faculty? A CERA Study

Family medicine (FM) residency programs continue to face unmet demands for recruiting high-quality, core faculty members. Data from both a 2016 Association of Family Medicine Residency Directors (AFMRD) member survey and a 2018 Council of Academic Family Medicine Educational Research Alliance (CERA) survey showed 60% or more FM residency programs are seeking one or more faculty members at any given time. Previous studies have considered success factors for faculty recruitment that were associated with the position itself ¹; the ideal characteristics of a faculty candidate ²; interests of residents in taking faculty positions ³; and strategies for rural physician recruitment. ⁴ None of these looked specifically at where faculty were recruited from. However, given that building and maintaining relationships was prioritized as the most important characteristic for faculty candidates ² and that recruitment costs for faculty, particularly external recruits, can be significant, ^5-7 understanding the likelihood of filling faculty positions through different strategies may help programs make more effective plans for future recruitment. The objectives of this study were (1) to define to what extent FM residency programs are relying on recruitment of program graduates, regional programs, or outside of their region for filling faculty roles; and (2) to explore the association of program characteristics with recruitment of faculty from these sources.

The survey questions were part of a larger omnibus CERA survey of all 719 US FM residency program directors (PDs) as identified by AFMRD. The methodology of these surveys has been described previously. ⁸ Data was collected from April 13, 2022 to May 16, 2022. In addition to standard questions asked on every CERA survey, we included questions about the number of classes a program had graduated; whether the program offered a fourth-year chief position, a faculty development fellowship, or clinical fellowships; and whether their residency program was 4 years. We asked what percentage of FM faculty were graduates of their program, a program in the region, or a distant program; and to what extent the program attempted to recruit its own residents to faculty positions. “Core faculty” was defined as those listed on a program’s website; “regional area” was self-defined as “how you define your workforce ‘catchment’ area.”

We calculated descriptive statistics using Microsoft Excel and Stata 17 and used Χ² for bivariate comparisons. We set statistical significance at P<.05. The project was approved by the American Academy of Family Physicians Institutional Review Board in April 2022.

A final sample of 298 survey responses was included in this analysis—a 41.4% overall response rate. Table 1 shows characteristics of the responding programs.

Table 2 shows summary data from all respondents about the percentage of their faculty that consisted of their own graduates, regional graduates, and distant graduates. Overall, more programs reported hiring more of their own graduates compared to regional or distant graduates; only 29.5% of programs reported hiring 25% or fewer of their own graduates contrasted with 47.0% and 52.0% of programs for hiring regional and distant graduates, respectively.

Table 3 shows PDs reporting priority for recruiting their own graduates and the percent of faculty that were program graduates. Forty percent (119/298) reported that their program prioritizes recruitment of their graduates for open positions, and those programs were significantly more likely to have a higher percentage of their graduates being retained on faculty.

Table 4 compares program characteristics and the percent of faculty that were program graduates. We noted positive correlations for university-based programs, programs in communities of fewer than 30,000 people, larger (>19 residents) programs, older programs, and programs offering clinical fellowships.

Regarding recruitment from regional or distant programs, we found only the existence of a faculty development fellowship in the respondent’s program was significantly associated with a higher percentage of faculty from regional programs (P=.037). Newer programs, smaller programs, and programs in smaller communities of fewer than 30,000 people were significantly more likely to report higher percentages of graduates from distant programs serving as faculty (P=.008, P=.045, and P=.011, respectively).

Neither the presence of a 4-year program nor the presence of a fourth-year chief resident position was correlated with recruiting graduates as faculty, but both were limited by the small number of respondents.

We also considered the effects of PD characteristics (ie, years in position, gender, from an underrepresented minority) on recruitment but found no significant associations.

These data show that recruitment of a higher proportion of a program’s own graduates was associated with more long-standing, larger, more urban, university-based programs, and those with clinical fellowships. Higher numbers of faculty from regional programs were correlated only with the presence of faculty development fellowships; recruitment of distant graduates was more common in newer and smaller programs as well as in programs in smaller communities.

We could not find data on the quality or retention of internal versus external residency faculty candidates. However, program graduates are a known quantity in terms of established relationships and experience with other preferred characteristics. ² From that quantitative data, we can deduce that retaining program graduates is likely less costly on average. Further, because most graduates practice within 100 miles of their residency training, ⁹ we might hypothesize that they would be relatively likely to stay. All these factors affirm that internal recruitment is clearly an important strategy.

While most associated factors in our study were not directly controlled by the program (eg, community size, program duration, and location), our findings suggest two primary strategies for programs interested in improving faculty recruitment from among their own graduates. The first is to prioritize recruitment of their graduates for faculty roles through relationship building and encouraging interest among skilled graduate recruits. The second is to develop clinical fellowships or faculty development fellowships to extend influence among regional programs. Fellowships of multiple types, both Accreditation Council for Graduate Medical Education (ACGME)-accredited and nonaccredited, are a significant opportunity for program enhancement as well as faculty recruitment and development. Program size, though technically controlled by the program, is often challenging to increase, given limited community resources and financing.

Limitations of this study include the analytic sample size with a 41.4% response rate and the limited nature of the questions, which precluded the ability to explore details of the factors identified. For example, our questions about recruiting residents did not specifically address recruiting residents who go on to do fellowships, another source of internal recruitment for programs. Additionally, we may be missing perspectives for some university-based programs where the PD does not drive faculty recruitment. Because the survey asked only about community size, the impact of rurality could not be independently evaluated, such as whether rural programs specifically have higher or lower graduate retention rates. This analysis also did not address the issues of faculty quality, faculty retention over time, or the faculty recruitment needs of developing and new programs, which remains one of the greatest challenges in the formation of new programs nationally. All the described areas would be ripe for future study, as would deeper exploration of program recruitment needs and strategies.

In summary, programs recruit a sizable part of their faculty from within their own program. We noted the increased success of retaining a program’s own graduates in institutions and programs that focused on internal recruitment and development of both clinical and faculty development fellowships. This approach may help existing programs develop recruitment strategies.