Community-based preceptors provide rich clinical experiences for medical students, which are integral to the students’ clinical education during medical school.1,2 The value of such ambulatory-based experiences is increasing as pressure mounts to reduce the length of hospital stays and to focus attention on chronic disease care in outpatient settings.3 However, competition to secure medical student clinical training sites has escalated because of increased class sizes in existing schools, the opening of new MD- and DO-granting medical schools, increased training needs for physician assistants and nurse practitioners, and increased pressures on physicians for clinical productivity.4,5 This “preceptor crisis” requires that we take action to ensure the continuity of the community-based preceptor experience for future generations of trainees.6
Previous studies have examined barriers to effective medical student training and proposed solutions from the viewpoint of educational program leaders. A common obstacle to participating in educational programs for preceptors is that they see fewer patients, and thereby do not meet quotas and have to work longer days,5–8 in the face of lower operating margins.5–11 Electronic health record and documentation requirements are viewed by some as additional impediments.6,12–15 To mitigate these barriers, compensation is offered to community-based preceptors by some U.S. institutions, but, more commonly, it is offered by non-U.S. medical schools instead.16 Some states have attempted to use educational tax incentives as an alternative to direct compensation.17 Other viable recommendations were presented in a recent consensus document by the Alliance for Clinical Education.6 They recommended preparing clinical sites for students’ expectations of autonomy and preparing students to perform clinical and administrative work, such as on-boarding to the electronic health record system. These activities may enhance both students’ value to clinical practices and the benefits to physicians serving as preceptors.
Previous studies have attempted to understand the perspectives of the preceptors themselves, who have voiced concerns about the requirements for documentation of educational activities and the need to use educational terminology and new teaching methods.18–20 However, these studies are limited to experiences at a single institution or offer only quantitative results.
To better understand the perspectives of community-based pediatricians across the United States, we conducted a multicenter qualitative study to explore the motivating factors and strategies of community preceptors with a track record of successful medical student integration and training in their practices. Our objectives were to characterize underlying motivational factors for becoming a preceptor and to identify strategies for recruiting and retaining community preceptors.
This multicenter qualitative action study included semistructured interviews with community-based pediatric preceptors affiliated with 12 institutions. Community-based preceptors were considered for inclusion if they were actively engaged in teaching students, had no significant financial relationship with the investigators’ institutions, and were volunteer/adjunct faculty. Participating institutions were diverse with respect to geographic location, private versus public, and class size (see Table 1). The investigators were all faculty involved in the administration of the pediatric clerkship at the institution that was sending medical students to the precepting site. The investigators also were all members of the Council on Medical Student Education in Pediatrics, who came together to address the motivations of community preceptors and the strategies for supporting them. Each site obtained institutional review board approval prior to conducting interviews.
Semistructured interviews were conducted by the site investigator or a designee from August to December 2015. Demographic questions were asked, followed by questions related to the participant’s motivation to be a preceptor. Questions were developed by the investigators through conference calls and e-mail interactions. The final wording was agreed on by the investigators and approved for use by the participating institutional review boards. Questions used to guide the interviews are included in List 1.
Participants were identified by each investigator with input from the pediatric clerkship administrators at her or his institution. Participants were community-based pediatricians, with a wide range of time in practice, who actively taught medical students in their practices. Each site planned to conduct up to eight interviews; most sites conducted three to eight interviews. Sample size was determined by saturation (i.e., the point in data collection when no new or relevant information emerged). Because local interviews were conducted by the site investigator, she or he determined when saturation was achieved. Consent was obtained from participants, and interviews were conducted over the telephone and transcribed verbatim. Final transcripts were deidentified and collated into a single document. When only one or two interviews were conducted at a site, the transcripts were still included because the data were analyzed as a whole and not by institution.
All of the interview transcripts were used in the analysis. A team of six investigators (A.M.A., G.L.B.D., C.C., C.R.P., W.A.M., C.V.) independently identified themes from five randomly chosen transcripts. They discussed these initial themes via conference calls and e-mail to develop the initial codebook, which consisted of 33 separate codes. Disagreements on the meaning of the codes were resolved through discussion until consensus was reached. After the development of the initial codebook, three teams of two investigators each divided the remaining transcripts to assign the appropriate codes. Through a constant comparative method,21 these three dyads independently coded the transcripts, compared the results within their dyads, and came to consensus on any disagreements. Once all of the teams had reached consensus, the six investigators reviewed all of the coded transcripts. This iterative process resulted in a final codebook of 41 items. All final coded transcripts were reviewed by the six investigators; disagreements were resolved through discussion and consensus was reached.
To triangulate the results, the coded transcripts were verified by the six other investigators (M.S.R., P.B.P., J.P., C.P., J.K.S., R.T.S.) who were not part of the coding process. Disagreements were resolved through discussion, and consensus was reached. The final interpretation of the meaning of the identified themes was decided by the entire research team. Because the codes represented more granular themes, we discussed using a different naming convention to minimize confusion. When we interpreted the meaning of the results, we referred to themes that fit together as dimensions, because they reflect the broader scope of the various themes that emerged from our analysis.
Semistructured Interview Questions Used in a Study of Community-Based Pediatricians’ Motivations for Precepting, 2015
- How often do you have students?
- What inspired you to start teaching medical students? Why do you continue to teach medical students?
- What hesitations did you have about teaching?
- What experiences did you have that prepared you to teach? What continuing education have you had that focused on teaching students (e.g., feedback, evaluation)?
- Consider your experiences teaching medical students. Tell me about a particular high point or time teaching that energized you while working with a student.
- What do you value most about teaching medical students?
- What do you least enjoy about teaching medical students?
- How do you manage a busy practice and still teach medical students?
- What advice do you have for clerkship directors when recruiting new community-based preceptors to teach medical students?
- What do you think the medical school could do to make your job as a preceptor better?
Fifty-one community-based preceptors from 12 different states participated (see Table 1 for demographics data). Participants included 35 women and 16 men. Years as a preceptor ranged from 1 to 39; only five participants had been teaching for less than 10 years.
Emergent themes coalesced into four dimensions: (1) least liked aspects of teaching, (2) preparation to teach, (3) inspiration to teach, and (4) ways to improve recruitment and retention.
Dimension 1: Least liked aspects of teaching
Despite the fact that participants enjoyed teaching, the negative aspects of this work were enough to make them want to stop. Themes that emerged included time constraints and increased time demands associated with teaching, electronic health records, ambivalent or disinterested learners, and difficulties in grading students.
Research has shown that teaching students adds time to a preceptor’s workday.22 The experience of our participants was no different. In addition, the inability to control patient schedules in an era of high productivity demands was a deterrent to teaching.
Time constraints. I get no reduction in patient workload even when I’m teaching. It’s a constant time management thing having to balance teaching with clinical duties.
I guess I just get a little anxious at times about keeping up with the volume and flow, so that can be stressful, so I least enjoy the stress.… It can be tiring talking all day long, especially at the beginning of the rotation [and then there is a lot to do at the end of the day and I have to do a lot of work on my own time]; it takes a lot out of you and … you have a lot to do on your own time.
Evolving electronic health record and documentation demands also have added time to a preceptor’s day.23 With students, the time burden of documenting patient encounters was typically much greater.
So dependent on the EMR. Far more time-consuming.… For example, I’m now 12 charts behind because our EMR crashed yesterday. And having a student come on top of that, it’s not fun.… They can’t help me on my charts. There is no benefit to having them here.
To ameliorate these problems, participants cited the creative scheduling methods they used to make the teaching experience manageable: (1) They identify patients who students can see (e.g., students do not see the difficult patients/parents or patients with certain sensitive and time-consuming issues); (2) they allow students to see one patient while they see a different patient; (3) they multitask (e.g., the preceptor charts while the student sees the next patient); (4) they allow students to shadow them part of the time so the students remain engaged in patient care; (5) they allow students to work with more than one physician over the course of the day, thereby dividing the responsibilities among preceptors; and (6) they allow students to work with nurses (e.g., learning how to give vaccines).
I often have the student see a patient simultaneously while I see another patient. The student writes the note which saves me time. If there are not two patients at a given time, we may go in together and I will listen and add. If it’s a really crazy morning or afternoon, I have the nurses teach the student how to give vaccines, perform rapid strep, etc.
I try to look ahead at the schedule a little bit and pick and choose who might be good for the student to see and I try to tell them a little about the family if I know them, especially if it is a special needs kid.
Next, participants indicated that enthusiastic students contributed to the joy of teaching, whereas ambivalent students were perceived to be deterrents.
It’s the students that you can tell so do not want to be there. They don’t realize I’m a volunteer.
Participants also expressed that medical schools and clerkships could do more to prepare students before they come to the preceptors’ clinics. This preparation may include an orientation to the importance of what students will experience, thereby enhancing their motivation.
Finally, participants indicated that they did not enjoy grading students—they were comfortable providing written feedback but did not feel qualified to assign actual grades.
Frustrated by grading system. Seems can’t give Pass anymore, but only two grades of “High Pass” or “Honors.”
To resolve this issue, participants suggested that preceptors write comments about the students’ performance and let the clerkship directors determine the final grade on the basis of these comments.
Dimension 2: Preparation to teach
A potential barrier to teaching for some participants was an initial feeling that they did not have the appropriate skills or training as an educator. When discussing their roles as preceptors, preparation to teach emerged from the themes relating to learning during residency or fellowship training and through continuing medical education (CME) activities.
Participants had both formal and informal training to be clinical instructors. Many received training during residency and/or through specific CME courses.
I had a lot of mentors in my residency. People that liked to teach and taught me how to teach. They were good role models and made teaching not so overwhelming, especially when I was a resident teaching students.
… since I’ve been in practice, I’ve attended teaching seminars.
Others identified role models from medical school and residency whom they look to as examples of how to effectively teach.
Modeling after the effective teachers that I saw was one of the biggest ones as a student, seeing how others did it well and not well.
Dimension 3: Inspiration to teach
Several themes emerged about participants’ inspiration, including the joy of teaching, the opportunity to continue learning and staying current, a sense of obligation to teach and to give back, and keeping their practice engaged in education.
Participants’ joy of teaching was influenced by the characteristics of their students as well as their own interests, such as sharing the experience of a student’s “light bulb moments” that occurred when students understood a key concept or made an insightful connection. Enthusiastic learners also contributed to this feeling.
I love seeing the light bulb go off in their eyes. Their enthusiasm is contagious. Watching a student get so excited about seeing something that he/she just read about.
Opportunities to share a longitudinal experience with a student (e.g., when a former patient becomes a student or when a student returns after the clerkship experience) and to observe students gain an appreciation for the practice of pediatrics emerged as factors that inspired participants to teach.
… it is a high point when you see that they get something; when they can see the value of primary care; appreciate the long-standing relationships developed with families and the fun of pediatrics.
What energizes me would be when they stay in contact with me and update me on how they are doing. I like knowing where they have gone and how I have influenced that decision that they’ve made.
Many participants described a sense of duty or responsibility to teach, citing their part in the cycle of teaching and receiving similar educational experiences as motivators. They also noted that teaching was a natural part of their careers.
It was a natural extension after being a chief resident. I think medical education is very important, and I feel I need to give back; do as my teachers did for me.
Really, I view it as a payback for all of the people that taught me.
Participants indicated that teaching students challenged them to stay current.
I enjoy the push that they give us to stay current on various topics that we have to teach them about. I can’t be teaching them outdated or incorrect information, so it keeps me sharp.
Compared with academic health centers, medicine is practiced differently in the community.24 Unlike physicians at academic centers, preceptors in ambulatory settings typically do not have easy access to consultants or technology, which requires them to develop different skills, expectations, and priorities to meet patient needs. For example, participants commented on the importance of exposing medical students to different patient populations with limited resources. They took pride in the way they practice medicine and enjoy exposing students to their world.
My responsibility to transfer all I have learned from my experience to them. How to handle situations like psychosocial issues and issues you don’t come across in books or in residency.
Dimension 4: Ways to improve recruitment and retention
Participants provided insightful ideas for recruiting new preceptors and retaining current ones. Their suggestions included the following:
I think my wonderful medical student along with a couple of my former patients who were medical students and in the class that graduated last year nominated me for the AOA volunteer teacher of the year—so that was really nice.…
- 2. Increased communication between the institution and the preceptor
Saying we want to hear from you on day 1 if a student is doing x, y, and z. So that they know they have a quick route. I think a lot of times if a student isn’t doing well, it’s just internalized. The practice complains, but no one ever gives you that feedback necessarily. Just knowing it’s automatically available and wanted, expected would be good.
- 3. Increased mentoring of new or potential preceptors by seasoned preceptors
Have a pediatrician who loves precepting speak with the potential preceptor. Appeal to their talent for teaching. Appeal to their altruistic side.
- 4. Increased monetary support, to a lesser degree
You must have incentive. Money is helpful, but will never be the primary reason.
The results of our study allow us to better understand what motivates community-based pediatricians in the United States to precept medical students. These findings build on a recent consensus statement developed by medical educators across disciplines,5 and they further explore the perspectives of the pediatric community preceptor beyond what has been studied through single-institution, quantitative studies.8 Our participants echoed the rewards of teaching, such as recognition, financial incentives, and CME/maintenance of certification opportunities, described in other studies.6,8,10,25,26 More important, they provided new insights into the major factors that influenced their decision to teach, and they offered suggestions for overcoming some of the commonly cited barriers to the recruitment and retention of preceptors. From these results, we recommend collaborative efforts to increase the pool of preceptors in the future.
Unlike the expert opinion offered by Christner and colleagues,6 our study solicited preceptors’ suggestions for overcoming perceived impediments to physicians’ participation as preceptors. Having enough time was the greatest obstacle for our participants and has been problematic in other studies as well.8,27 While all specialties report increasing demands on their time, comparatively, pediatricians express even greater concern, due in part to the shorter time available for each visit compared with other specialties.28–30 Teaching students in the clinic does not allow for a decrease in productivity, adding to time pressures. In recent years, time for education has been further constrained by the development and integration of electronic health records across academic and community-based sites.14,31
Participants shared several methods for overcoming time barriers, including creative scheduling practices and balancing students’ expectation of autonomy for patient care with what is feasible in a busy clinical practice.32 The themes of permitting shadowing at times33 or even spending occasional time away from direct patient care activities align with the theme of incorporating time for independent study, described in a previous report.34 Another option is dividing the patient panel such that the preceptor sees patients independently of the student (so-called “wave” scheduling).35 Interestingly, our participants did not explicitly highlight the incorporation of “value-added” techniques, as described in the literature, such as identifying methods for students to contribute to the electronic health record to facilitate patient throughput.6,36 Such techniques have been highlighted in a variety of studies but have not been broadly applied in current practice.
In addition to the barrier of time, participants expressed dissatisfaction in their roles as evaluators. More specifically, they were frustrated that they had to assign grades to students. This finding was surprising, as it has not been previously reported as a barrier. It may be related to our finding that another potential barrier to teaching is a lack of formal training in education. Even with training during residency or through CME courses, this finding likely reflects preceptors’ dissatisfaction with having to assign relatively arbitrary designations such as “Honors” or “High Pass” which, though helpful and perhaps intuitive for medical schools, are somewhat abstract concepts. Moreover, the use of the term “grading” and the expectation that preceptors must grade students troubled our participants. Evaluation and grading are distinct outcomes of summative assessment and not necessarily one and the same.37 Perhaps the role of the preceptor should be to comment on a learner’s performance (e.g., formative assessment) rather than assigning numbers or grades, whereas the role of the clerkship director should be to assign grades based on those comments. This model will require changes in medical school evaluation forms to solicit detailed feedback from preceptors so clerkship offices can assign grades.
Our participants highlighted the potential value of preceptors recruiting/retaining other community faculty. Peer mentoring has gained traction in academic medicine,38,39 but to our knowledge there are no peer mentoring programs connecting faculty in academic and community settings. This finding may be worth further exploration as part of a faculty development program.
Only two participants discussed monetary incentives, which was surprising. There are reports of offshore and DO-granting medical schools paying preceptors,5,10,16 which is a concern for MD-granting institutions in the United States with limited funding. Finding creative solutions in the form of tax incentives, similar to what the State of Georgia has done,17 may solve this conundrum. With only two participants mentioning this issue, the other suggestions participants had to improve the recruitment and retention of preceptors, as well as those identified by Christner and colleagues,6 may be more feasible and effective.
Our participants indicated that physicians are intrinsically motivated to teach. This theme was part of Dimension 3: Inspiration to Teach, as participants highlighted their sense of obligation to teach and the joy it provides. This intrinsic motivation appears to stem from notions of professional duty, a desire to be a role model, and valuing the relationship between preceptor and trainee.26 As health care becomes more complex and challenging, some have raised concerns that this motivation will diminish over time.28 Reassuringly, though, the preceptors we interviewed highlighted their innate desire to teach despite it becoming more difficult in their practice.28,40
Our participants also specifically commented on their desire to emphasize the joy of pediatrics as a specialty. Pediatricians, and general pediatricians in particular, commonly report higher rates of job satisfaction compared with physicians in other specialties.29 Similarly, when describing their ideal balance of clinical work, administrative duties, and medical education, pediatricians desire more time for medical education.41 This drive to share their passion for pediatrics and to teach the next generation of physicians is reassuring considering the long-term need for community-based teaching resources.
Finally, participants reported that they enjoyed the longitudinal relationships they formed with their learners. Other studies have illustrated how a longitudinal relationship provides value to both parties.42 Typically, these relationships are defined in the context of longitudinal integrated clerkships.43 However, our participants recognized the benefit of longitudinal relationships outside this context as well. For example, some participants mentioned their appreciation for working with students with whom they worked in other settings, such as during the preclinical phase of training. Others described experiences working with students for whom they had provided care in the past. While matching students to preceptors to foster longitudinal relationships may seem appealing, this practice should be considered with caution because of the potential risks of bias and compliance concerns. The Liaison Committee on Medical Education requires that “health professionals who provide health services … to a medical student have no involvement in the academic assessment or promotion of the medical student receiving those services.”18
Although we interviewed a convenience sample of community pediatricians associated with 12 medical schools, participants were chosen specifically because they continued to teach despite greater demands on their professional time. We plan to interview community-based preceptors who have chosen to stop teaching to identify the reasons why they made this choice. Our sample likely included preceptors with more innate desires to teach than it would have with a more diverse population. Similarly, it is unclear whether our sample represented diversity in terms of geography (i.e., rural vs. urban) or ethnicity as we did not explicitly measure these variables. In addition, our sample included more female than male preceptors. Although we were unable to identify literature regarding the effect of gender on willingness to teach students, it remains a potential research question for future investigations. Finally, saturation in qualitative research can be viewed as thick and rich,44 where thick is the quantity of the data and rich is the quality of the data. Our study did lack thick data from some sites because of limited participant consent. However, when we combined all of the transcripts, our data set was both thick and rich.
Community pediatricians, with their knowledge and experience providing ambulatory care, continue to be an indispensable resource for medical education. Our findings highlight the value of these physicians and provide concrete suggestions for improving their recruitment and retention. External rewards (e.g., recognition, CME credit) continue to serve as valuable incentives. However, community pediatricians also are inspired to share their enthusiasm for pediatrics and to develop longitudinal relationships with their learners. Successful preceptors have been able to balance the demands of their clinical practices with their desire to teach using creative scheduling practices and permitting “downtime” in a strategic manner. Finally, preceptors are willing to mentor their colleagues, a practice that could increase the collaboration between academic medical center and community-based physicians and offer a “win–win” for all stakeholders.
Acknowledgments: The authors would like to thank Dr. Mitzi Scotten for participating in this study and interviewing community-based preceptors affiliated with the University of Kansas School of Medicine.
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