Meeting the need to train more doctors: The role of community-based preceptors

Abstract

Community-based precepting is becoming a critical component of Canadian medical education. Calls from the public to train increased numbers of physicians have placed more students in community-based settings. Other countries are facing similar situations. Understanding the factors that make community-based practitioners decide to teach plays a significant role in recruiting and retaining potential preceptors. Ensuring that there are appropriate numbers of trainees and administrative supports, and that there is adequate recognition of these teachers, may be more important than financial incentives. A positive experience has been shown to reduce stress, enhance professional satisfaction and increase patients’ perceptions of their physicians. Ultimately, a positive experience can influence a trainee to take root in a community-based setting. Recognizing the most common causes of preceptor burnout will help to protect this group of faculty. Some of the myths surrounding community precepting, including massive time commitments, significant financial impact and poor patient acceptance of medical students, are discussed. Providing a range of tools to further educate and support this group of medical teachers is critical, especially in light of the rapidly expanding number of training positions.

The demand on community-based medical preceptors continues to grow. Following trends emerging throughout the world (1), Ontario has seen a substantial increase in the number of entry positions in its medical schools. Recent calls from both the College of Physicians and Surgeons of Ontario (2) and the Ontario provincial government to increase entry positions and international medical graduate training positions begs the questions, “Do we have sufficient educators to train this new generation of students?” and “Are we providing this faculty with adequate opportunities to develop teaching skills to ensure that the level of training that is given is of the highest quality?”.

Between 1999 and 2002, the Province of Ontario funded a marked increase in the number of entry positions into medical schools. A number of these positions were allocated to the Schulich School of Medicine and Dentistry at the University of Western Ontario (London, Ontario). The current enrolment of the Schulich School of Medicine and Dentistry exceeds the number of undergraduate training positions within the University of Western Ontario’s urban boundaries for some specialties, including paediatrics. Therefore, based on a successful model of medical training that was created in 1997 by the Southwestern Ontario Rural and Regional Medicine, Education and Research Unit, the Southwestern Ontario Medical Education Network was able to quickly expand through a network of established and experienced clinical preceptors in the region. By adding a previously underutilized group of preceptors in Windsor, Ontario, the University of Western Ontario was able to increase the size of its entry class by almost 40%, from 96 to 133. At the same time, an additional 20 postgraduate positions were created. Four of these postgraduate positions were added to the paediatric residency training program.

Other Ontario universities are also actively involved with training students and residents in nonurban settings. Most of this is accomplished through vast networks of volunteer or part-time staff. Based in Northern Ontario, the first new full Canadian medical school in 25 years has been established as a result of the province’s desire to train more physicians for rural and regional practice. Prepared to accept students in 2005, the Northern Ontario School of Medicine has already faced the onerous task of recruiting faculty for an entire medical school in a few years. It hopes to capitalize on the wealth of part-time teaching experience of physicians who are established in the area (3).

Given these disseminated or decentralized models of training, much of the demand falls on part-time (adjunct) faculty who are often serving divergent or competing interests – namely, teaching trainees versus high service demands. These faculty members may not be salaried. They may have little formal training in education methods. They may have heavy patient caseloads due to existing physician shortages. They provide significant after-hours services to their home communities. Many of these faculty members are not based at the university and may feel professionally isolated.

Risks of placing excessive demands on the current system are real. In London, Ontario, certain specialties have neared saturation in providing community-based preceptors for trainees. While the motivated student pursuing an elective experience may provide one set of challenges, the failing learner may require a higher degree of expertise for which a community-based preceptor may be ill prepared. Skills in identifying the learner who is having difficulty, defining their unique shortfalls, accurately assessing and documenting their performance, and developing remediation plans are skills that many community preceptors may not have.

Knowing what factors make people want to teach and what makes them burn out is critical in protecting the large number of community preceptors who have taken on this role.

WHY DO COMMUNITY PHYSICIANS WANT TO TEACH?

Most community preceptors derive an intrinsic enjoyment from teaching. Focus groups of community-based educators have identified the great degree of personal satisfaction that people express regarding their identity as teachers. For some, the feeling of duty to educate other physicians is strong. Others find that the experience provides them with a sense of professional camaraderie. Table 1 lists some of the most cited reasons for teaching (4).

TABLE 1.

Reasons why community-based preceptors teach

Intrinsic satisfaction

Decreased professional isolation

Mutual learning

Recognition through faculty appointment

Access to library or on-line resources

Continuing medical education credits

Stress reduction

Increased patient satisfaction with care

Financial rewards (minimal role for most)

Adapted from reference 18

Surprisingly, financial incentives are not usually rated highly in a decision to teach. Most studies show that precepting of students is generally financially neutral (4). In a recent article (5), the most highly valued reward for teaching was student feedback. In decreasing order of value, other methods of recognition included continuing medical education (CME) credits for teaching, volunteer faculty appointment, virtual library privileges, a thank you letter or a plaque for one’s office. Financial compensation ranked last of 20 rewards and recognitions according to the preceptors who were surveyed.

More interestingly, there are some studies that have identified an actual reduction in levels of stress and professional burnout in physicians who mentor trainees. However, there are other factors at play that can negate this benefit (6). In real terms, a study by Grayson et al (7) demonstrated that 82% of preceptors enjoyed medicine more and spent more time keeping abreast of the literature, while their patients perceived an increase in their status (8). One of the ultimate goals in training learners in the community is that they will have positive role models and experiences – a significant factor in future recruitment efforts (9–13). There is also evidence that a community-based paediatrics experience positively affects students’ views of paediatrics as a career choice (14) and paediatric residents choosing community-based paediatrics (15).

HOW CAN WE HELP REDUCE PRECEPTOR BURNOUT?

Factors that have been identified as contributing to community preceptor burnout are listed in Table 2. The underlying themes of lack of professional support, lack of empowerment and lack of appreciation are fairly intuitive. Some themes are more surprising, such as stress from having insufficient numbers of trainees, a situation that the author has experienced in his own network of training sites (16).

TABLE 2.

Reasons why preceptors burn out

Overcommitted or stressed before taking on a student

Excessive clinical workloads

Ambiguous roles/expectations

Reduction in leisure time

Insufficient/excessive numbers of trainees

Shorter rotations (excessive proportion of time orienting)

Lack of administrative support

Lack of adequate recognition

Financial stresses

Adapted from references 19 and 20

There may also be an optimal number of students that a preceptor should supervise. One study (17) found that one trainee can add up to 1 h of time to the average preceptor’s day. However, seeing students on a more regular basis can mitigate the financial and time impact.

Allowing preceptors sufficient autonomy, providing adequate guidance through clear objectives and having mechanisms to help them through difficult situations are critical in fostering a healthy relationship between the university and the outlying communities. Providing ongoing feedback regarding performance, opportunities for professional development and appointment of some form at the university are all essential. Remuneration has been a more variable requirement for a successful program, although it is still highly valued by individual preceptors.

WHAT ‘NOVEL’ TEACHING METHODS CAN I USE AS A COMMUNITY-BASED PRECEPTOR?

Increasingly, the role of multidisciplinary/interprofessional education in the community setting is gaining acceptance. For example, in a community-based paediatric rotation, the benefits that a trainee can obtain from spending time with a visiting home nurse, a child welfare agent, a child and youth worker, or a speech pathologist can be invaluable. Other health care trainees offer exciting opportunities to share experiences. Teaching learners to function in teams within the community will serve them well.

Multispecialty rounds that incorporate medical students or residents from different specialties can allow better interdepartmental communication, debate and collegiality with the local physicians involved in their training. The author recently had a student present a case of bacterial tracheitis to the paediatricians and emergency medicine physicians at a regional training site. The audience size tripled, providing a more stimulating experience for the student.

Videoconferencing is becoming increasingly used in disseminated learning models. Grand rounds, case presentations, off-site lectures and CME programs can all be accessed more easily across most of the country. Research is continuing to address the results of its impact.

Paediatric case-based student modules of high quality can be found on the University of Hawaii’s Web site. These cases all include a discussion, questions and answers. This allows you to draw out high quality cases on subjects that may be seen more infrequently in the office.

Ensuring that the trainee is included in committees, community-based projects and other events that occur outside of your office will also benefit the trainee in their view of ‘real-life medicine’. However, proper attention must be given to build these events into appropriate ‘teachable moments’. As an example, asking “How do you maintain appropriate patient and parent confidentiality during a multidisciplinary meeting?” or “How can you maintain a working relationship with a school and a therapeutic alliance with a family during a multidisciplinary meeting?” might lead a student to consider a wide range of issues during an in-school conference.

Allowing students to present in-services to nursing staff, participating in local CME programs and performing office-based research all highlight the community-based clinician’s role in lifelong learning. A variety of methods are listed in Table 3.

TABLE 3.

Sample of teaching strategies

Use adult learning principles

Encourage self-directed learning

Develop a library

Connect on-line with the university’s library

Use one teaching point per patient. Avoid excessive mini-lectures

Avoid excessive passive learning (eg, shadowing)

Videotape interviews. Allow trainees to view and critique themselves

Use multidisciplinary educators (eg, nurses, child protective services)

Obtain solicited patient feedback (or use unannounced standardized patients)*

Perform structured appraisal of written consultations

Participate in videoconferencing

Use Internet-based modules

^*Data from references 21 and 22

CONCLUSIONS

In summary, the medical education system is set to move even farther from the walls of the universities, rapidly consuming the capacity to train our next generation of physicians in the community. Understanding the rewards of precepting is fundamental in the recruitment of new junior preceptors. Careful attention to factors that could cause burnout will be required, lest we lose some of the more seasoned preceptors who have seen their role change in recent years. Strategies for further faculty development, with a need for basic as well as more advanced techniques, will be required to support educators in the field. Ensuring positive experiences for learners will be essential in helping to address recruitment disparities in years to come.