Clinical experiences with community preceptors offer medical students invaluable opportunities to learn critical elements of primary care medicine, including the continuity of care, the business aspects of the profession, and the management of chronic disease over time in direct patient care settings.1,2 Medical institutions and their leaders rely on community preceptors to teach their medical students.3 However, recruiting and retaining community preceptors has become increasingly difficult due to many factors including increased class sizes and competition throughout health professions programs.2–5 In a recent report sponsored by medicine, nursing, and physician assistant programs, at least 80% of institutional leaders across programs expressed concern regarding the adequacy in the number of clinical training sites, with particular difficulty in pediatrics and obstetrics–gynecology specialties.4
This “crisis” has led researchers to study suggested strategies for overcoming identified barriers for retaining clinical preceptors. Barriers such as new legal requirements and time associated with the incorporation of the electronic medical record (EMR) have emerged in the literature.5 Some proposed solutions include offering preceptors a variety of benefits such as direct financial compensation, tax incentives, and considerations for offering continuing medical education.5,6
In a recent multi-institutional study, we explored reasons why community pediatricians remained motivated to teach medical students. Some identified reasons included internal motivation to share enthusiasm, developing longitudinal relationships with learners, and external rewards such as recognition and educational credit.7 While studies such as this are helpful in identifying the reasons why physicians choose to precept medical students, our first study7 and other recent studies3,8,9 have left gaps in understanding those factors that influence a preceptor’s decision to stop or reduce their teaching time.
A single-institution quantitative study found that physicians who decline to precept students may respond to different motivators than those who chose to precept students.8 Such findings suggest that strategies different from those already described in the literature may be needed to increase the number of community preceptors. Another quantitative study highlighted the reliance of departmental chairs on community preceptors for primary care and ambulatory teaching and also described reasons for the decrease in preceptor teaching.3
While such quantitative studies list some systemic and institution-related reasons for the decline in community preceptors, questions still remain as to why the preceptor has decided to stop teaching. In a quantitative manner, May and colleagues assessed the motivation underpinning why German family medicine physicians taught medical students.9 However, the nature of quantitative studies hinders a fuller understanding of how the identified strategies and barriers may relate to a deep psychological construct that would provide insight into why a preceptor stops teaching students. To our knowledge, no study, including our first one, has addressed how fundamental social and psychological constructs may interplay with identified barriers and strategies. Questions still remain as to why indeed the community preceptor has decided to stop teaching.
Building on our earlier work,7 we aimed to explore these reasons from the perspective of the preceptors themselves. Therefore, this study explored the perspectives of community pediatricians who specifically had reduced or eliminated their interactions with medical students. Using a constructivist framework, we conducted a phenomenological study to add deeper and broader context to the reasons underlying the decline of community preceptor teaching.
Based on the community preceptor issues identified, we selected phenomenology as the philosophical framework most appropriate to guide our multi-institutional study.10 We recruited pediatric community preceptors from geographically diverse institutions to explore commonality regardless of the type or location of the preceptor’s institution. The sites selected for recruitment of participants were based on group consensus from lead investigators in the Council on Medical Student Education in Pediatrics (COMSEP) Research and Scholarship Collaborative and included sites participating in our initial study7 and institutions where the decline of clinical preceptors has been explicitly noted.
The majority of the research team were pediatric faculty with responsibility for the administration of the medical student clerkship. All of us were members of the COMSEP Research and Scholarship Collaborative. Each of us, with the assistance of clerkship administrators, identified potential participants. All participants were community pediatricians, with a wide range of clinical experience. Pediatricians considered for inclusion were volunteer or adjunct faculty, had completely stopped or decreased the amount of time spent teaching medical students, and had no significant and direct financial relationship with the investigator’s medical school. We initially contacted participants by phone, email, or in person. Each of our home institutions obtained institutional review board approval.
Standards defined by Creswell for phenomenological research, which suggested interviewing a minimum of 5 to 25 participants, determined sample size.10 Therefore, we sought to complete interviews with between 3 and 5 participants at each institution. As the study progressed, we recognized that the sensitive nature of our research question negatively influenced recruitment at some sites, and we were unable to achieve the preferred number of participants. The responses from participants, regardless of the number of interviews, were comparable across all institutions, thus allowing us to collectively analyze the data.
We conducted semistructured interviews between October 2017 and January 2018 using the interview guide in Supplemental Digital Appendix 1, available at http://links.lww.com/ACADMED/A736. We knew the participants who we interviewed. Interview questions were created through a process of reaching group consensus, pilot testing, and using some questions from our previous study.7 Peer-reviewed work also guided the content of the questions.2–5,7 Content domains included demographic data: length of time in practice, length of time teaching students, gender, type of practice and ownership, number of partners, nurse practitioners and physician assistants, and the number of other preceptors. Thematic content queries covered concepts such as “value or inspiration in teaching,” “least enjoyable aspects of teaching,” “reasons for leaving or reducing teaching,” and “possible benefits or changes that could change their desire to teach.”
We interviewed all participants by phone. The length of interviews varied between 30 and 45 minutes; all interviews were audio-recorded and transcribed verbatim. Interview transcripts were assigned a random identification number and collated into a single document for review and coding. The analysis included all of the interview transcripts. Three of us (C.R.P, C.V., A.A.) independently read a sample of the transcripts to develop the initial code book. For the code book, we used themes and codes from our previous study,7 with codes added or removed as appropriate. The initial code book included 21 codes. Three teams each consisting of 3 investigators divided the remaining transcripts to code, which resulted in 8 transcripts for each team. Members of each team independently coded the transcripts and then discussed differences in opinion to come to a consensus. Teams identified additional codes as they analyzed the transcripts. Once each team completed their coding, all investigators reviewed all of the transcripts and verified the codes. We all discussed coding disagreement through email and conference calls to come to a consensus. This iterative process resulted in a final code book with 37 codes.
We discussed the final interpretation of the meaning of identified codes and preliminary themes and recognized that some of the preliminary themes were closely aligned in meaning. Through consensus agreement, we identified 4 final organizing themes.
Twenty-seven participants (16 women and 11 men) from 10 institutions were interviewed. Four institutions were unable to interview any clinical preceptors despite several attempts for successful recruitment. The number of years precepting before completely stopping or decreasing the amount of time spent teaching ranged between 1 year and 36 years, with 22 of the 27 participants having precepted for more than 5 years. The ownership of the clinical practice of the preceptors varied from single physician ownership to partner ownership to health care or university system ownership. The number of pediatricians in each practice group ranged between 1 and 16, with most practices including more than 5 physicians and some practices also incorporating advanced practice providers.
Through the iterative process of analyzing the codes and themes, 4 organizing themes were finally selected: evolution of health care, personal barriers, educational system, and ideal situations to recruit and retain preceptors. Table 1 identifies the 3 organizing themes related to barriers for participating as a preceptor. Consistent patterns in theme generation were noted across institutions. We do not provide attributions to the participants due to the purview and constraints of our institutional review boards.
Evolution of health care
Community preceptors identified multiple changes in the health care system that affected their ability to continue precepting medical students. The widespread adoption of the EMR was one of the most significant changes in health care in the period during which many of the preceptors stopped precepting and arose as one of the primary themes in the evolution of health care. Until very recently, charting by medical students was prohibited to meet coding and billing requirements. These rules precluded students from assisting in documentation and negatively affected preceptor productivity. EMR implementation had significantly affected provider efficiency, leaving these preceptors with less time to accommodate the added burden of educating students.8 One participant commented:
Patients and documentation requirements have gone way up. [The] EMR has slowed the process down in many ways. There’s more time checking boxes and more time record taking and tasks that we now have to complete. When I had a student, I would probably chart for three to four hours a night to finish up all the things I didn’t do because I was talking to the students, rather than documenting my charts, so it would really slow you down.
Participants also felt pressure for time in the clinical setting to generate sufficient revenue and relative value units (RVUs). They noted that their salary was negatively affected by precepting students and therefore felt they could not continue to carry this financial loss:
Having students slows you down, going from 15 patients to 10 patients per half day which impacts your bottom line.
Of the participants who received compensation for teaching students, none felt that this was adequate reimbursement for the effect on their generation of RVUs:
It’s like a pittance. I don’t remember how much it is, maybe a couple hundred dollars. . . . It’s a token.
Finally, participants noted that they did not have sufficient support in their practice to precept students. This ranged from a general lack of financial support for precepting students to other providers in the practice being unwilling to precept students to a single provider being unable to precept a student full-time:
I cut back secondary to part time hours . . . and there was the inability to find a partner that would help with the students.
Based on the literature, precepting students increases the amount of time a provider spends per patient and adds time to the overall workday.9,10 This was noted by a participant:
It takes at least an hour of extra time per day to devote to them the time they need. This usually means leaving later from work or not giving them the time they deserve in being taught.
In some instances, for our participants, this led to conflicts over work–life balance, with preceptors feeling that they had to choose between their family or precepting medical students. Given this sense of conflict, preceptors would choose to prioritize their family:
I was willing to chart at home, but it was just that hour or so that I was just getting so far behind that it was more of a deterrent. To do three more hours at home and miss family time and really other than getting the satisfaction of teaching out of it—you get nothing out of it.
Participants also noted that they had a finite amount of cognitive energy and that students could add to the chaos of a practice, resulting in unexpected consequences:
Specific situation—I made a clinical error in busy winter months. Reflected on the chaos of practice and felt that out of concern for patients, patients come first, I needed to back away from taking students.
Participants also felt that precepting students created stress, which could originate from many areas, either related to the workplace and maintaining efficiency or additive to stress they were already undergoing in their personal lives. At times, they felt pulled between their patients and families and educating students:
Least enjoyed the time pressure. Had to give time to the patient and parent, but also the student. I felt stressed about meeting all these needs.
Preceptors also cited changes in the educational system that influenced their decision to completely stop or decrease the amount of time spent teaching students. Some preceptors highlighted the changing relationship between academic medical centers and the community physician where a lack of connectedness led to a decreased sense of obligation:
I could tell you from talking with lots of other preceptors, that there was a lot of disenchantment. I think the preceptors used to be more of a valued part of their community and part of medical center. Unfortunately, the folks that don’t work in the university have certainly become more detached to the university and feel less and less a part of it and feel less indebted to the university. There’s really no other benefit one way or another.
Other participants discussed a change in the preceptor–student dynamic where the preceptor perceived students were only with them because it was a required rotation. Disinterested students led to preceptors becoming disengaged in teaching and precepting:
[Preceptor] noted that she doesn’t think medical students are as appreciative or engaged as they used to be . . . they complain about more and are less thankful. Some students, especially those who are interested in pediatrics, are engaged and thankful. But others are not. They take less initiative with patients.
Curricular transformations are occurring in many medical schools across the United States. The changes being made may have unintended consequences. For instance, some participants noted that they were not able to teach as effectively because the shortened length of the clerkship lessened the longitudinal learning experience and impaired preceptors’ ability to teach the students as they were once able to:
The only reason I stopped was the time because they cut it to 2 weeks. I don’t think that’s enough, especially for me. I just didn’t feel like I could give them enough time in those 2 weeks to give them all the information I felt like I could give them or wanted to give them or the experience I wanted to give them.
Preceptors expressed concerns over a lack of recognition or acknowledgment of their efforts. Whether compensation consisted of financial gain or continuing medical education credits, most preceptors thought that these factors were insufficient to overcome the financial and time realities in their clinic:
I have stopped teaching because I won’t get paid the same and the human element is disappearing.
Participants desired clear direction from the clerkship with regard to goals and objectives, novel education techniques, and strategies to keep students engaged. However, they also wanted to ensure that these goals and teaching methods were realistic in the community practice setting:
Let me know what the clerkship goals are because I’m flying blind on a lot of it. They come in and say “This is what I need to learn” or whatever, but what I need to teach is not necessarily clear. . . . So an expectation of seeing x-number of x-type of patients is probably unrealistic. You got to take what is there.
I haven’t got a lot of experience with the new clerkship, but the goals that they came in with, were totally pediatric inappropriate.
Ideal situations to recruit and retain preceptors
We asked participants what recommendations they had to recruit and retain community preceptors; these responses are summarized in Table 2. Some reported that the clerkship could do nothing to retain them because cessation of teaching was related to personal circumstances. For those who did offer recommendations, 5 subthemes emerged from the data: compensation/benefits, personal relationships, good communication, faculty development, and preparation of students.
Participants felt that current monetary compensation models were inadequate due to an unrealistic concept of the actual time required to precept medical students and that this discrepancy needed to be addressed before some would consider a return to precepting:
To work on compensation as best they can because it’s just a very, very busy milieu to throw extra work into.
Several other forms of compensation were identified:
I mean, I precept, what, a month and change out of the year and I get to use the library resources year-round. . . . That would be expensive for the practice otherwise.
If they give me a scribe to do my notes, then I would teach again.
There was a contract . . . if you signed the . . . contract, your kids could go to [university] for free and then of course you took students . . . at least that was a benefit and that was offered. That is a huge benefit.
MOC part 4 credit would entice lots of people.
Develop personal relationships.
The development of personal relationships and personal communication was a key factor for participants. Many felt disconnected from the clerkship office and academic faculty. They reported that individualized strategies such as a personal phone call or visit would reestablish this sense of connectedness. They were also interested to know about the students who would be coming to their site:
I think personally either calling these preceptors, or personally going to see these preceptors. . . . I think a personal approach to each office would be helpful, because it helped me to start doing it.
I think that the only thing would be a little bit more helpful, is to get a little more background who they are, in some ways, so that you don’t have to spend time learning about who they are, that’s just my personal preference. I like to know the people that I am working with.
Related to the need for more personal relationships was a desire for recognition of the preceptors’ efforts. Recognition could be as simple as meaningful comments from the clerkship or from the students:
The last few years we’ve gotten back some little blurbs that the students have written about their experiences here and the majority of those are positive. Those probably mean more than anything else, than the university has done, so definitely continuing to do that would be important too . . . that is probably the best motivator for me!
Participants also desired early and meaningful communication regarding potential clerkship changes that may affect them. Given the already busy situations preceptors found themselves in, any modifications could shape their interest in continuing to precept. Specifically, preceptors identified that communication regarding directives, expectations, and curricular tools such as online resources would aid in their real-time teaching:
Giving some directions as to expectations of both students and preceptors (so we are all on the same page).
Send a schedule of grand rounds so that preceptors could attend and plan on what topics they want to go to. Give more information about curriculum such as OSCEs and access to Computer-Assisted Learning in Pediatrics cases.
Preceptors also expressed interest in feedback and concrete appreciation for things that they reported to the clerkship:
Not receiving communication back from the school of medicine when he reported a very significant professionalism concern about a student in writing and over the phone and would have appreciated a response thanking him for reporting this issue.
Preceptors wanted to become more successful, innovative teachers. They also desired to learn how to improve their efficiency and how to use students effectively in actual clinical settings:
Updates on how to teach more effectively and new ways of teaching. Sharing that knowledge in a more organized way, I’ve met with the clerkship director to talk about this but coming to the office and being involved in that experience would be cool.
I need a model for how to do it. . . . And so I’d like to learn how to structure my day with them so we can all get out of it what we need to get out of it.
Target and prepare students.
Preceptors expressed interest in working with students who were actively engaged in learning at their clinic, who were prepared for direct patient care in the community setting, who recognized this as a privilege, and who were ready to help their preceptor:
If I could have students interested in pediatrics, I would think about precepting again.
Tell students how they can be helpful to their preceptor: making sure to get medications and doses and how to do that if the parent doesn’t know the medication.
If students were to come, it would be helpful to have some sort of orientation so they know why they are there, what it means to work in an office, how to be useful, how to get something out of the experience.
The need for community precepting for medical students prevails. Recruiting and retaining these community preceptors has become increasingly difficult. Researchers are trying to identify and develop strategies to overcome these barriers so that students continue to benefit from clinical education in the community.3–5,8,11 Studies have examined reasons why some physicians continue to work with students despite perceived barriers.4,5,8,11 In this study, we explored these barriers and strategies more extensively and identified new themes regarding the cessation of or decrease in preceptors’ teaching time. We had previously described why preceptors decide to teach medical students.7 This study is the first, to our knowledge, to explore perspectives from the “other side”; namely, those who have stopped or decreased the amount of time spent teaching.
While our interviews were designed to investigate the “negative” reasons, some of our findings bear striking similarity to our previous exploration of pediatricians who continued to work with students.7 For example, in both populations, pediatricians identified factors such as a sense of giving back, clinic group practice, and enjoyment of teaching that provided initial motivation to teach the next generation of physicians. Similarly, some reasons identified for eliminating or decreasing teaching time mirrored our first study group’s reported negative aspects of teaching, including time constraints, the impact of the EMR on workload, work–life balance, and communication between the medical school and the preceptor. Finally, preceptors in this study offered recommendations to improve their recruitment and retention. Some of these proposals (e.g., increasing compensation, recognition, and improved communication from the medical school) were remarkably similar to those offered by preceptors who have continued to work with students.
With such mirroring between the group of preceptors who continue to teach despite the self-identified barriers and the group of preceptors who have stopped teaching because of these barriers, in an interpretivist approach, we can now consider those intrinsic factors that influence the decision to completely stop or decrease the amount of time spent teaching. What are social and psychological constructs including that of identity as a clinical educator that may influence this phenomenon?
Professional identity of clinician–educators
The concept of clinician–educator identity formation was well described in a recent scoping review.12 Cantillon and colleagues highlighted the tension that clinician–educators encounter when balancing teaching responsibilities with other responsibilities intrinsic to their professional and personal roles and responsibilities (e.g., providers of patient care, parents to their own children). Additionally, organizational and institutional factors contribute to the meaning afforded by their teaching roles. As a consequence of both individual and institutional considerations, clinician–educators must choose between competing priorities. Many choose to prioritize clinical roles over teaching roles due to perceived or realized social benefits afforded by those pursuits.13
Clinical preceptors in our study did not specifically use the words “identity as a teacher” to describe their reluctance to continue teaching students. However, these concepts were articulated in less direct ways. As one preceptor put it: “I don’t know that there’s anything that can be done, it’s just where I am in life.” For some preceptors, “where I am” likely refers to how one is coping with different competing identities, and which identity prevails when making decisions about which opportunities to pursue.
Furthering the notion of whether clinician–educators prioritize teaching over another competing interest is the concept of self-determination theory. Ryan and Deci have described the motivational processes that drive the natural growth and behaviors of learners and teachers in their personal and professional pursuits. Individuals are driven by 3 psychological needs: the need for autonomy, competence, and relatedness.13 Ten Cate and colleagues have suggested that modern medical education programs may unintentionally inhibit the stimulation of the 3 psychological needs underpinned by self-determination theory. For instance, the student-centeredness of curricula, while valuable for students, indirectly comes at a cost to the teacher’s perceived autonomy. In addition, regulations provided by accrediting bodies and the lack of a supportive educational community may serve as inhibitors when clinician–educators consider their motivation to teach over other responsibilities.14
Furthermore, decisions regarding teaching may be complicated by symptoms of burnout. Burnout has recently received much recognition in the medical literature.15,16 Our preceptors’ narratives echoed the literature’s varied definitions of burnout. Freudenberg, one of the first to describe the symptoms of exhaustion professionally, defined burnout as “state of mental and physical exhaustion caused by one’s professional life.”17 More recently, Maslach described burnout as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity. However, one may see burnout more generally as “a state of exhaustion in which one is cynical about the value of one’s occupation and doubtful of one’s capacity to perform.”18
In our study, some preceptors used the word “burnout” specifically: “been dealing with some feelings of professional burnout.” Others described symptoms of burnout when describing frustration with the EMR, work–life balance, the silo effect of community teaching separated from the large medical school enterprise, dramatic change in clerkship time given widespread curriculum transformation, and the subtle or frank decreases in compensation, which all relate to our themes of evolution of health care, personal barriers, and the educational system. The variables that appeared to contribute to burnout were not unique to this population of clinical preceptors. This observation is consistent with that in literature suggesting that burnout is related to both external stressors and the individual’s resilience, goals, and motivation.19
Collectively, factors associated with clinician–educators’ identity as teachers combined with symptoms of burnout may influence decisions to completely stop or decrease the amount of time spent teaching students. Solutions to counteract these issues must therefore consider how to foster educator identity and self-determination in busy clinicians while simultaneously mitigating symptoms of burnout. Fortunately, literature suggests that identities are malleable20 and that symptoms of burnout can be reduced.21
Improving teaching identity requires focus on the individual and the organizational and institutional structures in which the individual works.12 Self-determination theory suggests we should identify methods for improving preceptors’ motivation to teach by focusing on their needs for autonomy, competence, and relatedness. When describing methods to motivate classroom-based medical educators, Ten Cate and colleagues suggest allowing for flexibility in determining the instructional method for teaching, allowing the teacher some degree of autonomy with respect to content, and creating a sense of community with other teachers.14 The same concepts could be used to improve upon preceptor motivation in the community setting. Community preceptors enjoy sharing their knowledge and experience regarding the practical, psychosocial, and business aspects of medical care.1,22 In comparison, they often feel inundated with requirements for midrotation feedback, formal evaluations, and encounter documentation.5,7 While some of these issues are unavoidable due to accreditation standards, departments and institutions should consider, when possible, the burden placed on preceptors and the harm that this may pose to their autonomy.
One practical change involves the EMR, the presence of which appeared throughout participating preceptors’ remarks. While its impact on medical education is relatively recent, this impact is definitive and significant.11,23–26 A targeted approach to changing the EMR’s impact on student teaching can result in short- and long-term consequences in medical education. Many medical schools have already adopted the recent change in the Centers for Medicaid Services guidelines to allow students opportunities to document in university-based health care systems. Specific attention to the EMR in the community preceptor’s clinic could help negate this unintended consequence of changes in health care.
Another practical change involves the detachment that community preceptors feel from the large academic medical school. This issue relates to identity formation or “relatedness” and is a major contributor toward burnout.15,19,20 Our findings richly exemplify this disconnect. Participating preceptors offered solutions for remediating this gap through developing relationships between institutions and practices. Supporting a preceptor’s identity as a teacher and not just a clinician through training, time for connecting with others of a like mind, and cultural recognition of the benefits a teacher brings to the medical community would be of benefit. This may be challenging for academic institutions to accomplish if they do not have much to offer large, nonacademic practices. In that case, one possible solution would be for academic institutions to increase the size of their own primary care faculty to accommodate students.
Additionally, it appears that curriculum evolution affecting clerkship duration has significantly affected the preceptor’s teaching experience. Medical schools are attempting to transform how they teach to better reflect the realities of health care delivery. An unintended consequence is that this may have alienated community preceptors who have enjoyed teaching but feel that they cannot adequately do their job in the shorter durations imposed by curriculum reforms. Solutions may include faculty development for teaching effectively in a shorter period. However, more sustainable solutions may require a reconsideration of the curricula. Longer relationships with preceptors through longitudinal integrated clerkships may foster more connection between the preceptor, learner, and institution27 and may serve to invigorate community preceptors.
Although qualitative studies are not dependent on a specific sample size, one limitation of our study was the difficulty to recruit participants, especially at some institutions. The challenge of recruiting clinical preceptors may have been related to the nature of our study question as it asked participants to disclose a negative aspect of their profession. Yet, we noted that participating preceptors did have shared experiences that contributed to developing a framework that described the phenomenon related to the decline in community preceptor teaching. Another limitation was that our study, using an interpretivist, phenomenological framework, aimed to examine shared experiences from multiple institutions. This type of approach does not lend itself to examining differences between institutions or differences of the perspectives of clinical preceptors at different institutions. Institutional differences may lend to other discoveries that perhaps are specific to certain demographic features. Future studies are needed to better appreciate these targeted differences to identify the best approach to retain each potentially unique population of clinical preceptors. A final limitation was that our study included only pediatricians. However, findings such as concerns with the EMR, the feeling of being disconnected from large academic centers, and work–life balance do affect very many community-based physicians, and thus our findings likely traverse specialty lines.
Contributing to the literature regarding the decline in community preceptor teaching, our qualitative phenomenological study presents a novel viewpoint of preceptors who have completely stopped or decreased the amount of time spent teaching medical students. Specifically, our findings call for better recognition of the teaching identity of community preceptors, application of self-determination theory to foster that identity, and recognition and management of burnout to prevent further decline in community preceptor teaching and to optimize training for our medical students. We recommend the development of targeted materials and strategies, many actually offered by our own preceptors, for education leaders to guide further recruitment and retention efforts. Solutions to this crisis may require specific interventions beyond compensation, awards, and other recognition to enhance the teaching identity of community preceptors and their motivation to educate and inspire the next generation of physicians.
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