Study scenario and design

This quantitative descriptive study aimed to analyze the perspectives and perceptions of participants of the PTC about preceptorship and medical education activities. This educational initiative consists of a distance training program offered by the ‘Universidade Aberta do Sistema Único de Saúde’ (UNA-SUS), under Brazilian federal government funding. Since its launching in 2016, the PTC has offered three editions: First Edition (2016-2018), Second Edition (2018-2020), and Third Edition (2019-2021)^13)-(17.

The research was conducted from October/2020 to April/2021, being organized into two phases: ‘Population Outlining’ (Phase 1) and ‘Survey Questionnaire’ (Phase 2), which began after the approval of the Research Ethics Committee of the Federal University of Health Sciences of Porto Alegre (UFCSPA) - CAAE: 31351920.2.0000.5345 / Report: 4.164.125.

Data collection

In the ‘Population Outlining’ Phase, the casuistry consisted of the registration data of enrolled and completion PTC participants, from its three editions: First Edition (2016-2018), Second Edition (2018-2020), and Third Edition (2019-2021). We analyzed the sociodemographic variables obtained from the participants’ registration data, such as course edition, gender, age, and state and city of origin.

Regarding the Survey Questionnaire Phase, we included enrolled and completion PTC participants, who were invited via e-mail with the support of the UNA-SUS/UFCSPA Academic Secretariat, FM residency programs and medical entities. We applied the questionnaire using the Google Forms^® virtual environment.

The questionnaire included three thematic scopes: ‘Sociodemographic identification’ (gender, age, city and state of origin), ‘Academic Medical Profile’ (undergraduate institution, residency institution, experience in preceptorship), and ‘Interest in medical education’ (insertion perspectives, interest in teaching and/or preceptorship). As for the medical schools and FM residency institutions, we categorized these entities according to their administrative spheres into federal, state, municipal, and private/philanthropic.

The questionnaire sections about ‘Academic Medical Profile’ and ‘Interest in medical education’ were based on the study by Deutsch et al., which addressed experiences and interests in preceptorship activities of German family doctors¹⁹. Regarding the factors that stimulated one’s interest in preceptorship activities, we stratified the answers into degrees of stimulation, in order to establish the means that allows comparing the subgroups. Thus, the degrees of stimulation related to one’s interest were classified as: ‘No interest’ (0), ‘Low interest’ (+1), ‘Moderate interest’ (+2), ‘High interest’ (+3) and ‘Very high interest’ (+4).

Furthermore, we also classified potential difficulties in preceptorship performance in positive and negative degrees according to the presented propositions as: ‘Strongly disagree’ (-2), ‘Partially disagree’ (-1), ‘Partially agree’ (+1), and ‘Strongly agree’ (+2).

Data Analysis

We performed the statistical analysis using the Pearson’s chi-square Test for categorical variables and the Kruskal-Wallis Test for discrete quantitative variables with asymmetrical distribution, considering as a parameter of statistical significance a p-value less than or equal to 5% (p ≤0.05) with a 95% confidence interval(95%CI).

The distribution pattern of variables was verified through the Kolmogorov-Smirnov Normality Test, indicated for casuistries with more than 40 subjects, as observed in both phases (Phase 1 with n=2530, Phase 2 with n=232). We submitted the quantitative variables with statistical significance in the Kruskal-Wallis Test (p= <0.05) to the Scheffé Post-Hoc Test, adopted as an alternative to the Nemenyi Test, which is unavailable in the IBM software^® SPSS^® 23.

The preceptor’s role: conceptions, experiences, and contributions

Throughout history, medical education has been based on the master-apprentice paradigm, in which a seasoned physician would conduct the professional training process of his apprentices based on practical experiences^20),(21. The term ‘preceptor’ is the most established expression in literature, which originated from the Latin word ‘praecipio’ and was adopted to refer to the act of giving precepts or instructions during the Middle Ages. Since the 16^th century, the term has been associated with the concept of educator, mentor, and instructor²².

Despite the diversity of terminologies, we can understand the preceptors’ role based on their primary attributions: the supervision and guidance of students and residents in professional practice settings^10),(23. According to Botti and Rego, the preceptor performs several roles in medical training, acting as being a reference for professional attitudes, a facilitator of clinical reasoning, a manager of the teaching-learning process, and an evaluator of performance and technical progress²⁴.

Supporting the relevance of preceptors in medical education, the findings of the ‘Survey Questionnaire’ phase showed that a significant number of respondents attributed a positive role to preceptorship, stating that the preceptors’ contributions were ‘relevant’ and ‘totally relevant’ to their professional training. These results are in agreement with a study on a FM residency program in Northeast Brazil, which also identified positive considerations about the effectiveness of the preceptors in the learning process²⁵.

The preceptors’ contributions were positively correlated with the satisfaction with the FM residency programs. This association, although not very significant, may be related to the intense interaction between preceptors and residents during residency training, which determine most of the experiences in practical fields, and, consequently, the perception about the residency programs. However, further research is needed to clarify this trend.

Due to the diversity of Primary Health Care (PHC) settings, the experiences of students and residents may be heterogeneous, being strongly influenced by factors such as the preceptors’ technical and pedagogical competencies, conditions of the teaching-learning scenario, as well as the students’ personal characteristics²⁶. For this reason, the preceptors’ training is an essential component of medical education qualification.

The awakening of interest in medical education: the influence of residency experiences

Throughout medical residency, specializing doctors are often exposed to various teaching experiences, resulting from the supervision of students and residents²⁷. Therefore, several authors have highlighted the potential of residents’ involvement in teaching-learning activities, emphasizing their stimulus to critical reflection, clinical insight and intellectual skills, as well as encouragement to constant study and updating²⁸.

From this perspective, the substantial majority of the participants reported involvement in preceptorship activities during residency, either with undergraduate students (85.6%) and/or with other residents (54.6%). This tendency is in agreement with a Canadian research with FM residents, which identified about 80% participation in preceptorship activities²⁹.

According to DiPaula et al., the residents’ performance in preceptorship roles can stimulate their desire to become involved in medical education²⁷. Thus, considering that some of the current residents will be future preceptors or professors, we should consider stimulating the interest of these beginner professionals^27),(30),(31.

Considering such aspect, we found a significant interest in medical education among the participants, particularly regarding the roles of preceptor in undergraduate education (85%) and medical residency (89.5%).These findings diverge from a study with general practitioners in Germany, which evidenced a lower frequency of engagement (60.1%)¹⁹. This discrepancy may be related to the differences in the participants’ profiles: residents or newly FM specialists in the Course of Preceptorship and general practitioners in the German research.

The perspectives about medical education activities demonstrated a preference for those related to clinical practice, in agreement with findings reported by Deutsch et al.¹⁹, which showed a higher degree of attraction among general practitioners for activities in healthcare settings. However, although to a lesser extension, theorical activities also showed important predilections - 31% of ‘High interest’ and 44.8% of ‘Moderate interest’, agreeing with trends of a research with FM specialists in São Paulo - Brazil, which revealed 61.2% of interest in lectures and 48.1% in tutorials³². The preference for practical activities may be related to the intrinsic assistance-related characteristics of preceptorship and medical residency, the participants’ main experience contexts.

Experiences in preceptorship in the FM residency fostered interest in medical education, with the supervision of medical students increasing one’s aspiration to undergraduate preceptorship, whereas the guidance of beginner residents increased the inclination to become a preceptor in residency programs. However, such experiences should be supported by medical education training initiatives, in order to subsidize the ‘resident preceptors’ practices^28),(33.

From this point of view, Hill et al¹². denominated preceptorship training programs during residency as ‘Resident-as-Teacher programs’, emphasizing their potential contributions to improving pedagogical skills of resident physicians. Nevertheless, only half of the participants declared they had attended any programs or received educational instruction on preceptorship during their residency programs.

In accordance with our findings, Ng et al. also indicated that only 60% of FM residents reported receiving educational training in preceptorship²⁹. However, diverging from these trends, two North American studies observed preceptorship training initiatives in FM³⁴ and Emergency Medicine³⁵ residency programs, with 85% and 70%, respectively.

Regarding the difficulties in implementing ‘Resident-as-Teacher programs’, Achkar et al.³⁴ highlighted the availability and readiness of residents and teachers, as well as the lack of funding resources. Notwithstanding, further studies are needed to assess the effects and benefits of peer education.

Motivations and benefits of engaging in medical preceptorship

Understanding the motivations of engaging in medical education is an essential component for the recruiting and retaining of preceptors³⁶. Hence, Bentes et al.³⁷ classify the motivational factors as intrinsic, related to professional and educational identities (aspirations, previous experiences, personal satisfaction); and extrinsic, represented by financial rewards, working conditions, recognition by the medical-academic community and professional networking. Considering these aspects, the participants’ motivations were shown to be mainly related to extrinsic factors, such as curriculum enhancement, official recognition and academic degrees.

Moreover, it is worth mentioning that, particularly in the FM field, intrinsic motivations such as ‘pleasure in teaching’ and ‘transmission of generalist practice’ have also been described in the literature^18),(38, although we did not investigate these factors in the present study. Such tendencies emphasize the relevance given by family physicians to the recruitment of new professionals to the specialty^26),(39.

Other factor to be considered consists in the knowledge exchange and the encouragement of ‘recycling’ arising from the preceptor-student relationship^{18),(22),(40),(41}, as well as the stimulus to critical reflection about work processes and daily behavior due to the students’ presence in healthcare settings^23),(40.

Financial compensation appears among the main motivations, although with modest prominence in comparison to the other incentives. The offer of financial compensation is not a consensus in the literature, being pointed out sometimes as an important attribute for recruiting preceptors^{18),(19),(30),(42),(43}, and sometimes as a factor of little relevance for these professionals^26),(39.

Regardless of its attractiveness, financial incentives for preceptors are unusual in most medical residency programs. Traditionally, educational institutions have relied on altruistic feelings and intrinsic benefits to attract preceptors to PHC, contrary to the professionals’ recent propensity to value financial compensation^30),(31.

In contrast, educational institutions tend to provide alternative compensations, offering academic resources such as access to electronic libraries and databases, subsidies for attending conferences, seminars and courses, among other conveniences^31),(36. Within this scope, our findings showed a mild interest in gaining access to educational resources and the academic community, in agreement with the tendency identified by Latessa et al.⁴³.

The access to programs of continuing clinical education is a strong motivation among PHC preceptors in Australia¹⁸ and the United States⁴³, inspiring a feeling of appreciation among the professionals. From another point of view, general practitioners from Germany list adequate organization by the university, long-term planning, and the availability of teaching materials as the main motivations for involvement in medical education activities¹⁹. In spite of the diversity of the dimensions, the motivations for engaging in medical education are fundamental conditions for the recruitment and retention of professionals.

Difficulties and obstacles of preceptorship: the challenge of integrating medical education and healthcare

The FM practice encompasses a complex set of attributions and competencies that involve clinical, psychosocial, and community dimensions, demanding that family doctors develop certain skills as time management, teamwork and rational use of healthcare resources. Therefore, the involvement with preceptorship activities requires the conciliation of these responsibilities with the teaching-learning processes, which can make professional routines even more difficult^26),(36),(40.

In general, there was a low perception of difficulties and obstacles to acting as a preceptor among the participants, although they are concerned about time management. The time consumption is frequently reported in literature as a hardship to assume teaching responsibilities, mainly due to the concern of decreasing medical assistance productivity^{19),(26),(36),(40}.

However, Castells et al. ponder that the limitation of healthcare to outpatient-centered care, which privilege biomedical approaches, is focused on the diseases, opposing the person-centered principles that underlie FM practices⁴⁴. Moreover, the pressures of productivity goals and precarious working conditions together with the preceptorship demands may lead to disappointment, frustration, and withdrawal of these physicians⁴².

Regarding the medical-assistance scenario, we observed an infrequent perception about the patients’ discomfort with the presence of students, reinforcing that the integration between healthcare services and universities can be beneficial, improving the quality of health service as well as the patients’ satisfaction, as highlighted in a Brazilian study⁴⁵. According to this research, the patients consider having access to more information about their health situation in consultations with the presence of students, which may be related to the discussions between preceptors and students, where clinical conditions and diseases are explained in more details, frequently in the presence of the patients⁴⁵.

Considering these aspects, the relevance of integrating health services and universities becomes evident to ensure the improvement of medical education conditions and the work environment, as well as the qualification of healthcare assistance.