Starr, Susan MEd; Ferguson, Warren J. MD; Haley, Heather-Lyn MA; Quirk, Mark EdD
Clinical teaching programs have increasingly relied upon community physicians to teach their medical students and residents. Community physicians have been trained as professionals in providing medical care, but most have received little formal training in teaching.1 Many medical schools have initiated faculty development programs to teach the knowledge, skills, and attitudes that inform good teaching to community preceptors.2 At the University of Massachusetts Medical School, we have been involved with providing faculty development to community physicians for more than 20 years.1 The growing emphasis on preceptor development prompts the question: What do community faculty members think of themselves as teachers and what constitutes their “teacher identity”?
The assumptions underlying our study were that physicians who think of themselves as teachers are more likely to enjoy teaching, to teach more, and to be identified by students and other faculty members as good teachers. In an era of increasing demands on physician time, a strong teacher identity may help to facilitate recruitment and retention of high-quality, community faculty. Before we can test the relationship between teacher identity and positive outcomes, it is necessary to learn what factors contribute to a strong sense of teacher identity in physicians. In our study, we examined these factors in a group of community preceptors with a history of strong interest in teaching.
Numerous studies in the medical literature have discussed the importance of the teaching role of physicians and have examined the characteristics and behaviors of effective university and community teachers.3,4 Several studies have surveyed community physicians' satisfaction with teaching. Kollisch et al.5 found that 88% of community preceptors in a family practice program were satisfied with precepting students and cited intrinsic rewards such as stimulation from students and “sheer enjoyment of teaching.” Baldor et al.6 found that 75% of preceptors credited teaching for enhancing their enjoyment of patient care, and 52% felt that precepting improved the quality of their practice. Ullian and colleagues2 reported that the joy of teaching was a stronger motivator than tangible rewards. However, none of these studies specifically asked community physicians about their identity as teachers.
To our knowledge, only one published study has examined how physicians think of themselves as teachers. In 2002, Stone et al.7 conducted semistructured interviews with ten physicians associated with five New England medical schools who had been identified by program directors as “excellent teachers.” These clinical teachers described “an image of themselves as teachers,” along with familiarity with adult education principles and practice, an underlying sense of humanitarianism, and an appreciation for the benefits and drawbacks of teaching. The purpose of our study was to examine the teacher identities of a larger sample, specifically a group of experienced community-based faculty members.
Teacher and professional identities have been studied extensively in the social sciences. In our investigation, two paradigms from this literature guided the conceptualization and analysis of teaching identity. First, we defined professional identity as a developmental process, during which novices acquire specific knowledge and skill, develop new attitudes and values, and take on a self-concept associated with the new career role.8 Faculty development programs that teach knowledge, skills, and attitudes about education could be important in helping physicians develop competence and a strong teacher identity.
Second, we defined professional identity as multifactorial. Most researchers describe elements that are “internal” or coming from inside the individual, and elements that are “external” or coming from the discipline.9–11 Internal elements are the feelings and attitudes that lead to intrinsic satisfaction in one's professional role. External elements include a body of knowledge, rewards such as money or recognition, and social supports from colleagues or professional associations. Our study looked for evidence of those four common elements: intrinsic satisfaction, knowledge and skill, external rewards, and social supports. We also searched for additional themes that might emerge from a qualitative analysis of focus groups reporting the perceptions of community physicians about their roles as teachers.
We used focus group methodology to gain qualitative information about teacher identity from preceptors involved in teaching students and residents. Focus groups were selected rather than interviews or questionnaires because they better enable the researchers to capture diverse opinions, explore issues of importance in the participants' own vocabularies, gain a deep level of insight, and assess the complexity of responses.12,13 Kitzinger14 points out that focus groups are particularly well suited for studying attitudes.
Participants in our focus group study comprised a purposive sample of 35 community preceptors in pediatrics (20%), general internal medicine (32%), and family medicine (48%), who were attending a two-day faculty development conference. Participants represented 11 schools of medicine in New England and New York State. We deliberately chose the sample to represent community preceptors who have a history of strong interest in teaching.
All participants were graduates of the “Teaching of Tomorrow” (TOT) faculty development conference series for primary care physicians, sponsored by the Community Faculty Development Center at the University of Massachusetts Medical School, Worcester. The TOT program is designed to strengthen preceptors' understanding of teaching and learning, as well as to provide a network for teaching in primary care settings. TOT graduates from 1995–2000 were invited to a “Return of Teaching of Tomorrow” (ROTOT) conference in April 2001 to refresh their teaching skills and share experiences since finishing the initial course.
In our study, we hypothesized that TOT graduates, who self-selected for additional faculty development at the ROTOT, were likely to have a strong interest in teaching. Focus group research suggests using a purposive sample when the researchers have a specific targeted agenda or want to explore the way a particular group thinks or acts.14 We postulated that a purposive sample of committed teachers would elicit the richest descriptions.
We divided participants into five focus groups. Groups were evenly balanced to represent the three primary care disciplines and a diverse sample of medical schools represented by the participants. We asked group members to answer seven questions related to “teacher identity.” Questions asked participants to reflect on the meaning of teacher identity, their role as teachers, the value of the TOT faculty development program, and factors that might strengthen their identity as teachers (List 1).
We audiotaped the focus group discussions and transcribed the tapes. Systematic content analysis was performed according to guidelines for multi-investigator analysis of focus groups recommended by Krueger.12 Initially, one of us (SS) coded all of the responses for the four themes suggested in the literature: intrinsic satisfaction, knowledge and skill, extrinsic supports, and social supports. Subsequently, two of us (WF, MQ) coded the responses from two of the focus groups (163 discreet comments) and suggested three additional themes. Themes were selected by three criteria suggested in the literature about focus groups: frequency of comments, extensiveness of comments (how many different people talked about an idea), and intensity of comments. All three coders then met and agreed on a total of seven themes that emerged from content analysis. Finally, a random sample of 32 responses that had not previously been discussed and that met scoring criteria from all five transcribed groups was analyzed independently by the three coders, using the seven themes to establish inter-rater reliability of coding.
Participants' ages were normally distributed, with the majority (35%) falling between 41–45 years old. Sixty-four percent of the preceptors self-identified as white or Caucasian, 15% identified as African-American or Asian, and 21% did not identify by race. Fifty-eight percent of the sample were men, and 42% were women. At the time of our study, 44% of participants practiced in primary care clinics associated with an academic health center environment, and 28% were in solo private practice. The remaining 28% were divided between multi- and single-specialty health centers and other types of arrangements in the community. Forty-eight percent of participants reported working in at least one underserved area, with 16% seeing patients in two or more types of underserved areas.
ROTOT participants represented a wide range of levels of experience with practicing and teaching clinical medicine (Figure 1). Thirteen percent of the sample had been practicing medicine for less than three years; 16% had been practicing for more than 20 years. Although 33% of participants reported having practiced medicine for between 11–20 years, only 23% reported having spent that much time teaching. The majority reported having practiced (37%) and taught (50%) for four to ten years. Seventy-one percent taught first-year medical students, 67% second-year students, 76% third-year students, and 67% fourth-year students.
There was unanimous agreement among the three raters on 24 of 32 responses (75%). Two of the three raters agreed on 30 of 32 responses (94%). After discussion of each response, there was unanimous agreement on the scoring of each. In the sample of 32 responses, raters identified all seven themes discussed below.
Themes of Identity
Feeling intrinsic satisfaction.
Of the seven themes relating to teacher identity, the most common in frequency and extensiveness was related to the intrinsic satisfaction gained from the teaching role. One preceptor said, “It connects you to your idealism, what brought you there in the first place.” One expressed the satisfaction in seeing learners grow: “Seeing someone get from one level of understanding to another. … I just love to see them get to that goal. … It's just very exciting.” Another said, “A lot of us will remember one or two great teachers we had and for me being that person for a learner is a very big honor.” Other comments suggested that students become colleagues by bringing the latest information. One participant commented:
[I'm] sort of facing the burnout factor once in a while. [It's] great to sit with the student and start listening to myself. … It's really helpful to me. I am definitely renewed by that.
Having knowledge and skill about teaching.
Many preceptors attested to their increased awareness of, and reflection on, teaching as part of their identity development. One said that his teaching “has gotten more organized and purposeful.” Another said that he “would like to go back to colleagues and say, ‘There's a better way to do this.’” Comments suggested the value of faculty development programs for learning general teaching skills. As one participant said, “[I] used to spend too much time imparting my knowledge. Now I spend time to assess the student's knowledge.” Other comments suggested increased comfort in teaching. One preceptor said, “[When I] first started, I wasn't confident in what I had to bring to it. Now I feel much more confidant.”
Belonging to a group of teachers.
Responses suggested that talking about teaching with colleagues validates one's identity as a teacher. Many comments reflected on the value of “interacting with colleagues who share interest” in teaching. One preceptor said:
[It's] great to get together with others with similar interests. Although others take students in my practice, we never talk about teaching. We always talk about practice.
One respondent described the TOT program:
This is a room of colleagues. Hearing stories, that validates my experience and I think, ‘Oh, I must be a teacher.’
Most physicians suggested that faculty development programs could play a major role in increasing their identity as teachers. In addition to increasing knowledge and skill and providing social supports as mentioned above, faculty development programs gave preceptors the message that medical schools recognize and value their contribution to the teaching programs. One preceptor said: “[Faculty development programs] strengthen identity as a teacher. Teaching is recognized as a value, genuine recognition that is valuable.” Another stated that:
The importance of this course has not been so much the particulars of the process, but has been the recognition of the teaching process, that we were important enough to be invited to a program like this…to be with colleagues that hold as much importance on teaching.
There were also a number of comments related to this theme that described barriers to teacher identity. Comments were characterized by an intensity of feeling and described increasing pressures from clinical responsibilities and productivity demands that limit the quality and amount of their teaching. One preceptor said: “It's frustrating to see the students and residents feeling so squished. I feel like I'm doing them a disservice.” Another said, “More fundamental resources, money [would help].”
Being a physician means being a teacher.
A theme that emerged reminded us of the true meaning of the word doctor (viz., teacher). Participants noted that to be a physician means teaching patients, so that all physicians are teachers. Comments suggested the integration of the roles of teacher and physician. In one physician's words:
[I am a] teacher almost all the time. Sometimes I teach to students in a formal way, NPs [nurse practitioners] that I precept on a regular basis, and with my patients I am a teacher constantly. And then I go home [to my children]. So I really am a teacher. I don't think there is ever a time I step out of that role.
Another said, “To me being a doctor means being a teacher so my role as a teacher of students, residents, and faculty is a natural extension of my patient care efforts.” Other participants commented:
[There are] two bodies of knowledge: teaching patients and teaching students. We are teachers every day as physicians.
Viewing our role as clinicians, we are still educators, educating medical student, residents, patients. [We] do diabetes education, using an inhaler, educating patients continually where you have a student or not. That role is almost more important because you do it on a daily basis.
Feeling a sense of responsibility to teach medicine.
Many participants expressed a sense of responsibility to teach. Their comments indicated that responsibility (obligation) was distinct from the intrinsic satisfaction (enjoyment) that derives from teaching. Responses gave the sense that teaching young physicians has a “potential impact on so many more people.” and involves a “responsibility to promote growth and learning, [to] help achieve the highest capacity.” One preceptor said:
I also look at it as a pay back. Your medical education has been subsidized, somehow, wherever you went, and society, taxpayers helped pay for that. At a certain point in your career I think it's important to give back.
Sharing clinical expertise.
Lastly, community faculty members embraced the opportunity to model their role as clinical experts in community-based primary care, especially as representatives of their disciplines. Respondents spoke about the importance of contributing their experience to the textbook knowledge that students gain from the medical school. Most importantly, preceptors believed they were modeling love and respect for patients. One physician commented: “I would like them to see that love I have for the kids and their families…to see how important [it] is to treat people well.” Another said: “[I tell students] ‘Don't worry about the medicine so much, concentrate on the relationship.’” Preceptors expressed pride in their discipline, as exemplified by this comment: “I want family medicine to be seen as a ‘safe haven’ for learning.”
All four of the themes identified in the social science literature on professional identity were evident in the focus group discussions: intrinsic satisfaction, knowledge and skill about teaching, importance of external rewards, and the value of social groups. Of special interest are the three new themes that emerged specific to primary care preceptors: the integrated identity of physician-teacher, a sense of responsibility to teach, and a sense of their roles as clinical experts in primary care.
Intrinsic satisfaction, or joy of teaching, was the most commonly occurring theme, affirming reports by Ullian et al., Kollisch et al., and Baldor et al.2,5,6 This particular feature of identity, however, may prove short lived, especially considering demands in other areas of professional roles such as clinical responsibilities. The social science literature suggests that “sheer intrinsic enjoyment of the subject matter” can wane when the costs outweigh the benefits.11 The increasing pressures from clinical responsibilities, voiced strongly as barriers to teaching, may have begun to tip the scale. Preceptors may increasingly look to extrinsic rewards to counter the pressure of clinical practice. Baldor et al.6 found that up to 56% of preceptors wanted compensation for lost time and income. Compensation does not always need to be financial; preceptors in our study requested acknowledgment and social support, but rarely mentioned monetary remuneration.
Participants in our study felt a strong sense of responsibility to educate the next generation of doctors. This responsibility, part of the profession since Hippocrates, was clearly related to the preceptors' feelings about the importance of primary care practice. Preceptors expressed a sense of themselves as clinical experts in this area, especially in their respective disciplines. Many statements attested to their belief that they are the best role models for continuous relationships with patients, a skill that they say students cannot learn at the hospital. Preceptors also felt responsible for influencing the career choices of students and received satisfaction when students chose their discipline, a finding that mirrors data by Paukert and Richards4 on students' descriptions of the characteristics of influential clinical teachers. It may be helpful to involve these preceptors as student advisors and perhaps invite them to participate in student specialty selection and interest groups.
Our study supports previous studies of medical education demonstrating that community faculty members enjoy and benefit from learning about teaching strategies.15 Comments were notable for their intensity, mirroring professional literature that suggests that becoming a professional teacher requires acquisition of a formal body of knowledge and skill in teaching.9,10 Preceptors also described the support gained by spending time with colleagues who were interested in education. Several participants expressed the belief that the dollars spent on faculty development were proof of the value medical schools placed on their teaching, a factor that appears to validate their identity as teachers. Efforts to enhance faculty development for preceptors at “no cost” should result in greater identity for many volunteer faculty members. In addition, special teaching awards and recognition of exemplary faculty will be considered important by some faculty.
Our data revealed that many preceptors have a strong belief that being a physician means being a teacher. Primary care physicians may recognize that the skills they use teaching patients are similar to the skills required to teach students. This would help explain why preceptors are willing to perform as teachers with little or no formal teacher training. If preceptors already believe they are effective teachers because they teach patients every day, then it's a small leap to effectively teaching students and residents. Perhaps explicitly focusing faculty development on skills that enhance patient as well as student and resident education will appeal to preceptors who derive their identity in this manner.
The finding that community physicians described a variety of factors that contribute to their identities as teachers is important. Many participants had never thought about teacher identity, and the discussion itself was an affirming process. Faculty development programs may want to include a menu of activities and resources that help preceptors define themselves as teachers, a finding supported by Ullian et al.2 in an analysis of an extensive faculty development project. Our results support the value of including time for networking around educational experiences, drawing parallels between teaching patients and teaching learners, and offering a needs-based system of rewards for teaching.
Each of the seven themes of teacher identity we discuss in this article could be described as elements along continua, e.g., “strong knowledge and skill” to “little knowledge and skill,” “strong sense of responsibility to teach” to “little sense of responsibility to teach.” Future studies should measure preceptors' teacher identity based on their positions relative to the seven themes. A teacher identity scale would allow us to perform a more structured needs assessment and to measure the effect of faculty development programs and other forms of rewards. In an effort to gain greater insight into the most effective strategies for enhancing teacher identity, we should also examine its relationship to preceptor age and gender.
Limitations to our study included a small and purposeful participant sample. The 35 participants in the ROTOT program self-selected to attend an advanced program in clinical teaching that followed a yearlong program. They were likely to have had a strong sense of themselves as teachers. This highly selective and motivated group of preceptors was exposed to extensive training that develops educational strategies by building on skills physicians already know. Participants drew parallels between the doctor–patient relationship and the teacher–student relationship. TOT graduates may have a blended physician–teacher identity that is not representative of a general group of preceptors. The sample was purposefully selected to yield the richest information. Future studies might examine preceptors who have not participated in faculty development programs.
In conclusion, we believe that this group of clinical teachers was able to identify elements that contributed to their sense of identity as teachers. Their passion during focus group discussions validated our interest in further study of teacher identity, both within the community and within the medical school. The implications of our findings may be helpful for medical schools that want to strengthen their needs assessment and evaluation of faculty development programs as well as their relationships with community-based faculty members.
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