Teherani, Arianne; O'Brien, Bridget C.; Masters, Dylan E.; Poncelet, Ann N.; Robertson, Patricia A.; Hauer, Karen E.
Marked by disjointed and brief experiences coupled with insufficient integration among specialties, core clinical education in medical schools does not optimally prepare trainees to meet the complex health care needs of a chronically ill and aging society.1,2 Moreover, in ambulatory care settings, teaching is characterized by brief student–faculty interactions that focus on management and treatment over teaching and feedback.3
To address these challenges, clinical education should be designed to promote continuity of educational experiences.2–4 One form of continuity, that of supervision, entails clinical teachers precepting and mentoring students longitudinally. In this model, responsibility for patient care is shared by the student and faculty, with the faculty overseeing the student's learning.2 To enrich students' learning, clinical education, particularly ambulatory care education, should be anchored in apprenticeship experiences, in which learners work with master clinicians and encounter patients with conditions appropriate to their level of learning.5
Clinical teachers are key to learner satisfaction and learning,6,7 yet we do not know about the impact of continuity of supervision on clinical teachers. We interviewed faculty members who could compare their longitudinal and their nonlongitudinal teaching experiences to answer the following research questions: (1) What are the experiences of preceptors who teach medical students during a yearlong longitudinal integrated clerkship (LIC)? (2) What are these preceptors' perceptions of their own teaching and students' learning during an LIC? (3) How do preceptors compare their experiences teaching students in an LIC with their experiences teaching traditional clerkship (TC) students?
This was a qualitative exploratory study using semistructured interviews. We invited all 47 preceptors from seven specialties (Family Medicine, Medicine, Neurology, Obstetrics–Gynecology, Psychiatry, Pediatrics, and Surgery) who precepted third-year medical students during the 2007–2008 academic year in an LIC at one school. Faculty members were recruited to precept, and those who were interested volunteered. Preceptors were invited up to three times to participate in interviews. Interviews occurred from May to August 2008, after the end of the third year. The institutional review board approved the study.
Students enrolled in the LIC completed primary care and specialty longitudinal preceptorships in parallel for a year, working with one preceptor per discipline in 16 to 40 four-hour sessions. The LIC addressed the same learning objectives as the TC. Students acquired a panel of patients through the emergency room and the outpatient preceptorships and followed their patients into various settings. Students also completed an inpatient component which included two weeks of Medicine, one week of Obstetrics–Gynecology, and a two-week selective in the specialty of their choice. Eight students, selected via lottery, participated in the first year of the LIC which began in April 2007.
We developed an instrument consisting of open-ended questions guided by the following key questions asking preceptors to (1) describe their overall LIC precepting experience including time devoted to teaching, structure of precepting sessions, and accommodations to teach students, (2) describe the learning progression of their LIC student during the year including interpersonal skills, and (3) compare their precepting experience between the LIC and TC.
The interview protocol was pilot tested with two preceptors and modified subsequently for clarity.
Two researchers (A.T., B.C.O.) conducted the interviews. Interviews were audio-recorded and transcribed. We used a grounded theory approach including (1) an iterative study design in which interviews were conducted and analyzed simultaneously, and analysis informed subsequent interviews, (2) purposeful sampling by selecting to interview first preceptors who had taught in both the LIC and TC, and (3) a “constant comparative” approach to analysis in which findings were compared with each preceptor's comments.8 We ceased interviewing participants when thematic saturation was achieved.
Initially, three investigators (A.T., B.C.O., K.E.H.) read four transcripts independently to develop an open coding list.8 Thirteen interviews were coded by at least two investigators. One investigator (A.T.) coded the remaining 10 interviews, drawing on other investigators to resolve difficult-to-code passages. Three investigators (A.T., B.C.O., K.E.H.) identified final themes through discussion of passages pertaining to each theme. Results are presented as theme(s) and, in parentheses, number of preceptors discussing each theme.
Twenty-seven (57%) preceptors were interviewed, and interviews lasted from 11 to 47 minutes. Fourteen (52%) of the interviewees were male. Interviewee specialties, relative to the number of LIC preceptors in that specialty, were 5/7 Family Medicine, 5/6 Medicine, 4/8 Neurology, 2/5 Obstetrics–Gynecology, 4/5 Psychiatry, 3/7 Pediatrics, and 4/8 Surgery. The preceptors had 1 to 20+ years of experience teaching third-year medical students. Eighteen (67%) preceptors had prior experience teaching in the inpatient and 22 (81%) in the outpatient setting. Nineteen (70%) preceptors simultaneously taught third-year students on the TC in their specialty. Twenty-one (78%) preceptors taught one LIC student and six (22%) preceptors taught two LIC students during the year. Of the preceptors interviewed, 23 (85%) precepted LIC students again in the 2008–2009 academic year.
A majority of preceptors described their LIC teaching experience as positive, satisfying, and rewarding (21). Unlike the TC, in which longitudinal, one-on-one relationships with students were rare, preceptors appreciated the opportunity to see LIC students develop over time and felt they personally influenced students' learning. Some preceptors voiced that working with one preceptor might limit the students' exposure to other clinicians' perspectives in that discipline. Overall, preceptors felt the LIC was a constructive way for preceptors to teach and for students to learn. As one preceptor described, “It is a big change from what we have done in the past three decades.”
Preceptors' time, effort, and clinic
Most preceptors (15) added to their required time with students for more patient care and discussions of clinical topics. Many (14) altered their clinic schedules to accommodate students. To allow students more time with patients, preceptors who could do so reduced the number of patients seen by approximately one to three per session. Because of departmental mandates, full clinics, or lack of examination room space, certain preceptors were unable to reduce the number of patients seen (10). These preceptors used other strategies to accommodate student learning: They started earlier in the day and “loaded up on patients” by either seeing more patients themselves or having the student see some patients on their own first with the preceptor joining later, or had students accompany them to other patient-care sites. Some preceptors watched persistently for examination room openings so that students could see additional patients, and a few added an entirely new clinic devoted solely to their LIC student.
A majority of preceptors stated that patients, particularly those who had continuity with students, commented on the positive experience of working with a student (21). Patients appreciated that students helped them navigate the system, provided continuity, and advocated for them. As one preceptor related,
[The patient] had other kinds of medical problems and an incidental diagnosis of lung cancer made when she was on the surgery service, and she didn't know any of the surgeons. But she knew [the student]. And so, she said, ‘when [the student] came by, it was the high point of my day.'
Outside patient care, preceptors devoted one to six additional hours per month to their LIC students. This time was to discuss patient care: (13) preparing students for upcoming patient visits, postvisit debriefing, providing feedback on patient write-ups, and answering students' questions about patient care for all patients including ones from other preceptorships. Preceptors reported devoting time to coordinating preceptor–student schedules (9), particularly scheduling students for follow-up visits with continuity patients. One preceptor described that the coordination “was pretty logistically difficult, on all ends—it's difficult for patients, it's difficult for the student, it's difficult for our clinic.”
Because of the one-on-one nature, added time, and disruption to clinic practice, most preceptors felt that teaching LIC students required more time than TC students (15). A few preceptors felt that time commitment between the clerkships was similar (6). These preceptors, some of whom were unable to change their clinic routines, found that the student integrated into the clinic practice so that by midyear the time required to precept was reduced because the student developed more skills and understood the practice better. As one preceptor explained,
The fact that the student keeps coming back repeatedly means that you're doing less, spending less time on operational precepting, and more time on content. When you have a different student every week, you tend to spend 10 or 15 minutes of the session talking about how to fill out the forms and where the bathroom is.
Preceptors worried that students' learning was dependent on the patient opportunities available (11). Subspecialty preceptors worried about the limited patient diversity in their practices. Student participation in longitudinal care was limited because of infrequent return patients or patients coming from such a distance that the preceptor felt obligated to attend. Preceptors from specialties such as surgery indicated that the LIC model did not align well with the acute, short-term, intensive patient care typical of their discipline (5). As one preceptor described,
That whole pre- and postoperative management, that part the student didn't see. Such critical elements of what it is to be a surgeon, and be a part of the surgical team, are just not something that can be easily scheduled.
However, preceptors from specialties which emphasized outpatient, longitudinal care felt that the LIC taught the richness of their specialty better than the TC (7).
Initially, LIC students were observers focused on learning history-taking and physical examination technique (6). Unlike the immersion in one discipline that occurs during the TC, LIC students were learning many disciplines simultaneously. Consequently, LIC students required more time to consolidate discipline-specific knowledge. Preceptors estimated that, after five to seven sessions with the preceptor, “learning traction” occurred and learning “took off.”
Preceptors noted that LIC students' skills in clinical reasoning, patient education, and management and coordination of care progressed during the year (6). Not confined by the demands and constraints of a short rotation, LIC students enjoyed opportunities for meaningful responsibility for patients and realized consequences of management decisions (5). By the end of the year, most LIC students were independently conducting most patient interviews and taking ownership of patient care. They were able to generate differential diagnoses and treatment plans, reliably manage patient problems (especially problems encountered in the preceptor's clinic), and efficiently conduct patient visits (7). Preceptors noted that LIC students achieved an expected level of and comparable competency to TC students by the end of the year (8).
A few preceptors (4) reported that LIC students lacked knowledge of inpatient medicine and in-depth, discipline-specific knowledge, but more preceptors (11) stated that LIC students had a greater knowledge than TC students of outpatient medicine, systems-based care, disease progression, chronic illness, longitudinal patient care, relationship building, and the importance of integrating knowledge across disciplines. One preceptor observed,
I don't think the [TC] students necessarily come away with the concept of longitudinal care where they get to see diseases evolve, all the treatments begin to have effect. [LIC students] develop a relationship with the patient, which I think is very important.
Another preceptor commented,
It was rewarding to see how [the LIC student] would go to other clinics—for example, Neurology, or Obstetrics–Gynecology—and then come back to the medicine clinic, and really apply those skills to her patients in medicine clinic.
Preceptors indicated that LIC students knew their patients better and developed deeper patient relationships than TC students (9). By the end of the year, some patients identified LIC students as coclinicians with the preceptor (3). Even LIC students who already had advanced interpersonal skills when starting the year improved further (8).
Although some preceptors approached teaching as they would with TC students, they soon realized that alternate teaching skills were required. Preceptors often had to teach basics of coordination of care and administration, tasks typically relegated to residents in an inpatient-based TC (3). Preceptors recognized that teaching LIC students required “developmental precepting” (9). Because preceptors worked with the LIC students for a year, they gained insight into students' learning styles, strengths, and weaknesses, and they could tailor teaching and feedback accordingly (6). Preceptors contrasted this approach to their short interactions with TC students during which they rarely learned about students' individual struggles or had opportunity to intervene. As one preceptor stated,
One thing that the [LIC] would do very, very well is prevent somebody from falling between the cracks, or would clearly identify and enable specific deficits to be identified and corrected, which is much less likely to happen in the [TC].
Preceptors identified themselves as mentors with great influence on their students' development but also an urgent responsibility to ensure the students' education in their discipline (5). One preceptor stated,
Rather than 1 of their 40 attendings throughout the year, I was one of seven or eight. And it's neat to be able to have that kind of a relationship with a student, and think that you're making a bigger difference in their development—sort of a mentoring aspect. The difference is, I took responsibility for these students. I don't think I ever felt like I was really that responsible for the [TC] students, because the residents were kind of responsible for them.
Preceptors revealed that individual students' abilities affected the amount of time and effort required of the preceptor (15). Because LIC preceptors felt exclusive responsibility for their students' development, weaker students generated a greater amount of work for preceptors. At the same time, preceptors weighed their roles as teachers who provided formative feedback with their accountability to generate summative student evaluations. One preceptor lamented, “It is like being asked to evaluate a family member.”
Precepting students in an LIC is characterized by a substantial burden, a profound sense of responsibility, and a deeply gratifying reward. Preceptors perceived that they devoted more time and effort to and modified their clinics substantially for LIC teaching. LIC preceptors felt they bore sole responsibility for ensuring students' discipline-specific learning. However, collegial relationships with students, shared patient-care responsibilities, insight into students' development, and a sense of meaningful impact on students' growth were deeply rewarding to LIC preceptors.
Preceptors perceived many differences in learning and teaching between LIC and TC students, but they somewhat paradoxically thought both groups achieved similar levels of competency. The disadvantages of the LIC to students' learning were lack of multiple faculty disciplinary perspectives and contact with limited patient cases in some disciplines. LIC students excelled at developing strong patient relationships and providing longitudinal care. Faculty may be sensing a difference in the process of learning that does not yield differences in outcomes. Alternatively, faculty may be ill-equipped to measure differences in learning outcomes with existing assessment tools at our institution. Differences in outcomes may also impact students' behaviors and attitudes in ways that are best captured with long-term follow-up after the LIC. Yet the importance of continuity and strong patient relationships cannot be minimized because these may mitigate the erosion of outcomes such as professionalism that typically occur by the end of the clerkship year.2
The LIC model requires a substantial commitment from faculty. Clinical teaching is currently an unfunded mandate, and most institutions rely on residents for a large portion of clinical teaching. Stringent resident duty hours limitations are forcing medical schools to shift increasing responsibilities for both patient care and teaching to faculty.9 The LIC model for teaching may compel institutions to consider how best to allocate funds for teaching. We, like others,10 found that patients appreciated the presence of a student in their care, and preceptors reported the burden of teaching dwindling as students gained skills. Teaching models that enhance students' responsibilities in patient care must assess the benefits to patients of having students involved in their care longitudinally and across disciplines as a first step to determining how these factors may offset some of the costs of teaching, such as increased time and effort.
We found that students needed five to seven sessions with preceptors for “learning traction” to occur. Resource allocation and faculty development should focus on methods to help preceptors through these initially difficult sessions. Alternate curricular models that allow students more time to function at a level of greater patient ownership (i.e., continuity experiences extending more than a year) and low-stakes opportunities for ramp-up such as starting clerkships before the third year might help optimize the third-year LIC experience. LIC faculty development must also focus on equipping faculty members with approaches to teaching learners with difficulties, perhaps in combination with other faculty members when remediation is needed or curricular resources for students needing extra guidance.
Our study was conducted at a single institution. Because preceptors' reports were gathered at the end of the academic year, recall of the influences on time, effort, and clinic might represent mitigated views. However, our retrospective design allowed preceptors to reflect on the overall experience of precepting during an LIC.
In response to the changing face of clinical education, longitudinal clinical teaching for core clerkships has gained increased attention. Preceptors characterize clinical teaching during an LIC as entailing significant burden, responsibility, and reward. For most preceptors, the magnitude of the reward exceeded the logistical and time challenges. To ensure that LIC precepting continues to be a rewarding experience, LIC developers should focus on targeted faculty development and allocation of resources to clinical teaching to support and sustain the reward of LIC teaching for faculty.
The Parnassus Integrated Student Clinical Experiences Longitudinal Integrated Clerkship was funded by the Drown Foundation through the University of California, San Francisco School of Medicine Academy of Medical Educators, Office of Medical Education, and participating departments.