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INTRODUCTION
Updates on the concept of health and its care model have encouraged debates, in Brazil and worldwide, about the changes required to adapt medical education to emerging demands. Evidence in medical education affirms that curricula with a strong inclination towards practice are more effective in training professionals prepared for the needs of their localities1)-(4. In Brazil, the National Curriculum Guidelines (NCG) of the Undergraduate Medical School indicate the need to adapt the curricula to expand the practice scenarios and emphasize primary care5)-(7.
The preceptor is essential for in-service training in undergraduate medical school. Most studies use the term “preceptor” to designate those who accompany or facilitate the teaching-learning process in practice scenarios8)-(12. However, the inclusion of students in health services alone does not guarantee effective learning9),(10. The presence of students in unprepared educational environments can generate negative results for both students and the professionals involved11),(12. The scenario of inclusion of students from the early periods into professional practice exposes the importance of the preceptor in the training of new doctors.
To understand how the preceptor works, the aim of this study was to verify in the scientific literature the world experiences in preceptorship in the undergraduate medical school.
METHOD
The methodological choice for the study was the integrative literature review, as it integrates Evidence-Based Medicine and due to the scope amplitude for the analysis. This method allows the inclusion of experimental and non-experimental studies for several purposes, such as defining concepts and reviewing theories and evidence that enhance the understanding of a consistent and understandable panorama13),(14.
This review used the following phases in its design13: creation of the guiding question; literature search; definition of information extracted from the selected studies; evaluation of included studies and presentation of the integrative review.
The guiding question was: What are the world experiences with preceptorship in undergraduate teaching in Medicine? The literature search was performed using publications indexed in the electronic databases: Literatura Latino-Americana e Literatura do Caribe em Ciências da Saúde (LILACS), Medical Literature Analysis and Retrieval System online (MEDLINE) and Scientific Electronic Library Online (SCIELO) arranged according to the standards of the Health Sciences Descriptors (DeCS) in Portuguese, English and Spanish: preceptoria/preceptorship/preceptoría; educação de graduação em medicina/education, medical, undergraduate/educación de pregrado en medicina and educação médica/medical education/educación médica. The search terms were individually crossed in the aforementioned electronic databases, using the Boolean operator “AND” aiming to restrict the scope of the search and include articles relevant to the topic.
The study inclusion criteria were: original articles that answer the guiding question of this review, published between 2009 and 2019; full texts available in the electronic databases; publications in Portuguese, English and/or Spanish; articles related to the Undergraduate Course in Medicine. The first exclusion criteria were texts in the form of theses, dissertations, monographs, editorials, review articles (narrative, systematic and integrative) and abstracts from events. After the initial corpus was defined, we progressed to the article content stage, starting with the title, abstract and full text. For this process, we used the concept of preceptorship as those professionals who supervise or accompany the teaching-learning process in practice scenarios8)-(12.
After this stage, the identified articles were analyzed using the thematic category technique15. Working with categories means grouping elements, ideas or expressions around a concept capable of encompassing the classifications, aiming to make extensive contact with the material and allow oneself to be infused by its content. The objective at this point was to have an overview of the articles. After this process, in-depth readings of each article started, in which we sought to detail the essence of the results by separating the excerpts considered relevant for the study. Finally, these excerpts were divided into two thematic categories: a) intrinsic and extrinsic aspects for the exercise of preceptorship b) educational strategies used by the preceptor.
The presentation of the integrative review was divided into results, in which general aspects of the sample appear; and discussion, based on the listed thematic categories.
RESULTS
The search in the databases resulted in 274 studies, from the following databases: MEDLINE (n=101), LILACS (n=87) and SciELO (n=86). After reading the titles and excluding the repeated ones, 50 articles were selected for the reading of the abstracts. Eighteen articles were excluded after reading the abstracts, leaving 32 articles for the reading of their content in full. Ultimately, 23 articles were considered eligible for the study, whose results were analyzed and discussed in full (Figure 1). The selected studies, 08 national and 15 international ones, are distributed in 13 different journals (Graph 1). The articles and results selected for the analysis are qualitatively shown in Table 1.
Table 1 Selected articles.
| Title | Preceptor’s work Scenario | Year/Country/ Database | Type of Study | Results |
|---|---|---|---|---|
| Visão de preceptores sobre o processo de ensino-aprendizagem no internato | PHC (Primary Health Care) and Hospital | 2014/ Brazil/ Scielo | Qualitative Descriptive survey Cross-sectional | Teaching and assessment methodologies centered on the preceptor and the student were verified. The internship teaching plans, in general, do not describe a teaching model or methodologies to be used by preceptors, although the pedagogical project of the course proposes a critical-reflective teaching perspective. |
| Percepção sobre o Internato de Medicina da Universidade Federal do Rio de Janeiro pelos Preceptores do Serviço na Atenção Básica: um Estudo de Caso | PHC | 2016/ Brazil/ Scielo | Exploratory Qualitative Case study | The preceptors feel acknowledged and encouraged by the students, but they do not feel valued by the head of the service, which does not provide physical space and time for the activities. The preceptors wish to receive training for the activity, strengthening ties with the University. |
| Qualificação como Médico Preceptor e a Satisfação de Seus Clientes quanto à Assistência Recebida na UBS de Origem | PHC | 2017/ Brazil/ Scielo | Qualitative/ Quantitative Descriptive Cross-sectional | More than 90% of clients assisted by preceptors are satisfied with the assistance received and 80% of the interviewed physicians report the preceptorship as an instrument to qualify their professional activity. |
| Avaliação Discente de um Internato Médico em Atenção Primária à Saúde | PHC | 2016/ Brazil/ Scielo | Qualitative/ Quantitative Descriptive Cross-sectional | Preceptorship was considered excellent (82%) or good (16.1%) in 98.1% of cases. The criticisms were related to structural aspects such as transport/food aid and infrastructure. |
| Preceptoria Médica em Serviço de Emergência e Urgência Hospitalar na Perspectiva de Médicos | Hospital | 2016/ Brazil/ Scielo | Qualitative Case study Descriptive Cross-sectional | Preceptorship contributes a lot to professional training, as well as facing many structural challenges, which shows a reform in working conditions and training. |
| Curso de formação pedagógica para preceptores do internato médico | Not available | 2012/ Brazil/ Scielo | Qualitative Quantitative Descriptive exploratory | The graduates were able to improve their skills and put them into practice in their work routine. Pedagogical training for medical preceptors was considered important, necessary and feasible to achieve desirable changes in medical education. |
| Uma avaliação do processo de formação pedagógica de preceptores do internato médico | Not available | 2011/ Brazil/ Scielo | Qualitative Descriptive Cross-sectional | The importance of the course in their pedagogical training was reported, due to the lack of knowledge about the preceptor’s role. It helped in instrumentalization, self-esteem and pedagogical conduct. |
| Recruitment and Retention of Community Preceptors | Hospital | 2018/ USA, Canada/ Medline | Quantitative Descriptive | The principals of medical schools (n=67%) have difficulty maintaining or recruiting preceptors and 51% have difficulty related to the dependence on professionals. There is a competition with other tutoring programs (n=92%). Few principals reported the presence of financial incentives and the feasibility of rewards in their programs. |
| Implementing a logbook on entrustable professional activities in the final year of undergraduate medical education in Germany-a multicentric pilot study | PHC and Hospital | 2019/ Germany/Medline | Qualitative | Aspects of EPA Implementation: EPA Curriculum Implementation Process and Required Resources; delivery process; feedback sessions with supervisors; perception of the role of students and supervisors; overall impact of EPAs on training conditions in the practical year. |
| Patient and preceptor attitudes towards teaching medical students in General Practice | PHC | 2013/ Austria/ Scielo | Quantitative Descriptive exploratory | The motivation to be a preceptor is driven primarily by personal and professional values rather than economic incentives. Additionally, patients have even more positive attitudes than preceptors regarding the presence of students during the consultation. |
| Community Preceptor Perspectives on Recruitment and Retention: The CoPPRR Study | PHC | 2019/ USA/ Medline | Qualitative | The intrinsic motivations to remain working in preceptorship permeate the opportunity to continue learning, the maintenance of the ability to teach and the satisfaction in giving feedback. Extrinsic reasons for continuing to be a preceptor are related to acknowledgement. |
| Texting Brief Podcasts to Deliver Faculty Development to Community-Based Preceptors in Longitudinal Integrated Clerkships | PHC | 2018/ USA/ Medline | Quantitative, quasi-experimental | There was an increase (not statistically significant) in the use of learned educational strategies. Few have heard all podcasts. Most would recommend them to their colleagues. |
| Electronic Health Record Impacts on Family Medicine Teachers: Survey of Third-Year Medical Student Clerkship Preceptors at an Academic Medical Center | PHC | 2017/ USA/ Medline | Mixed Method: Qualitative/ Quantitative | Among the positive points are a better visualization of patient information, teaching evidence-based Medicine, and student feedback. The raised negative points were reduction of interaction time with the student and with the patient, impairment in the construction of clinical skills by the student. |
| Utility of an app-based system to improve feedback following workplace-based assessment | PHC and Hospital | 2017/ England/ Medline | Mixed Method: Qualitative/ Quantitative | Positive feasibility and acceptance. The preservation of the parts positively influenced the feedback provided. The absence of a clear objective and recipient showed a negative effect. The educational impact was greatest when preceptors detailed the assessments. |
| It’s all about relationships: A qualitative study of family physicians teaching experiences in rural longitudinal clerkships | PHC | 2018/ Canada/ Medline | Qualitative | Three aspects were observed: preceptors developed trusting personal and professional relationships with students over time; the approach is based on the relation of the student’s individual understanding; preceptors collaboratively define learning goals with the students, integrating them into the learning process. |
| Desempeño del tutor en la formación del médico general / Performance of course tutors in the training of general doctors | APS | 2013/ Cuba/ Scielo | Mixed Method: Qualitative/ Quantitative | The preparation of the preceptor in the process of training general practitioners is characterized by preceptors who have a vast experience as specialists as Grade I in General Integral Medicine. There is a prevalence of instructors, and a significant portion does not have a teaching position. |
| Aprendizagem Baseada em Problemas no Internato: Há Continuidade do Processo de Ensino e Aprendizagem Ativo? | PHC and Hospital | 2015/ Brazil/ Scielo | Qualitative | Need to change the posture. The understanding of the pedagogical process is not occurring gradually in these activities. The preceptors, like the students, are not very active in the teaching and learning process. |
| Contemporary teaching strategies of exemplary community preceptors--is technology helping? | PHC | 2014/ USA/ Medline | Qualitative | Teaching strategies were used, such as adjusting instruction to the student’s needs and technological resources to facilitate outpatient teaching. The preceptors enjoyed teaching and found it rewarding. |
| Teaching points-do they occur and what do they contain? An observation study concerning the general practice rotation | PHC and Hospital | 2016/ Germany / Medline | Quantitative | Learning moments occurred in 66.3% of consultations, divided into categories: therapy, clinical history, diagnostic procedures, physical examination, pathophysiology, differential diagnoses, risk factors and case presentation. |
| Student-centred GP ambassadors: Perceptions of experienced clinical tutors in general practice undergraduate training | PHC | 2015/ Denmark, Finland, Iceland, Norway and Sweden/ Medline | Qualitative | GPs describe their skills as: complex and diverse; ambassadors to general practice, essential for the process of recruiting a new generation of general practitioners. They understand that they need support, time and resources to facilitate a sustainable tutoring and a good learning environment. |
| Effective Learning in an Ambulatory Family Medicine Clerkship: A Qualitative Study of Medical Student Midpoint Feedback | PHC | 2017/ USA/ Lilacs | Qualitative | The most common characteristic of effective learning identified by the interviewees was autonomy in practice. Other prominent topics included the encouragement of critical thinking and feedback. |
| Tobacco dependence treatment teaching by medical school clerkship preceptors: Survey responses from more than 1000 US medical students | PHC and Hospital | 2013/ USA/ Medline | Quantitative | Creating models and providing clear instructions on ways to provide tobacco counseling was relevant. In contrast, providing clear feedback and goals for the treatment of tobacco dependence was less relevant. |
| Faculty verbal evaluations reveal strategies used to promote medical student performance | PHC and Hospital | 2011/ USA/ Medline | Qualitative | Lack of structure in the history and physical examination commonly hinder progression. The results illustrate how multidisciplinary preceptors can use a common assessment framework to identify strategies aiming to improve performance and longitudinally follow student performance. |
Source: Created by the authors, 2021.
Data: N=23 articles selected for reading in full and represented in the table.
DISCUSSION
The term preceptor16)-(34 was homogeneously used, revealing a wide dissemination of the concept. Other names found in the studies to refer to the preceptor were: internship supervisor32, medical supervisor35, clinical tutor27),(36 and tutor16),(27),(37.
The preceptorship activity is crucial for the student’s good development in practice scenarios16)-(19 and has a positive impact on patients cared for by the student and/or preceptor20),(21. Due to the preceptorship, physicians have the opportunity to improve and systematize care, exchange and update medical knowledge, discuss with other colleagues at the university, improve communication and maintain a good physician-patient relationship16),(22. Although the patient’s perspective in relation to the care provided by preceptors and students has been little explored in the articles, the obtained results conclude that 90% of the patients were satisfied with the care they received22 and most of them reported a better understanding of their health status. Yet, a minority of physicians consider that the presence of the student impairs the doctor-patient relationship21.
The details of world experiences in preceptorship were systematized into two categories: intrinsic and extrinsic aspects for the exercise of preceptorship and educational strategies used by the preceptor.
Intrinsic and extrinsic aspects for the exercise of preceptorship
The motivations that influence the exercise of preceptorship are important analytical factors and it is suggested that they must be considered when proposing or monitoring a preceptorship program. As a merely didactic division, they are presented in two main blocks: a) intrinsic aspects that correspond to the preceptor’s personal interests/motivations; b) extrinsic aspects that are related to the environment in which the activity takes place, the associated institution, health service and the workload. Both aspects are interrelated and can affect each other in order to enhance or weaken the preceptorship program.
Personal motivations for preceptorship include the opportunity for professional development through contact with students20),(21),(23),(24, the satisfaction of contributing to the training and education of future doctors21),(23)-(25, the possibility of becoming a professional model in which students can mirror themselves20),(21),(38, personal fulfillment21),(24),(38, intellectual stimulation20),(38, one’s pleasure in teaching and enthusiasm and appreciation for students20. Other motivators such as a closer approach, good relationships, appreciation and interest of students also have a positive impact on the practice and satisfaction of preceptors23),(24),(26),(27.
The extrinsic issues were more diverse and correspond to three large groups: the relationship between university and preceptor; exercise of the activity and recruitment/retention.
The relationship between the University and the preceptor has a significant influence on the preceptorship activity, including relating to the recruitment and retention of preceptors23),(24),(26),(28),(38. The fact of getting closer to the institution is considered an appeal38. Benefits such as awards, access to the database20),(28, annual appreciation events28, professional acknowledgement23),(24, continuing medical education and issuing certificates and titles20),(23),(24),(28 are possibilities for establishing the link between educational institution and preceptor. On the other hand, the distancing between the University and the preceptor, demonstrated by the lack of guidance, support and communication, in addition to the devaluation by the manager,24),(29),(38 weakens the work in preceptorship as it hinders the understanding of the pedagogical process18, generates insecurity about the didactics23),(38),(26 and assigns roles that do not correspond to the expectations and potentials24 of the preceptor physician. In this context, the training of preceptors emerges as an important tool for professional development and permanent education17 and as an attraction for the exercise of the activity24),(26),(38. The lack of continuing education18),(24),(26),(38 represents an obstacle to the activity of the preceptorship, as it directly influences the preceptor’s performance17),(26.
Unfavorable aspects relevant to the exercise of the preceptorship activity include the increase in the daily workload20),(21),(24, which is directly related to the time dedicated to preceptorship; the demand for productivity by the service to which they are linked23; and excessive work and bureaucracy20),(23),(24. In the pedagogical sphere, this reflects in the lack of sufficient time to teach20),(24),(38 and a lot of content to cover20, although there is some flexibility in the pedagogical interaction and the addressed topics23. Other points that negatively influence the exercise of the activity include lack of physical space and infrastructure such as equipment, medications, and materials24),(38.
On the other hand, the diversity of complex clinical cases, if the location is a teaching hospital and if it has residency programs for internal support24),(28, can help in the development of the activity. Moreover, a positive impact on the flow of patients and on the collection of information was mentioned27.
Regarding the recruitment and retention of preceptors, internal competition (between undergraduate years) and external competition (with other programs) for preceptors must be considered28. There are divergences about remuneration as the only determining factor for motivation and appreciation of the performed work20),(21),(23),(28. While three articles indicated that the bonus could improve adherence rates20),(21),(28, one study pointed out that it does not seem to encourage the activity23.
Pedagogical Aspects
Preceptorship activities, as a component of medical education, advance to the perspective of the horizontal preceptor-student relationship, in which the student enhances their learning process to learn critically and reflexively through contact with reality under the preceptor’s mediation, making learning meaningful. The teaching strategies that delineate the teaching-learning process create a positive environment for this to occur27),(29),(36.
The relationship developed between preceptors and students deepens over time, regarding both professional and personal aspects. The article by Cuncic C. et al.25 associates the preceptor-student relationship constructed in the longitudinal stage with the expansion of the preceptor’s view beyond the academic development of students. The individualization of the preceptor-student interaction makes it possible to identify knowledge gaps and promote actions to overcome these difficulties, such as pointing out specific study points or exercises to students who have deficiencies25),(30. Considering the level of knowledge, potential and difficulties of each student helps in the development of a balanced activity20),(25),(30.
The strategy of decomposing learning into stages is a powerful one, as it sets progressively more difficult goals as students reach some goals20),(25),(30. Autonomy must be assessed at the level of the students’ education trajectory, so that it intensifies over the years29. One of the ways to assess autonomy is through the EPA (Entrustable Professional Activities). The EPAs, a competency-oriented curriculum perspective, are units of professional practice mediated by the attribution of trust at different levels of supervision35.
Another strategy is teaching through the example (role-modeling)18),(19),(25),(29),(31, which provides the modeling of behaviors, skills and provides opportunities for students to demonstrate examination techniques29. The examples, both good and bad, suggest reflection on how patients are treated18),(25),(31 and the attitude in the presence of error and lack of knowledge20),(25. Co-learning20 appears in this context, characterized by the initiative to learn something together with the student. Generally, the performance of this strategy involves the use of evidence-based clinical decision-making tools as a resource for education20.
Sharing the thinking process and encouraging clinical reasoning, critical thinking and research were also strategies identified by the studies18),(20),(29. Other relevant educational strategies are conversation circles and/or tutoring using the problem-based learning model, seminars presented by students after identifying knowledge gaps, and joint development of care protocols32.
Preceptor-centered strategies, such as lectures20),(29),(32),(33, appeared in fewer numbers when compared to student-centered strategies.
Assessment is an indispensable part of the teaching-learning process, and the use of formative and summative assessment instruments is considered essential.
Feedback appears as the most used and validated formative assessment instrument among the assessed experiences20),(26),(29)-(31),(35),(36. Feedback is seen as a way to promote learning and improve skills through sporadic interventions and performance comments25),(29),(30.
In this context, the Reporter-Interpreter-Manager-Educator (RIME)30 is a reference tool for the continuous assessment of the student’s performance, who must attain certain knowledge, skills, and attitudes. The RIME consists of criteria that guide the feedback and interventions necessary for the progression in it.
Given the importance of feedback and the difficulty in carrying it out due to limited time, one experience27 proposed the use of a “work based assessment” application for the production and recording of formal feedback from preceptors to students. Using the application facilitated access to the curriculum, familiarizing the preceptor with the teaching plans.
In addition to scheduled feedbacks, the mini-Cex (mini-clinical assessment exam) was also used to assess final-year students in an EPA curriculum. In this experience, the exam provided subsidies to assign tasks to the student, considering the level of autonomy identified and expected for the moment of training35.
Organizational and managerial aspects of preceptorship
The health service to where students are assigned is, at the same time, an environment for the production of care and professional training. Therefore, the elements related to the organization of the activity are also part of the preceptorship exercise20),(25),(32),(36. They are: clarification of the service’s regulations32, introduction of the team, organization of the agenda and activity routine36, reserving some time to discuss cases with students18),(20 and designation of a space for students to study36. Students recognize this role of the preceptor in the structuring of the internship dynamic18 and how it is capable of providing an educational environment that is not intimidating and accessible29.
In the real scenario of professional practice, the selection of patients who will be assisted was considered an important strategy for the student’s teaching-learning process20),(27),(29),(30. The different criteria for choosing the patient considered the triggers that it provides20, the personal interests and difficulties identified by the students themselves25 and greater exposure of a student to a particular issue, in order to reinforce this knowledge30. One of the experiences describes that for the timely use of learning moments, the preceptor discerned which topics could be addressed during the medical consultation and which would be better explored at a moment after the consultation20.
It was observed that the greater the students’ exposure to the practice environment, together with the preceptors, the greater the students’ safety in clinical practice. This indicates the importance of working with preceptors to acquire professional skills19),(29),(35),(33.
Aspects related to the evaluation of preceptorship
From the student perspective, the articles positively evaluated preceptorship16),(18),(22),(29. The objective of these articles was the evaluation of students about the internships, also including the preceptorship activity.
Positive assessments include: encouragement of critical thinking regarding the patient’s case; sharing the thought process; encouragement to take an active role in learning; the opportunity to observe the preceptor performing the physical examination and learn the techniques; the identification of critical issues for student learning in each case; timely feedback29; encouraging the active search for knowledge18),(22; availability to teach16),(18; the integration of theoretical and practical knowledge; evidence-based practices16; considering the preceptor as an example of professionalism18; and clinical effectiveness16),(18. The negative evaluations are aimed at unprepared pedagogical action16),(18 due to the lack of training18.
Only one study showed the assessment of preceptorship from the patients’ point of view. The presence of the figure of the preceptor physician with students was considered to be positive. The main aspects mentioned were the quality of care, the appraisal of the complaint, the time available for the medical consultation, effectiveness and reliable guidance22.
FINAL CONSIDERATIONS
The changes in the medical training model and the evidence found reveal disclose the need and importance of preceptorship in the teaching-learning process. A critical factor for the success of the monitoring of students in professional practice is the preceptor’s ability to see the student from the perspective of integral development, beyond the technical-scientific functions. By knowing and applying teaching strategies, the preceptor becomes more than the medical professional who accompanies the student, and also assumes on the role of educator. Likewise, the individualization of the preceptor-student interaction allows the identification of the teaching moment, the choice of patients, the identification of personal gaps and the opportunity to improve them, as well as timely feedback.
Therefore, the relevance of the preceptors’ qualification is highlighted, so they can effectively participate in the teaching-learning process and in the assessment of medical students regarding the acquisition of professional skills in real-life scenarios, with qualification being an open field for constant investigations.
One limitation of the present study is the diversity of educational contexts and curriculum matrices found in different countries. Therefore, it is necessary to take into account that the curricula are distributed in diverse manners, and the student joins the professional practice scenario at different moments and situations, and with different autonomy, which makes generalizations impossible, even if points in common can be observed.
In the Brazilian context, in which the NCG itself encourages professional practice in the initial undergraduate years, it is imperative to understand the preceptorship activity in the beginning of medical training, since the analyzed studies are concentrated on the final years of the course.
Given the importance of comprehensive health care, it is necessary to assimilate the role of preceptors in different health professions from the perspective of interprofessional education in undergraduate medical school.
Finally, we reiterate the importance of knowing the world experiences about preceptorship, the development of more studies on the subject and the critical-reflective training of medical professionals.
