Latessa, Robyn MD; Beaty, Norma MS, MAEd; Landis, Suzanne MD, MPH; Colvin, Gaye; Janes, Cynthia PhD
Presently, community-based preceptors provide considerable training for health science students. During the past decade, these primary care health providers have been asked to teach more students, yet compensation for their contributions has remained at modest levels.1–8 The number of students involved in community-based rotations across North Carolina has increased almost 400%, from 595 in 1993 to more than 2,250 in 2002.9 This trend of shifting student education from university inpatient to community ambulatory settings is expected to continue in the future and translates into a growing need for more preceptors and practice sites.10
At the same time, other factors are placing greater pressures on community primary care providers/educators. Reduced reimbursement by third-party payers and the demands of managed care contracts force physicians to see more patients per day.11,12 Recently, the Association of American Medical Colleges called for a 30% increase in U.S. medical school enrollment to meet the projected shortage of physicians.13 Factors influencing this include population growth nationwide, the growing segment of geriatric patients, an aging physician workforce, and a new generation of health care providers choosing to work fewer hours. All these issues will continue to place additional burdens on community preceptors.14–17
Anecdotally, many educators across the nation discuss the increasing dropout rates of preceptors, but there are few published studies related to this topic. A review of literature on community preceptor satisfaction and rewards revealed no studies with a large sample size and response rate, none that were multidisciplinary regarding preceptor degree groups, and few after the year 2000.1–8,11–12
In North Carolina, no statewide preceptor outcomes have been measured since the inception of community-based preceptor programs in 1993. Therefore, we developed this survey to determine North Carolina preceptors' degree of satisfaction, likelihood of continuing precepting, influence of having students, motivation for teaching, professional satisfaction, and value placed on rewards/incentives. Our primary objective was to gather baseline data to both evaluate and improve services in our state. Wealso hoped that our survey would be replicated in other states, starting a movement for further study of community-based education nationally and providing outcomes data for related evaluation and strategic planning.
North Carolina has one of the original and largest area health education center (AHEC) programs in the nation. Each regional AHEC in the North Carolina system has an office of regional primary care education (ORPCE), which provides an integrated system of support for primary care and community-based education.18 These offices were established in 1993 as part of the AHEC Regional Primary Care Education Initiative to strengthen support and expand capacity for training primary care students in community settings across the state.
Funding received at that time allowed the regional ORPCEs to provide modest financial compensation and logistical support to preceptors, expand student housing, and act as liaisons between community preceptors, students, and the education institutions. Support services include coordinating preceptors' access to information resources, continuing education programs, academic appointments, and preceptor payments for teaching students.
In the spring of 2005, we mailed surveys to all 2,061 primary care preceptors who receive services through the North Carolina AHEC program. This group included mainly private-practice physicians (PHY), pharmacists (PHA), advanced-practice nurses (APN; nurse practitioners and certified nurse midwives), and physician assistants (PA). The health science students were enrolled in graduate health professions programs (medical, pharmacy, nurse practitioner, physician assistant, and certified nurse midwife) from 10 public and private institutions statewide. Unlike most other preceptors, physicians also teach physician assistant and advanced-practice nursing students.
We designed a four-page, 24-item survey to measure the following areas: overall degree of satisfaction with precepting, likelihood of continuing as a community preceptor in the next five years, influence of teaching students on their practice,7,19 reasons for teaching students,5,7,19,20 satisfaction with professional life,11,12,15,20,21 satisfaction with services provided by AHEC, and satisfaction with and value placed on incentives.5–7 Preceptors responded using a five-point Likert scale. Descriptor anchors ranged from very dissatisfied to very satisfied. We also collected information on preceptor and practice demographics, in addition to the contact information of their name, degree, and address. These data included gender, age, race, practice location, years in practice, hours worked per week, years precepting, and weeks precepting per year. Two preceptor focus groups pretested the questionnaire. After review by ORPCE staff, the final revision received approval by the institutional review board. A copy of the survey can be obtained on request from the first author.
The mailed survey packet included a numbered survey, personalized cover letter, and self-addressed stamped envelope (SASE). To increase response rate, we entered responding preceptors in a random drawing for one of four free weekend getaway packages. Three weeks after the first mailing, we sent a second letter, survey, and SASE to nonresponding preceptors. Three weeks after the second mailing, the remaining preceptors received a final appeal and copy of the survey by fax. Numbered surveys enabled us to keep individual data confidential while tracking response rates. We also plan to recontact all current respondents, as well as any new preceptors, in five years. That survey would reassess their satisfaction and anticipated continuation as a preceptor or, if they no longer precept, determine their reasons for stopping.
Summary statistics were calculated on all variables. Analysis focused on whether there were any differences in survey responses among degree groups (PHY, PHA, APN, and PA) using chi-square for categorical variables, correcting for continuity in 2 × 2 tables and t tests for continuous data. We used SPSS 13.0 for Windows, with significance set at P < .05.
More than 69% (1,428/2,061) ofthe surveyed preceptors returned questionnaires. We knew in advance of participants' response the name, degree, and AHEC affiliation of every preceptor who received a survey. We used the preceptors' given names to determine the gender of nonresponders. Preceptors who completed and returned the questionnaire did not differ from nonresponders in gender or AHEC affiliation, but there was an association between return rate and degree groups. Physicians were less likely to respond than were the other three groups (66.9% PHY, 75.9% PHA, 74.5% APN, and 70.8% PA).
Reflecting the population of preceptors, the typical respondent was a Caucasian male, rural family medicine physician. As a group, preceptors were experienced and mature professionals in terms of age, years in practice, and years precepting students (see Table 1). The following medical specialties were represented: family medicine (37.3% of respondents), pharmacy (16.9%), internal medicine (15.9%), pediatrics (14.7%), obstetrics–gynecology (6.3%), and other (9.0%).
Almost all respondents (1,320/1,419, or 93.0%) reported being very satisfied or satisfied with their experience as community preceptors. (Italicized words indicate actual survey response categories.) Similarly, 90.9% answered definitely or probably to the question, “How likely are you to continue as a community preceptor over the next five years?” The remaining 9.1% answered not sure, probably not, or definitely not to the same question. Further analysis of these questions showed no statistical differences among degree groups.
Regarding the effect of having a student in the practice, a majority of respondents rated teaching students as having a positive or very positive influence on their overall job satisfaction (1,177/1,413 or 83.3%), relationships with patients (809/1,414 or 57.2%), relationships with colleagues and staff (810/1,420 or 57.1%), and patient satisfaction (778/1,412 or 55.1%). Physicians were more likely than others to indicate a negative or very negative influence on patient flow, working hours, and income (see Table 2).
As a measure of intrinsic motivation, we asked preceptors about their reasons for precepting students. A majority indicated the following had great or very great importance in their decision to teach students: demonstrating what community practice is like (1,185/1,423 or 84.4%), enjoyment of teaching (1,181/1,423 or 83.0%), giving something back to their profession (1,166/1,417 or 82.3%), intellectual stimulation (1,111/1,423 or 78.1%), and being a role model (1,060/1,424 or 74.4%). The items rated as least important included recruiting future partners and increasing status with patients. Physicians more often expressed little importance for all other intrinsic reasons than other preceptors. Conversely, pharmacists, advanced-practice nurses, and physician assistants placed significantly greater importance than physicians on being role models (71.6% PHY, 76.2% PHA, 81.5% APN, 75.0% PA, P = .031), keeping knowledge up to date (44.8% PHY, 70.5% PHA, 64.8% APN, 70.6% PA, P ≤ .001), and a renewed sense of importance of work (38.3% PHY, 54.6% PHA, 52.8% APN, 48.5% PA, P ≤ .001).
Almost all preceptors (1,301/1,389 or 93.7%) reported satisfaction (satisfied or very satisfied) with their professional lives. The professionally satisfied preceptors were also more likely to indicate fulfillment with their experience as community preceptors than were the latter two groups (93.9% versus 80.1% satisfied or very satisfied, P ≤ .001). In contrast, the professionally dissatisfied group was three times more likely than the satisfied preceptors to indicate they would discontinue precepting during the next five years (26.1% versus 8.2% definitely not or probably not or not sure, P ≤ .001). Physicians indicated less satisfaction than pharmacists, advanced-practice nurses, and physician assistants regarding personal time (38.9% PHY, 43.8% PHA, 56.8% APN, and 53.7% PA, P ≤ .001) and adequate time for patients (33.6% PHY, 39.8% PHA, 46.8% APN, and 56.1% PA, P ≤ .001).
More than half of preceptors (762/1,357 or 56.2%) were satisfied or very satisfied with services provided by their AHEC. Pharmacists were significantly more likely to be satisfied or very satisfied with AHEC services (71.0% PHA, 54.1% PHY, 48.3% APN, and 46.3% PA, P ≤ .001), whereas the physicians, advanced-practice nurses, and physician assistants more frequently indicated they were neither satisfied nor dissatisfied (43.6% PHY, 50.4% APN, and 47.7% PA 26.8% PHA, P ≤ .001).
Overall, 57.2 % (790/1,382) of community preceptors were satisfied or very satisfied with the incentives they received. Few preceptors were very dissatisfied or dissatisfied with incentives, whereas 34.7 % (479/1,382) reported being neither satisfied nor dissatisfied. No significant differences were noted among degree groups relating to overall satisfaction with incentives. Interestingly, a percentage of preceptors indicated that they do not receive some incentives that are actually available to them (see Table 3).
The most highly valued incentives (rated as great or very great) included Category II CME credit for teaching (available to physicians only), no-cost access to online library resources, continuing education programs on clinical topics, anduniversity academic appointments (see Figure 1). Financial compensation placed fifth among all preceptors. Lesser-valued rewards included preceptor newsletters, appreciation meals, site visits, and teaching recognition certificates.
Responding to questions about the value placed on incentives, degree groups differed on all incentives. Many physicians placed great or very great value on Category II CME credit for teaching students. Compared with other groups, physicians less often placed great or very great value on no-cost access to online library resources, continuing education, and financial compensation. Conversely, pharmacists, advanced-practice nurses, and physician assistants placed significantly more value on these items, except that pharmacists were less likely to value academic appointments.
Our large, multidisciplinary study had a high response rate and reveals a remarkable level of preceptor satisfaction. To our knowledge, no recent studies of this size and scope have addressed the important issue of community preceptor retention. Most community preceptors in this study said they were likely to continue precepting in the next five years, similar to rates found in two smaller studies in North Carolina.6,21 In contrast, one Pacific Northwest study of first- and second-year medical student preceptors noted a 7% dropout rate, whereas physicians in health maintenance organizations (HMOs) had a 23% dropout rate.20 Even if dropout rates are not high, the natural attrition rate with retirements and the increased demands for numbers of preceptors will create a need for increased recruitment. Efforts in the future will need to focus on both retention and recruitment of preceptors. One way to increase our preceptor pool is to encourage new residency graduates to become preceptors.
Although it was not unexpected to see response variations among degree groups, physicians responded more negatively to questions regarding the effect of teaching students on their practice, as well as their satisfaction with aspects of professional life. The more complex practice/teaching demands placed on physicians potentially put them at greater risk for compromising the balance between the joys and challenges of teaching, thus increasing the likelihood that they may drop out.
This study shows that preceptors generally think the intrinsic reasons (i.e., enjoyment of teaching) outweighed the extrinsic rewards (i.e., financial compensation) in their motivation to teach students. These findings confirm those of previous studies.1–3,5,19,22–26 Developing creative ways to maximize intrinsic rewards for teaching may enhance the satisfaction, retention, and recruitment of preceptors.27 One approach is to provide a setting where health care providers can rediscover and nurture the meaning of their work. Groups such as Finding Meaning in Medicine, founded by Rachel Naomi Remen, MD, meet monthly for storytelling sessions.28 In over 40 groups across the country, 5 to 15 physicians gather to explore self-selected topics such as service, compassion, forgiveness, mistakes, and joy. There are several other organizations which promote physician well-being, including The Center for Professional Well-Being in Durham, NC, The Foundation for Medical Excellence in Portland, Ore, and Grapevine Discovery, Inc., in Phoenix, Ariz. Locally, we always include time during our preceptor training or CME programs for the group to connect and share stories about student teaching experiences.
Although intrinsic reasons are the main motivation for precepting, preceptors in our study also value extrinsic rewards. Because all degree groups placed differing importance on extrinsic rewards/incentives, tailoring extrinsic rewards for individual groups could also promote preceptor retention. For instance, because CME topped the list of physician incentives, we plan to develop and market a point-of-care CME program to teach physicians how to obtain 0.5 CME credits for documenting an answer to a clinical question.29 Resources should be focused on awareness and opportunities to deliver those rewards that are consistently valued most by preceptor groups.
The higher appreciation pharmacists indicated for online library services may reflect the lower awareness other preceptors have of this incentive. This raises questions about how perception and awareness of incentives can affect their usage and, ultimately, may improve satisfaction levels. It also presents an opportunity to increase and improve marketing strategies. To this end, we have shared individual data with each ORPCE so that efforts may also be tailored for their specific preceptor population.
A limitation of this study is that the participants precept in only one state. It is unknown whether these results can be generalized nationally. The lesser penetration of HMOs in this state may contribute to the higher rates of preceptor satisfaction and lower dropout rates.30 The organizational structure and resources available through the North Carolina AHEC system also provide a level of support that is generally not available in other states. Studies are needed in other states to determine whether these results can be duplicated, and to generate broader data necessary for designing models of medical education to meet future needs. The high satisfaction rate may reflect the greater willingness of satisfied respondents to return questionnaires, as could be said for any survey.
This statewide project with a high response rate found that most community-based preceptors were satisfied with their experience teaching students and with their professional lives. Additionally, a majority of preceptors reported a high likelihood of continuing to precept; however, the actual dropout rate cannot be determined by this one study. These high levels of satisfaction among this group of preceptors may be attributed in part to the longstanding, strong AHEC support for community-based education in North Carolina. The current survey will be revised and distributed statewide again in five years to document the actual dropout rate and changes in preceptors' opinions, with a special emphasis on those who have chosen to discontinue teaching. Similar studies in other states are needed to see whether the high satisfaction levels and other results reported here are representative of preceptors nationwide. We need to be proactive and perform these studies before our preceptor pool decreases.
This study confirms the finding that intrinsic reasons for teaching generally outweigh most extrinsic rewards, although preceptors do value certain extrinsic rewards. Measuring degree group preferences will facilitate tailoring, marketing, and delivery of services to fit the needs of each preceptor group, as well as aid in recruitment of new preceptors. This is especially true for physicians, who reported a more negative influence of students, were less satisfied with aspects of their professional practice, and comprise the largest group of preceptors. The rewards of teaching students must outweigh the burdens, or we risk losing community preceptors, thus affecting the education of health science students.
The authors thank the following for contributions to survey design: John Langlois, MD, Mountain Area Health Education Center; Barcey Levy, MD, University of Iowa Health Care; Ashir Kumar, MD, Michigan State University Department of Pediatrics and Human Development; and Peg Boyle Single, PhD, University of Vermont Department of Education. The authors also thank Ms. Margaret Vital-Lozier for data entry and administrative support.
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