BRIEF COMMUNICATION

Year : 2010  |  Volume : 23  |  Issue : 2  |  Page : 366

What Community-based Preceptors Want in Teaching Medical Students: Findings from a Mixed Methods Study

MJ Hashim¹, A Prinsloo¹, C Leduc¹, BA Raasch², DM Mirza^1
1 UAE University, Department of Family Medicine, Faculty of Medicine and Health Sciences, Al-Ain, United Arab Emirates
² UAE University, Department of Family Medicine, Faculty of Medicine and Health Sciences, Al-AinUAE University, Department of Family Medicine, Faculty of Medicine and Health Sciences, Al-Ain, United Arab Emirates

Correspondence Address:
M J Hashim
P O Box 17666, Al Ain
United Arab Emirates

Source of Support: None, Conflict of Interest: None

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PMID: 20853238

Context: Clinical clerkships in medical colleges are increasingly relying on teaching by community physicians in ambulatory clinics.
Objectives: The aim of the study was to determine the attitudes and perceptions of community physicians towards teaching medical students at their clinics.
Methods: A focus group discussion with 14 and a survey questionnaire of 23 community-based physicians were conducted.
Findings: The focus group discussion session yielded insight into the expectations of community physicians about student attachments, including: the need for learning objectives; continuity; feedback; ongoing communication; and planned placement of students. The answers to the survey questions showed willingness to teach medical students (mean score = 4.7 on a scale of 1 to 5) and the view that medical students added value to the clinics (mean = 4.4). However, the respondents gave lower ratings to the questions about students being able to independently evaluate patients in the beginning of their clerkship (mean = 3.3).
Conclusions: Community physicians request clear learning objectives, assessment criteria and advance planning for teaching medical students. Clerkship coordinators should ensure ongoing communication with community preceptors in these areas as well as offer recognition of teaching contribution and opportunities for professional development.

Keywords: Community, clinical clerkships, medical students, community-based

Context



Medical schools are increasingly relying on community-based physicians for the teaching of medical students. Teaching hospitals, which have traditionally been the mainstay of medical student education, now have become sub-specialised and often have a faster turnover of patients¹. Those patients admitted are more seriously ill (as more disease is managed in the community) and are consequently less able to be seen by students². Moreover, as a relatively small proportion of patients from any community will end up in a teaching hospital, clinical experience gained exclusively from the hospital becomes less representative of ‘real life medicine’³. There is also a discordance between holistic educational goals of modern curricula and the limited focus of medical practice in secondary care⁴. In this context, community-based clinics or community clinics provide a setting for students to learn about common medical conditions, chronic diseases, preventive care and psychosocial issues involved in the patient-physician interaction^4-6.



The increasing shift to community-based medical education has produced several studies exploring the perceptions of physicians based in the community^7-11. Previous research indicates that community physicians enjoy teaching medical students in their clinics¹¹. They value the intrinsic rewards of teaching such as contributing to the education of young professionals, although extrinsic factors such as faculty recognition and financial issues are also important.



Objectives



Before placing students into community clinics, we wanted to explore the clinic physicians’ needs as teachers and identify any potential barriers to medical student teaching.



Methods



We used a focus group discussion and a survey questionnaire as a ‘mixed-methods’ approach to determine the attitudes and perceptions of community physicians to teaching medical students in their clinics^12-15. The clinics were selected on the basis of convenience from amongst the more than 30 healthcare centers located in the Al Ain medical district where approximately 300 physicians practice.



A focus group discussion was conducted in October 2008 with 14 community physicians, facilitated by two full-time faculty members. The group participants were selected from the primary care physicians at the three clinics chosen as teaching sites. The medical director of the clinics coordinated the invitation process within the clinics. The group was invited more than a week in advance and was aware that the topics of discussion would be precepting and placement of students in community clinics.



Participants attending the focus group represented several categories of primary care physicians working in the clinics, increasing the likelihood of providing different perspectives. For example, the group consisted of general practitioners with prior, present and no previous exposure to teaching students placed under their supervision. Clinic managers (also rendering active clinical services), as well as sole service providers, were represented.



The two participating faculty members (one male, one female) were newly appointed faculty with no prior contacts with most of the group members. Following introductions, the group discussion was facilitated by one of the faculty members. Open-ended questions were posed to the group on their feelings about teaching medical students in clinics, logistic/administrative issues and their workload. Participatory discussion was encouraged throughout the session by using a circular sitting arrangement, through initial introductions and by giving all participants an opportunity to speak. Written notes were recorded by the faculty members during the two-hour session. For validation, a summary of the discussion was circulated to the participants on a group email that was created following the discussion.



The discussion was used as a starting point to guide the development of further interactions with the group. The focus group discussion led to a workshop on teaching medical students as requested by the community physicians. The topics of this workshop were based on the learning needs identified during the discussion. Continuing medical education (CME) points were offered for attendance at the workshop as an incentive for physicians to come. During this workshop, a written, self-administered survey questionnaire was used to assess the perceptions of the community physicians. The survey instrument was developed after several revisions by the authors and a consensus was achieved to keep the survey brief and focused. Four questions with 5-point Likert scale ratings and two open-ended questions were included. Participation in the survey was voluntary and all information collected was kept anonymous and confidential. The data were analyzed by quantifying the opinion scales and obtaining means¹⁶. The open-ended questions were analyzed using inductive content analysis¹⁷.



Findings



Focus group discussion:  Fourteen community physicians along with two faculty members and the medical director (a family physician) attended the focus group discussion. The key themes identified during the discussion were:

• Willingness to be involved in medical student training. Physicians expressed interest in precepting and had a range of prior clinical and teaching experience.
  
  
• Adequate notification of student placement was requested given the increasing number of students and limited human resources and physical facilities at the clinics.
  
  
• Continuity in student placement over longer periods as opposed to ad hoc daily placements.
  
  
• Functional communication systems between clinic preceptors and faculty members.
  
  
• Timely distribution of logistical information such as student rosters.
  
  
• Access to formal documentation regarding the intended aims, objectives and outcomes for student placements.
  
  
• Feedback from students and reports of student performance.
  
  
• Need for a method to track student attendance without burdening the preceptors.
  
  
• Reluctance to be involved with summative assessment and willingness to participate in formative assessment after appropriate training.
  
  
• Need for preceptor training workshops using adult learning principles rather than didactic lectures.

Survey questionnaire:  A total of 23 community physicians, all of whom were primary care physicians, completed the written questionnaire. Over one-half of the participants (13 physicians, 57%) were women. Most of the participants were experienced clinicians, with a mean self-reported 21.6 (sd=8.4; minimum=5; maximum=36) years of clinical practice.



Overall, the community physicians were positive about teaching (see Table 1). These findings correlated with the focus group discussion held earlier. Answers to the two open-ended questions revealed that physicians thought some recognition in the form of certificates or faculty rank would be a reward for their teaching efforts (six physicians). One physician felt that the intrinsic satisfaction of helping students learn would be an adequate reward. Two physicians indicated the preference for a monetary reward for teaching, whilst another mentioned there was a need to reduce the patient volume with medical students present. Open communication between full-time faculty members and community physicians was felt to be valuable (two physicians) and further workshops on time management, teaching skills and ethics were requested (10 physicians).



Table 1:  Community physicians’ responses to a survey questionnaire on teaching medical students







Discussion



Our study yields insights for supporting the teaching involvement of community physicians within this setting. We found that, in general, community physicians are motivated to teach medical students at their clinics, albeit with certain expectations and concerns.



Our study confirms the expectation that teaching by these physicians be recognized in some form such as certificates of teaching contribution, letters of appreciation and honorary academic ranks in the faculty. A desire for financial remuneration was expressed by only a small number of physicians, but this may have been due to reservations about voicing this opinion in an open forum in the presence of their clinic administrative head. These findings differ from a telephone survey of community physicians in North Carolina in which intrinsic rewards such as the ‘love of teaching’ and ‘giving back’ to the specialty of family medicine were more important than external recognition⁹. This difference may be due to the different methods used in that study (telephone surveys facilitate greater anonymity) compared to the mixture of focus group discussion and questionnaire that we used, which allowed less privacy.



We also found that community physicians valued continued communication and contact with the full-time faculty members. This appreciation may reflect the need to be part of a teaching ‘team’, and to be perceived as making a valuable contribution by the faculty⁷. Such contact with faculty may include activities such as faculty development workshops and regularly scheduled group discussions to elicit feedback from the preceptors. Seeking preceptors’ views and needs has been emphasized by previous researchers^8,9,11. A consistent finding across studies has been the preceptors’ interest in acquiring teaching skills and professional development through workshops^7-9,11. In our study, preceptors expressed a need for medical education workshops on precepting and communication skills, rather than on clinical topics.



A finding of our study not observed in previous studies was that the preceptors expressed the need for clear objectives for the community clerkship. These physicians may possibly be motivated to contribute to defining educational goals and helping students achieve their learning needs. We feel this is a valuable finding of our study and it indicates the need to not only communicate learning objectives in advance of the student attachment, but to also seek the input of community preceptors in determining the learning outcomes.



Our study was limited only to the family physicians working at three selected clinics and to just 23 physicians. Thus, these findings may not reflect the perceptions of all community physicians in the region. The presence of the medical director could have been a potential inhibiting factor in the focus group discussion.



Conclusions



Community physicians’ perceptions were generally positive about teaching medical students but with some concerns and expectations. Teaching workshops, recognition of precepting and communication with full-time faculty were felt to be valuable by the community physicians. Community-based physicians were motivated to be a part of the medical students’ clinical learning experience; however, they require clear learning objectives, assessment criteria and advance planning of attachment schedules. Clerkship coordinators should ensure early and ongoing communication with community preceptors in these areas as well as offer recognition of teaching contributions and further opportunities for development.



Acknowledgements



We would like to acknowledge the participation of community physicians from Al Ain Hospital clinics and the support of the hospital’s administration for academic activities.



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