INTRODUCTION

First appeared in Brazil in the 1940s, Medical Residency (MR) is a type of training for physicians¹. After approximately 30 years of its implementation, it has been duly regulated by Decree n. 80.281/77², which defined:

Medical Residency is a modality of postgraduate education aimed at physicians, constituting a specialization course, characterized by in-service training on an exclusive dedication regimen, carried out in health institutions, in a university environment or not, under the guidance of physicians with high ethical and professional qualifications².

The resident, usually a recently graduated professional and/or with little professional experience, has the chance to obtain theoretical and, above all, practical experiences in the different specialties offered at the MR. As it is a practical training, MR is usually so impactful that it can be considered as the stage of personal and professional life that most affects the profile of young physicians³.

According to Pessoa and Constantino⁴, it is “the best way to improve and specialize in Medicine”. This idea is reinforced by Trindade⁵, who states that there is “no doubt that MR is still the best way to train medical professionals, with their learning based on in-service training and under the supervision of a preceptor”. It is also considered the gold standard, a reference for training specialist physicians in Brazil², attaining relevance and a huge degree of responsibility for having this characteristic of continuing medical training after graduation.

METHODS

A descriptive and quantitative study was carried out, developed at Universidade Estadual de Ciências da Saúde de Alagoas (Uncisal).

There are approximately 450 preceptors in the city of Maceió, AL. The population of the present study was obtained by convenience, consisting of 300 MR preceptors, of both genders and from all age groups. This sample is considered representative of this universe. Specialist physicians who performed pedagogical together with assistance activities¹² with their resident physicians, in a MEC-accredited MRP in Maceió, AL, were considered preceptors. Preceptors who were on leave from their teaching duties were excluded.

Data collection was carried out using the same procedure and the same instrument, in two different moments: in-person (September 2019 to March 2020); and remote (due to the Covid-19 pandemic), between July and August 2020. Even though it was necessary to carry out two approaches for this collection, no difficulties or obstacles were observed that deserved to be recorded for the data analysis.

The invitation to participate in the study was sent personally (in-person collection) and through a message exchange application (remote collection). After acceptance, the filling out of the questionnaire was scheduled for the in-person collection, in which the participants received clarifications about the stages of the study, its purpose and relevance. Data confidentiality was also observed. Afterwards, the Free and Informed Consent form (FICF) was verified for acceptance and subsequent signature. As for the remote format, information was sent to the participants about the study, in addition to the informed consent form, by e-mail or through a messaging application. After signing the FICF, access to the online questionnaire was made available.

The data collection instrument used in the study was developed and validated by Girotto¹³, in her Master’s Degree thesis, after an extensive literature review and consensus of experts in preceptorship and health education. Its purpose is to promote a more detailed analysis of preceptorship, focusing on the preceptors’ observation and opinion about their activities in the training of specialists, in addition to the structure in the institutions where preceptorship is carried out¹³.

This questionnaire has a total of 35 statements related to the preceptors’ view of their role in the educational process, in addition to the practice scenarios. The answers to the statements were constructed using a five-point Likert scale: Totally Agree (TA), Partially Agree (PA), Indifferent (I), Partially Disagree (PD) and Totally Disagree (TD). A value (score) was assigned to each of the responses: 5=TA, 4=PA, 3=I, 2=PD and 1=TD. For the statements that represented negative concepts about preceptorship, their scores were inverted for the purpose of the analysis of the results¹³. It was explained to the interviewees that they had to interpret the term “student”, found in the questionnaire, as “resident”.

When analyzing the results of his questionnaire, Girotto¹³ grouped the answers, in which a Positive Perception (PP) was considered for the respondents’ answers “TA” and “PA” regarding the statement. In turn, the answers “I”, “PD” and “TD” were included in a second group, considered as a Negative Perception (NP). The answers were later analyzed through the obtained percentages of PP and NP, in each statement. Therefore, this same methodology validated by the author of the questionnaire¹³ was accurately followed in this study.

Girotto, based on the analysis of the information (when validating her questionnaire), identified five domains¹³. Each statement belongs to one of these five topics below:

Pedagogical Competence: includes statements involving the preceptor’s training in teaching aspects, analysis of pedagogical needs and updating, issues related to the preceptor’s updating, in addition to the impact of preceptorship on the preceptor.

Educational Support and Resources: analyzes aspects related to the support by the management and to the hospital, in addition to the necessary structure for the preceptor.

Educational Program Planning: it includes topics related to the preceptorship’s agreement with the National Curricular Guidelines (NCG), in addition to curricular issues and the importance of the preceptor in the training of the resident.

Teaching-Service Integration: it involves aspects related to comprehensive care and aspects of the health-disease process, in addition to identifying the users’ needs to define educational objectives.

Student Presence in the Field of Practice: addresses statements involving the resident physician and their presence in the service, in addition to possible difficulties with the team and with the users. It also addresses the issue between the resident physician and the patients.

RESULTS

The results presented herein derive from a sample of 300 physicians, MR preceptors belonging to five hospital institutions in Maceió, AL: a federal public university institution, a state public university teaching institution and three private hospitals.

Regarding the sociodemographic data, the preceptors’ mean age was 42.70 ± 10.06 years. Regarding gender, there was a slight majority of male individuals (50.34%, and 49.66% female). The mean time after graduation was 18.67 ± 10.38 years, with a mean time of preceptorship experience of 6.99 ± 6.66 years. Regarding the medical specialties of the preceptors who answered the questionnaire, the ones most frequently mentioned were the following: Anesthesiology (17.33%) Gynecology and Obstetrics (16.67%), General Surgery (10%), Radiology and Diagnostic Imaging (8.33%), Pediatrics (7.33%), Internal Medicine (6.67%) and Orthopedics and Traumatology (5%).

DISCUSSION

Regarding the age of the preceptors in this study, the mean age is close to the national average of physicians, which can be justified by the phenomenon of rejuvenation in Medicine, resulting from the recent opening of new undergraduate courses¹⁴. Regarding gender, the results are similar to those found in the literature^1),(22. The mean time of experience in preceptorship indicates preceptors who are qualified, which may reflect the quality in the MR teaching.

Regarding the specialties of the preceptors analyzed in this study, of the five most prevalent ones, four (pediatrics, general surgery, gynecology and obstetrics and anesthesiology) are precisely the medical specialties with the highest number of board-certified professionals in the country (approximately 45% of the specialists)¹⁴.

Regarding the five domains of the questionnaire created and validated by Girotto¹³, in Pedagogical Competence, the results suggest that the participants of this study recognize the importance of their competences in the educational process of MR. They also claim to be aware of the importance of scientific updating and continuous improvement to perform their tasks in MR with quality.

The concept of competence, as well as its importance (especially in MR) can be defined by the use of knowledge and skills, aiming to benefit the individual or an entire society²³. And updating throughout one’s professional life is of the utmost importance for preceptorship to be developed with quality. Barreto and De Marco²⁴, in qualitative study with preceptors, observed that there is a demand from preceptors for update offers, especially in health education, although these professionals do not independently seek these courses.

Almost all respondents claimed to correlate theory and practice in their everyday practice with residents. They also mentioned performing continuous evaluations and at the end of the MR period (statements 26 and 27), thus generating several learning opportunities. It is mandatory to assess the resident, and their criteria must also be known¹¹.

The questionnaire validated by Girotto¹³, despite addressing the topic of resident evaluation, does not focus on details of the assessment process. According to the resolution of the National Commission of Medical Residency (CNRM, Comissão Nacional de Residência Médica) number 02/200611, the theoretical, practical and attitudinal assessment types are predicted, including ethical-social behavior. The minimum frequency of these evaluations must be quarterly and, in addition to meeting the workload, approval in the evaluations is a requirement for promoting the resident to the following year and for completion of the program¹¹. However, the aforementioned resolution¹¹ does not specify how the preceptor should evaluate their resident. The formative evaluation is characterized by being carried out in several stages and by stimulating the development and acquisition of skills, allowing readjustments during the period. It includes the feedback (the feedback from the preceptor) as the most effective tool²⁵.

In general, these preceptors feel prepared to develop their teaching activities (statement 11, Pedagogical Competence), suggesting that they feel secure both in their assistance (attending their patients) and teaching functions (accompanying their residents), in their commitment to the residents.

Regarding teaching, it is important to highlight that those teachers/preceptors who have a greater aptitude for teaching will have an enormous potential to positively influence their students. Otherwise, students who have contact with tutors with little teaching skills may demonstrate lower rates of significant learning¹⁵. Thus, the preceptor who is technically and pedagogically prepared for preceptorship will have a greater chance of having tools that will help them in their task of teaching. Hence the importance of carrying out pedagogical training by the preceptor to better perform their teaching activities.

In response to statement 34, it was shown that preceptors are interested in teaching, with 55% of PP for this statement. One possibility that may explain this finding is the fact that the teaching career (in the context of undergraduate school) is yet another professional option, considering the expansion of medical courses across the country¹⁴. It can also constitute one more sign of the preceptors’ interest and commitment with medical education. However, a factor that can negatively influence the interest in teaching is the low remuneration, according to Barbosa²⁶, especially when compared to other higher education professions.

Finally, Girotto¹³ described a similar finding to this study, when reporting a predominance of PP for the identification of their needs to prepare for preceptorship (statement 25), even considering themselves mostly adequate for this activity (statement 11).

In the Educational Support and Resources domain, the results showed that in general the preceptors claim to be in an appropriate physical space and structure for MR activities. Therefore, when concerning aspects such as support and physical structure, they consider that the fact they have the necessary means to carry out their educational practices (predominance of PP in statement 7) means the acknowledgement of the importance of their activity in MR. They also claim they have adequate physical space (PP predominance in statements 32) and that they receive adequate support from their managers and the institutions that regulate the MRP (PP predominance in statements 10, 13 and 17).

This means that Maceió has preceptors in the MRP who have the appropriate structure for the efficient running of MR activities, in addition to the necessary support from their managers and the hospital institution, which even appreciate them as educators. This is a strong sign that there is a commitment by these other actors, who are also fundamental for MR, aiming to promote quality in their MRPs.

One statement stood out positively was statement number 10 (about the preceptor receiving support from their managers for the preceptorship), reporting the service’s commitment to contributing to improvements in the physical structure, aiming to assist in the preceptors’ pedagogical activities with their residents. Therefore, the presence of the residents themselves in the service already has the potential to cause positive impacts on its physical structure, reflected in the acquisition of new materials and improvements in general.

Nevertheless, attention was drawn to the topic of pedagogical training, which showed a proportion of 72% of NP in statement 7. This can be explained by the low number of training courses for preceptorship, which is a matter of concern, as it is important to invest in these preparatory courses. Marins¹⁶⁾ emphasizes this concern, noting that in most health professions there is no tradition in pedagogical training. The author states that, in this environment, there is an established a view that, regardless of having undergone training or not, a professional will necessarily be a good preceptor. Finally, he observes an increase in the training requirements for the preceptor regarding the teaching aspects¹⁶.

A study with preceptors²² identified some rewards they refer to when exercising the preceptorship: continuous updating, service qualification, social transformation, contact with other professionals, daily challenge, personal satisfaction and the possibility of helping to train doctors.

It is worth noting that, although a minority received pedagogical training, most preceptors feel able to carry out their educational tasks (predominance of PP for statement 11 - present in Domain 1). Apparently, there seems to be a contradiction in the preceptors’ responses, even when dealing with different domains. One must take into account that, from the preceptors’ point of view, it may seem that the knowledge and experience of the specialty technique would be more valuable skills for preceptors in the exercise of preceptorship than pedagogical training, since there is no obligation to carry out previous training to carry out this activity. Thus, the preceptor can perform this activity and feel technically ready, even without training.

With institutional support, there should be additional benefits, such as the chance to stimulate training through courses, valorization and the possibility of financial benefits²². Girotto reported disagreements about aspects of preceptorship recognition by their institutions. The author corroborates the importance of acknowledging preceptorship by the institutions¹³.

The Educational Program Planning domain addresses issues related to the planning of teaching activities, as well as statements regarding the definition of the academic curriculum and educational proposals¹³. In this study, a predominance of PP was observed in almost all statements. The preceptors reported that their tasks needed to be reorganized because of the residents. Moreover, these teachers also claimed integrating, as much as possible, the resident physician into the teams; in general, they mentioned knowing the curriculum of the MRPs in which they are involved.

This represents an understanding of the analyzed preceptors that there is an integration between the teaching network and the service, where the resident physician (professional in training) complements the training (obtained during the undergraduate school) with postgraduate studies, carried out in health institutions, either public or private. These results can be explained by a concern and commitment of the involved parties in providing a quality MR service.

Still in relation to this domain, some data draw a negative attention. Less than half of the preceptors reported carrying out research with residents, a fact that deserves due attention. This means that, from the point of view of the preceptors analyzed in this study, in general there is neither practice, nor the promotion of research within the scope of the MR, which is a point to be improved. This fact can be explained by the low stimulus to research by the hospital institutions. It can also be explained by the excessive workload undertaken by physicians^8),(27, with research taking a secondary role.

The literature is scarce about research in the MR. It is worth emphasizing that, in this context, there is still little interest and little incentive for research⁸. In general, the preceptors are not seen as researchers and, overall, health work is not yet considered as something that integrates teaching and research²⁵. Unfortunately, preceptors still tend to receive little or no preparation for research orientation, due to curricular failures in their training¹³.

The CNRM resolution number 02/2006, despite requiring that topics such as Scientific Methodology and Biostatistics be addressed among the theoretical-complementary activities, does not condition the performance or participation in research as a prerequisite for the completion of the program¹¹. However, although the MR is mainly aimed at technical education and in-service training², it is important that residents be encouraged to perform this type of activity.

The inclusion in research and performance of scientific studies and/or term paper during the MR can undoubtedly be very valid for the training of this physician undergoing specialization, in the sense of promoting in this student the interest in teaching and research²⁸. According to Marchiori, MRP preceptors are responsible for creating conditions for the development of these activities, offering residents a more comprehensive training²⁸.

Girotto¹³, when analyzing this third domain, disclosed positive perceptions for most statements. However, she reported that most preceptors are unaware of the curriculum of the program in which they are preceptors.

The Teaching-Service Integration domain revealed that these preceptors have a predominantly positive perception of the three statements involving these aspects. This means that they articulate biological, cultural and social aspects of the health-disease process in preceptorship. A possible explanation for this fact would be the existence of the preceptors’ awareness to use this environment of integration to favor their residents and health users.

A study¹³ showed similar data, with a PP from their preceptors on the aspects addressed in this fourth factor. According to the author, preceptors understand the importance of training professionals focused on comprehensive care.

Moreover, the preceptors of this study also reported identifying challenges in the demands of health users to use as the basis for establishing educational goals in the MR context. That is, they have the ability to integrate care and teaching with their residents. There are reports in the literature of the benefits of this integration, such as an improvement in care for their patients after the implementation of an MR service. The presence of residents, with their natural questions (despite the initial challenges and resistance) tends to motivate preceptors and the entire service, thus allowing a more complete and better quality care for their patients²⁷.

Regarding the factor Student Presence in the Field of Practice, given the importance of these topics and discussions involving the resident in practice, it is undisputedly the most frequently analyzed factor, involving the highest number of statements. Most of the preceptors in this research reported that residents in general do not contribute to the overload of their tasks. On the contrary, they mentioned that the inclusion of residents generates benefits not only to their quality of life but also to the quality of care.

Moreover, according to the assessed individuals, the presence of residents tends to give the preceptor, as an educator/assistant, greater learning opportunities. These results can be justified by the preceptors’ acknowledgement that their residents represent excellent opportunities and incentives for them to seek improvement in learning and refreshing of knowledge, making it necessary to continue studying and updating themselves.

These mutual benefits generated by this exchange of experiences between preceptor and resident are broad and have also been described in the context of other health professions. Ribeiro and Prado⁷, analyzing practices in health residencies, reported that the preceptor has chances to learn, while helping their students to improve, gain experience and knowledge in practice.

In addition to the MR context, the relationship between preceptor and student is also important in undergraduate school and should be considered as important as the relationship between physician and patient. In this environment, the preceptor is responsible for the professional initiation of the future physician.

Nevertheless, studies with divergent results were found. The possible work overload was also reported¹³, where the preceptors demonstrated that the students had a negative influence, overloading their activities. This pressure can mean the preceptor’s unpreparedness, as they start to accumulate functions, becoming at the same time a service provider (with an increasing work demand) and an educator²².

Regarding the impact of residents on health users and on the service, the present study reported that their presence does not displease them. Residents do not cause harm to patient safety. Moreover, health teams in general welcome them, and can even have a positive impact on their training. The preceptors also stated that, in general, there are no conflicts between residents and their respective services.

The literature reinforces the improvement that an MR can have on the safety and quality of patient care, reflected by the possibility of upgrades and updates of techniques or new procedures. This tends to increase user safety²⁹.

However, on the contrary, a study¹³ described a negative perception of preceptors, who, in general, reported that the presence of residents was displeasing to users, even with the potential risk of compromising their safety. However, the study did not explain the cause for these results.

In this study, only a minority of preceptors mentioned being paid to carry out their educational attributions, whose justification may be related to the scarcity of scholarships or financial aid for preceptorship in Maceió. This is a sign of alarm and devaluation of preceptorship, which can cause dissatisfaction at work and low self-esteem, given the commitment and responsibility the preceptor has in the training of the resident physician. It is worth mentioning that the issue of negative impacts resulting from low or absence of remuneration is well evidenced in the literature, such as discouragement, learning difficulties and drop in performance²⁷.

FINAL CONSIDERATIONS

The results disclosed that most preceptors state they are included in a socially pleasant and suitable environment to carry out pedagogical activities with residents and care for their patients. They report the improvement in their quality of professional life with the company of residents. They also have an adequate physical structure, in addition to the due recognition and support of their respective managers and the institution for carrying out this activity in the MR.

The preceptors also reported having a commitment to the stages of the educational process of their residents. They stated they are prepared to be preceptors, being aware of their own needs for pedagogical training, since the vast majority did not receive preparation to develop teaching activities in preceptorship, a fact that can be of concern. They are aware of the benefits that this type of preparation can bring.

It was also verified that the preceptors have curricular knowledge of the MRPs of which they are part, reporting they have the necessary freedom to define teaching proposals, in addition to seeking to carry out an adequate integration between teaching and service, including the resident into this entire context. However, they drew attention to two points that could be improved. The preceptors, in general, are not conducting research with their residents and are not being adequately paid, which may negatively impact their teaching activities in the MR.

As implications of this study, we suggest the adoption of measures to encourage pedagogical training, the establishment of a remuneration for preceptorship (aiming at professional valorization), in addition to the implementation of measures to encourage research within the scope of the MR.

The data obtained from this study are representative of the preceptors of the city in which this study was carried out; however, it is not representative for the universe of MR preceptors in Brazil. Undoubtedly, the presented data help to elucidate several aspects of this very relevant topic and could be the basis for future studies where an analysis of the power of the study can be carried out, or we suggest a national study involving MR preceptors, with the application of this questionnaire created and validated by Girotto.

Additionally, this knowledge can be considered as the basis for future analyses of other populations of preceptors, in addition to other studies on preceptorship, provided that possible population and regional particularities are considered.