Latessa, Robyn MD; Colvin, Gaye MLIS; Beaty, Norma MS, MAEd; Steiner, Beat D. MD, MPH; Pathman, Donald E. MD, MPH
Community preceptors provide much of the outpatient clinical training of health professions students (medical, pharmacy, nurse practitioner, physician assistant, and certified nurse midwife) yet often receive little or no direct compensation. Relying on community teachers has been a sustainable health education model because preceptors principally teach students for intrinsic reasons, most importantly the pure enjoyment of teaching.1–8 The current community teaching model may be at risk due to increased numbers of learners, economic pressures on practices, and productivity demands on clinicians. Nationally, the number of health professions schools and class sizes has increased, yielding ever more requests for student placements.9–12 In North Carolina, the number of students in community-based rotations increased from 2,046 learners in 2005 to 2,430 learners in 2011.13
Are the costs of precepting beginning to outweigh the benefits or intrinsic motivations for teaching? A statewide survey of 2,061 community preceptors in 2005 suggested that North Carolina was far from such a tipping point. A strong majority of those preceptors reported their satisfaction with teaching (93%, 1,320) and foresaw the high likelihood of continuing to teach for the next five years (91%, 1,298).14 Studies in other settings have suggested that community-based education may be approaching the point where its costs (e.g., lower productivity and longer work days) will begin to eclipse benefits for community practitioners and that traditional models of community teaching might need reevaluation.7,15–17 If the intrinsic rewards of teaching (e.g., enjoyment of teaching) are not sufficient, then perhaps extrinsic rewards (e.g., monetary compensation) have become more important for recruiting and retaining community preceptors. In a national survey of pharmacy preceptors, over a third placed high value on a monetary stipend for their teaching efforts.9 Another study of primary care physician preceptors concluded that raising stipends was associated with greater retention of teachers and that preceptors paid directly (rather than payment going to their organizations) showed more willingness to continue teaching.18
Although there is a body of literature on the topic of community preceptor satisfaction and rewards,1–9,14–29 no large-scale studies have measured changes in satisfaction and other outcomes for preceptors over time. Given the recent changes in the practice environment of health care and the increasing demand for preceptors, data regarding such trends may now be important.
The North Carolina Area Health Education Centers (NCAHEC) system has an Office of Regional Primary Care Education (ORPCE) in each of nine Area Health Education Center (AHEC) regions. These offices, established in 1993, provide an integrated system of support for primary care and community-based education.18
In this 2011 study, we primarily aimed to measure the satisfaction, motivations, and value placed on teaching by community preceptors of health professions students in North Carolina and to compare this information with responses to the same questions posed to our state’s community preceptors in 2005. We hypothesized that preceptors’ perceptions and opinions over this six-year period had declined and would yield lower overall satisfaction with teaching and with students’ influence on other aspects of their work. On the basis of a few recent studies and statewide anecdotal reports, we anticipated more negative responses from preceptors of all health disciplines.8–11,30–34 Regarding incentives, we specifically expected to find that extrinsic rewards, including money, had become more important to preceptors. Our goal was to learn if the community preceptor model in health professions education was still viable or if we were beginning to see trends in preceptor satisfaction data that would suggest that this teaching model might need redesign.
Beginning in the spring of 2011, we mailed questionnaires to all 2,359 primary care preceptors who taught students for the NCAHEC ORPCE system during the 18-month period of July 2009 through December 2010. The roster of active preceptors for this study was provided by the NCAHEC Program Office. This group included mainly private practice physicians, pharmacists, advanced practice nurses (nurse practitioners and certified nurse midwives), and physician assistants, who precepted for a subset of community-based primary care rotations. The health professions students were enrolled in health professions degree programs (medical, pharmacy, nurse practitioner, physician assistant, and certified nurse midwife) in 14 NCAHEC-affiliated statewide public and private institutions, including four medical schools. These rotations varied in length from a few days to nine weeks and served all levels of graduate learners. The institutional review board of Mission Health in Asheville, North Carolina, approved the study in March 2011.
Data and data collection
We used the same survey items in the 200514 and 2011 North Carolina AHEC Preceptor Surveys. A four-page questionnaire, which promised anonymity for participants, asked preceptors to provide the following information: (1) overall level of satisfaction with precepting, (2) anticipated likelihood of continuing to serve as a community preceptor for the next five years, (3) perceived influence of teaching students on their practice, (4) reasons for teaching students, (5) satisfaction with and value placed on various tangible incentives (e.g., money, access to online library services, continuing education, academic appointments), and (6) satisfaction with professional life. The questionnaire also solicited information on preceptor demographics and characteristics of their work, including gender, age, race/ethnicity, practice location, years in practice, hours worked per week, years precepting, and number of weeks precepting per year. The only difference between the 2005 and 2011 questionnaires was that we revised a few of the 2005 items (i.e., fair compensation, age, and years in practice) from open-ended to fixed-response options for the 2011 version. A copy of both questionnaires can be obtained on request to the first author.
We initially e-mailed a survey invitation letter on April 24, 2011, to all 1,185 preceptors for whom we had an e-mail address. The letter stated the study’s purpose, ensured anonymity, and promised a drawing for four $250 cash prizes as an incentive. Winners were randomly selected and gift cards mailed to winning preceptors’ addresses. Nonrespondents received reminders every two weeks for a period of six weeks.
For 1,174 preceptors without e-mail addresses, we sent an auto-numbered paper questionnaire on May 16, 2011, via the U.S. Postal Service, accompanied by the same cover letter and a self-addressed, stamped return envelope. Almost three months following the initial mailing, on August 8, 2011, we mailed another paper-based questionnaire to all 1,713 remaining nonrespondents, including both those initially contacted by e-mail and those contacted via the U.S. Postal Service. Regional AHEC ORPCE personnel made one last effort to contact nonrespondents through faxes or phone calls. Numbering on surveys enabled us to keep data anonymous while tracking responses. Response data were processed by a few key personnel, and coded data were password protected. Except for not using an electronic survey in 2005, the survey processes were similar in 2011 and 2005. Final survey returns were accepted within six months of initial request.
We applied descriptive statistics to characterize respondents’ demographics. Five-value Likert-scaled satisfaction and value items were dichotomized for analyses to help reduce the amount of information included in analyses, which carries higher risks of type II errors, and to simplify the presentation of results. In all cases except one, we combined the highest two positive Likert response values (e.g., “very satisfied,” “satisfied”) and combined the lowest and neutral response values (e.g., “very dissatisfied,” “dissatisfied,” “neutral”), believing that we want preceptors to feel positive about all aspects of their teaching and that neutral views were unacceptable. Only in the banks of questions relating to the perceived influence of having students in the office did we group neutral responses with the two positive Likert response values, because this is how the values were grouped in the 2005 comparison study. Chi-square tests were performed to examine differences in dichotomized outcomes for demographic subgroups and discipline groups (physicians, pharmacists, advanced practice nurses, and physician assistants) and to compare group responses between the 2005 and 2011 respondents. We used SPSS 19 for Windows (IBM Corp., Armonk, New York), with statistical significance set at a somewhat tighter than standard P < .01 to partially account for this study’s many group comparisons.
Response rate and demographics
In 2011, a total of 54.2% (1,278/2,359) of the surveyed preceptors completed questionnaires. Preceptors who completed questionnaires did not differ from nonrespondents in gender, but slightly fewer physicians 51% (633/1,241) responded than the other three groups: 57.6% (265/460) pharmacists, 58.4% (305/522) advanced practice nurses, and 58.6% (75/128) physician assistants (P<.01). The response rate differed slightly across the state’s AHEC regions, varying from a high of 62.8% (98/156) in South East AHEC to a low of 45.1% (120/266) in Southern Regional AHEC. The overall survey response rate for the 2005 study was 69.3% (1,428/2,061).
Of the 2,359 North Carolina AHEC preceptors in 2011, 766 (32.5%) were included in the 2005 pool. Additionally, 1,593 new preceptors were added over the six years between the surveys (2005–2011). Of the 766 preceptors who were part of the common active preceptor pool in both survey years, 59% (452) responded to both surveys. Although a considerable number of preceptors (1,295) did not continue teaching from 2005 to 2011, more new preceptors (1,593) were added to the active pool during this period.
Table 1 lists the 2011 respondents’ demographics and descriptions of their practices and experiences as teachers. Almost half of the 1,278 respondents were physicians (49.5%, 633), followed by pharmacists (20.7%, 265), advanced practice nurses (23.9%, 305), and physician assistants (5.9%, 75). Practice specialties for the 1,236 respondents included these disciplines: family medicine (38.3%, 474), pharmacy (18.6%, 230), pediatrics (16.3%, 201), internal medicine (11.6%, 143), obstetrics–gynecology (8.0%, 99), and other (7.2%, 89). Demographics and practice and teaching experience of respondents were similar in 2005, with the exceptions in 2011 being a higher percentage of females (53.1%, 661/1,244) and a higher percentage of preceptors with more than 25 years of practice (24.5%, 301/1,229).
Overall satisfaction and perceptions of teaching students
The vast majority of 2011 respondents (91.7%, 1,159/1,264) reported being very satisfied or satisfied with their experience as community preceptors. A similarly high proportion (88.7%, 1,120/1,262) answered definitely or probably to a question regarding their likelihood to continue as a community preceptor over the next five years. There were no statistical differences in these areas among the four discipline groups in 2005 and none between 2005 and 2011 (Table 2).
Almost all preceptors in 2011 (93.7%, 1,158/1,236) reported they were satisfied or very satisfied with their professional lives generally. Pharmacists were most often satisfied (98.1%, 252/257), and physicians were least often satisfied (90.0%, 550/611; P < .001); however, both remained very satisfied.
Regarding the perceived effects of having a student in the practice, a majority of the 2011 respondents rated teaching students as having a positive or very positive influence on the following: overall job satisfaction (83.4%, 1,055/1,265), relationships with colleagues and staff (59.2%, 748/1,263), relationships with patients (58.9%, 745/1,264), and patient satisfaction (56.8%, 718/1,263). Physicians more often than other disciplines indicated that having a student had a negative or very negative influence on patient flow (45.1%, 283/627), working hours (39.7%, 249/627), and income (15.5%, 97/626) (Table 3). These findings showed no significant differences from the 2005 data.
Motivations and incentives for teaching
To assess preceptors’ intrinsic motivations to teach, we asked about reasons for teaching students. In 2011, a majority indicated that most of the queried intrinsic reasons had some, great, or very great importance in their decision to teach students, though physicians often placed lower value on these motivations than the other groups (Table 4). When compared with 2005, the 2011 preceptors placed greater value on 6 of the 14 intrinsic reasons, whereas physician preceptors showed significantly increased value on 4 of the 14 reasons (Table 5).
Overall, 48.9% (596/1,220) of the 2011 community preceptors responded that they were satisfied or very satisfied with the incentives they received to teach, without significant differences among the disciplines. The proportion of preceptors who were satisfied or very satisfied with overall incentives decreased significantly from 57.4% (777/1,356) in 2005 to 48.9% (596/1,220) in 2011 (P < .001). The most highly valued incentives (rated some, great, or very great) remained the continuing education credit for teaching (86.5%, 876/1,013), continuing education programs on clinical topics (72.9%, 615/844), free online library resources (72.1%, 667/925), academic appointments (65.9%, 488/740), and financial compensation (61.9%, 594/959). Disciplines differed in the value they placed on various incentives. In 2011, except for academic appointments, physicians rated 11 of the 12 incentives lower than other disciplines (10 were significant at P < .001).
When preceptors were asked directly about fair compensation for having a student in their practices, the survey listed the following options: $50–$100/week, $101–$150/week, $151–$200/week, and >$200/week. In 2011, 42.9% (465/1,085) of preceptors indicated greater than $150 per week. (Currently, community preceptors in North Carolina receive from $93.75 to $112.50 per week, depending on practices’ NCAHEC rural designation status.) Fewer preceptors in 2005 (31.4%, 304/967, P < .001) indicated fair compensation to be over $150 per student each week. Among discipline groups in 2011, more physicians (53.1%, 280/527) reported that fair compensation was an amount greater than $150/week. Of the other groups, only 32.5% (76/234) of pharmacists, 35.2% (92/261) of advanced practice nurses, and 26.9% (17/63) of physician assistants indicated fair compensation to be over $150 per week (P < .001 for all).
Contrary to our hypothesis, overall preceptor satisfaction remained very high in this large study. We did not find that the present health care climate has actually led to lower overall preceptor satisfaction over the past six years. One possible reason might be that the characteristics of those who are drawn to teach may also make them inherently more satisfied individuals, less affected by what some view as a deteriorating practice climate.26 Indeed, our respondents’ satisfaction rating with their professional lives was higher than the norm.26,35,36 Another reason might be that complaining about circumstances does not always equal true dissatisfaction, and despite verbal expressions of dissatisfaction, preceptors remain satisfied.37 Also, teaching is a highly valued role in society, and preceptors may be hesitant to admit dissatisfaction with teaching, introducing a social desirability bias.
Of the disciplines, physician preceptors reported lower satisfaction with various aspects of teaching in 2011. They were more likely to indicate that having a student had a negative or very negative influence on patient flow, work hours, and income. More physicians than others also expressed lower importance on most of the intrinsic reasons to teach. Additionally, physicians rated 9 of the 12 extrinsic incentives significantly lower than the rest of the disciplines. The culture and educational climate of physician practices may be distinct because of a greater push for productivity and transitions to electronic health records, leading to an environment in which teaching may be less compatible with their work than other preceptors. These factors may place a greater burden on physician preceptors and may lead to lower measured satisfaction. National data show that physician productivity increased nearly 20% between 2006 and 2009.38
These results have significant policy implications. Teaching medical students even in today’s busy outpatient settings is intrinsically satisfying for many clinicians and should not be abandoned as a model. Giving back to one’s profession, the intellectual stimulation, and the enjoyment of teaching were particularly important to the preceptors in 2011. Developing creative opportunities for preceptors to nurture these values provides strategies to further improve the model of outpatient teaching. For example, offering quality continued medical education events where preceptors interact and share their ideas and enjoyment of teaching may help cultivate those core values. Developing “specialized teaching practices” where teaching is valued and supported could further nurture these core values. Longitudinal experiences, similar to the Cambridge model in which physician preceptors teach students one half-day each week over several months rather than most days for four or six week blocks,39 are another strategy to develop a culture of learning and long-term relationships withstudents.
The data supported our hypothesis of preceptors placing increased importance on monetary compensation in 2011 compared with 2005. More preceptors in 2011 indicated higher monetary amounts when asked about fair compensation. In 2011, most physicians (53.1%) reported that fair compensation would be an amount over $150 per week. Peters et al18 found that retention of preceptors was improved if the preceptor received the funds directly. Our results suggest that medical schools do need to pay more attention to providing reasonable monetary compensations to outpatient preceptors. Direct compensation to preceptors might be of most value, possibly via fee supplements directly to them through Medicare and Medicaid.
Our study’s response rate was higher than many other recent studies of clinicians; still, nearly half of targeted preceptors chose not to participate. The high preceptor satisfaction rate may reflect the greater willingness of satisfied preceptors to return questionnaires, yielding a response bias. Also related to limitations around assessing preceptor satisfaction is the lack of more detail about the small groups of preceptors who did not respond positively to questions about satisfaction with precepting (8%, 105/1,264) and overall satisfaction with professional life (6%, 78/1,236). It would be valuable to examine this group more in depth in future studies; however, the small respondent number in each category makes statistical analysis of existing data challenging. Although we are able to comment on the variance in the preceptor pool from 2005 to 2011, we do not have the data to know why the preceptors who discontinued teaching did so. Of note, several ORPCE courses were dropped from the approved courses during this time period, potentially affecting the number or preceptors who continued teaching. Another study limitation is the unknown applicability of the study findings to other states and other community teaching models.
In this statewide study with data collected at two points in time, we found that preceptors generally continue to be satisfied with their experiences teaching students. Intrinsic reasons remained an important motivation to precept, but monetary compensation may be increasing in importance to community preceptors. Our data indicate that the present use of community preceptors to educate students in the health professions remains a viable model in our state, although perhaps less so for physicians. We are beginning to see trends in preceptor satisfaction that might suggest the need to redesign these teaching models for physicians.
Within our state, we are sharing these results with preceptors, with ORPCE partners, and at a statewide health professions education conference. We hope to stimulate a conversation and learn if and how the state’s health professions schools and AHEC can better support community preceptors and ensure their continued service as educators. Additionally, we are reaching out to other states to determine whether results reported for North Carolina are relevant nationally.
Acknowledgments: The authors wish to thank Reid Johnson, University of North Carolina School of Medicine, for Qualtrics online survey management and data entry; Alan Brown, MSW, and David Holmes of the North Carolina AHEC Program Office for facilitating financial support and preceptor data; and the North Carolina AHEC Program’s nine Offices of Regional Primary Care Education for support with data collection.
Funding/Support: This study was supported in part by funds from the North Carolina AHEC Program Office, the University of North Carolina School of Medicine Academy of Educators, and Mountain Area Health Education Center.
Other disclosures: None.
Ethical approval: This study was reviewed and approved by the Mission Health institutional review board. The requirement to obtain written informed consent documentation was waived under federal regulation 45 CFR 46.116(1-4).
Previous presentations: Preliminary data were presented at (1) Predoctoral Meeting of Society of Teachers of Family Medicine, Long Beach, California, February 3, 2012, (2) North Carolina AHEC Faculty Day at University of North Carolina School of Medicine, Chapel Hill, North Carolina, May 24, 2012, (3) North Carolina AHEC Statewide Meeting 2012, Raleigh, North Carolina, September 20, 2012, (4) Statewide Office of Regional Primary Care Meeting, Greenville, North Carolina, October 16, 2012, and (5) The Future of Community-Based Education in North Carolina: A Conference for Health Science Schools, Chapel Hill, North Carolina, March 21, 2013.
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