Identifying oneself as a teacher: the perceptions of preceptors

Identifying oneself as a teacher: the perceptionsof preceptors

Sarah Stone,1 Beth Ellers,2 Deborah Holmes,3 Rosemary Orgren,4

Donna Qualters5 & Janet Thompson6

Introduction Attracting and retaining quali®ed medical

educators will be a continuing challenge as physicians

feel more pressure to produce clinical revenue. With

this paper we hope to begin to identify how clinical

teachers, judged as excellent by their peers, establish

their professional identity as physician and teacher.

Method This qualitative study examines the views of 10

clinical teachers to identify the characteristics excellent

preceptors attribute to their teaching identity.

Results This study revealed four themes that in¯uence

faculty teaching identity: underlying humanitarianism,

familiarity with adult learning principles, understanding

of the bene®ts and drawbacks of teaching, and the

image of self as teacher.

Conclusion Using the ®ndings from this study, sugges-

tions are given to faculty developers for activities to

increase physician identity as teacher.

Keywords Curriculum; education, medical/*methods;

physicians; *preceptorship; professional competence.

Medical Education 2002;36:180±185

Introduction

Clinical teachers play a crucial role in the education of

our future physicians. Although faculty train for their

role as physicians, most receive limited training in their

role as teachers. When faculty identify themselves as

teachers, this identi®cation may in¯uence their desire to

teach and improve their teaching skills, satisfaction with

teaching and, ultimately, student learning. Faculty

development programmes support and enhance the

teaching skills of clinical faculty; an additional outcome

of faculty development programmes may be to develop

and support the identity of preceptors as teachers.

The characteristics that contribute to the identity of a

teacher have not been thoroughly studied.1 Limited

research has focused on physicians' attitudes towards

clinical teaching. While the research on teaching atti-

tudes does not directly address the concept of teacher

identity, it does suggest the importance of subjective

feelings about teaching. In an exploration of resident

attitudes towards teaching, the desire to teach corre-

lated with enjoyment of teaching and feeling that the

teaching role is important.2 Faculty and residents

reported that the bene®ts of teaching include profes-

sional growth3 and increased clinical knowledge.4

Intangible rewards, such as love of teaching or giving

back to the profession, outweighed the tangible rewards

with regard to desire to precept.5

Several studies have examined characteristics and

behaviours of effective clinical teachers.6±8

Irby9,10 described the roles of the clinical teacher

as role model, clinical supervisor and instructional

leader/scholar. Preceptor con®dence in teaching may be

a key factor in the use of effective teaching behav-

iours.11 It is interesting to note that a negative attitude

towards learners is the leading characteristic of inef-

fective clinical teachers.12 Characteristics and behav-

iours of teachers as observed by learners are essential

components which contribute to teaching effectiveness;

however, these are distinct from the concept of identity,

which is how a preceptor views himself as a teacher.

Despite considerable effort to develop physicians as

teachers, little attention has been devoted to the con-

1University of Massachusetts Medical Center, Worcester, Massachu-

setts, USA2University of New England College of Osteopathic Medicine, Bidde

ford, Maine, USA3Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,

USA4Dartmouth Medical School, Lebanon, New Hampshire, USA5Northeastern University, Boston, USA6Independent author

Correspondence: Donna M Qualters, Northeastern University, 225

Hayden Hall, Boston, MA 02115, USA

Discussion paper

180 Ó Blackwell Science Ltd MEDICAL EDUCATION 2002;36:180±185

cept of the development of the physician/teacher as a

professional. According to Young,13 professionals de-

®ne their ®eld and its standards and are expected to

embrace a service orientation. While the ®eld of

medicine certainly embodies the concept of profes-

sionalism, the concept of professional identity as tea-

cher is less strong even though many medical colleges

now offer promotion on a clinician-educator track.

The literature on professional identity formation tells

us that for individuals to feel they have an identity in a

profession, changes must occur on two levels ± exter-

nally and internally.14±16 Externally, individuals learn

new information and develop a new social set while

becoming acculturated to a profession. Internally, it

becomes more of a transformation where the profession

is seen as a calling or, as McGowen and Hart17 refer to

it, subjective self-conceptualization associated with the

role. This internal piece also extends to the external

piece of professional socialization, that is, part of

forming a professional identity is being around others in

the same profession and feeling part of a select

community.18 The last factor contributing to profes-

sional identity formation is mentoring, whereby sea-

soned teaching professionals assist neophytes as they

mature in the profession.16

These elements are all present in the formation of a

physician identity. New doctors learn a tremendous

amount of new information and a vast array of medical

jargon. They also develop new friends and acquaint-

ances within the community of medical health providers

and they are continually mentored throughout their

residency and often into the early years of practice. This

may or may not be true for physicians who teach. Their

mentors may be familiar with educational terminology

and may network with medical educators, but the

chances are more likely that is not the case. It may also

depend on the environment in which they choose to

practice. Working and training in an academic teaching

hospital is different from precepting in a private of®ce.

This variability in training settings may play a role in

the availability of mentoring and the concept of parti-

cipation in a community to reinforce identity as a

teacher. The question then becomes, is it possible to

identify as a teacher without the above elements or do

physicians who identify as teachers create these

components for themselves?

The Faculty Development Work Group of the

Northern New England Medical Education Consor-

tium* addressed the issue of de®ning outcomes of

faculty development programmes. We assumed that

faculty development programmes which promote pre-

ceptor identity as teacher can lead to improved teaching

skills, which will enhance student learning. We further

assumed such self-identi®cation will positively in¯u-

ence preceptors' desire to teach, their satisfaction with

teaching, and their motivation to participate in faculty

development activities. In order to test our assump-

tions, we ®rst needed to understand the characteristics

of the concept of physician identity as teacher. This

paper describes a qualitative study examining factors

that preceptors perceive as important to their identity as

teachers.�NNEMEC was formed in 1995 with support from

the Generalist Physician Initiative of the Robert Wood

Johnson Foundation. It has representatives from Bos-

ton University School of Medicine, Dartmouth Medical

School, Maine Medical Center, University of Massa-

chusetts Medical School, University of New England

College of Osteopathic Medicine, and University of

Vermont School of Medicine.

Methods

We conducted semi-structured interviews with 10

physicians associated with ®ve medical schools in

northern New England (Medical School, University of

New England College of Osteopathic Medicine, and

University of Vermont School of Medicine). Physicians

were selected based upon a 75% or better match to the

following criteria: (1) at least two years of clinical

teaching experience (2) positive teaching evaluations

from medical students and/or residents (3) recognized

as an excellent teacher by the programme director, and

(4) awarded special recognition for his/her teaching

role.

Programme directors and faculty with signi®cant

educational administrative responsibility were excluded.

The physicians selected for interviews were chosen so

that half were employed by teaching hospitals or

colleges and the other half were not. The interviews

were audiotaped and transcribed. Coding categories

Key learning points

Preceptors associate strong feelings with their

identity as teacher

Four aspects of teacher identity are as follows:

humanitarianism; adult learning principles; bene-

®ts and drawbacks, and image of self as teacher

Teacher identity was not associated with student

learning

Faculty development can foster preceptor identity

as teacher

Ó Blackwell Science Ltd MEDICAL EDUCATION 2002;36:180±185

Identifying oneself as a teacher · S Stone et al. 181

were developed and analyzed independently by two of

the authors using standard qualitative methods, with

approximately 95% agreement between the coders.19

(See Table 1).

Results

Four aspects of teacher identity emerged from the

interviews: (1) an underlying humanitarianism; (2)

familiarity with adult education principles and practices;

(3) appreciation for both bene®ts and drawbacks of

teaching; and (4) the image of self as a teacher.

An underlying humanitarianism

Throughout the interviews, respondents revealed an

underlying humanitarianism in their thoughts and

feelings about their role as teachers. They often com-

mented on this role in a larger context of involvement

with humanity:

I feel that my obligation [is] to be part of the teaching

process so that ¼ citizens of this country can have

good doctors in the future.

I would say the teaching of the non-traditional, not

the diagnostic [aspects of medicine] is ¼ how to be a

human being, how to be a person, and how to still

practice medicine.

Humanitarianism was re¯ected in respondents'

descriptions of their attitudes toward students. The

importance of supporting students' self-esteem and

showing respect was often expressed.

It was found that most of the complaints from

medical students about educators were that

they were demeaned, they were treated without respect.

A sense of equality and mutualism and a desire to

connect with the learner also characterized the teacher-

learner relationship:

I'm a real person ¼ not an ivory tower physician ¼[I] come across as an equal.

¼ it matters less what the speci®c type of information

being transferred is (than) the connection you make

with the student or the resident.

Some of the speci®c teaching strategies described

by respondents further illustrated a humanitarianism

sensibility.

We spend too much time in medical education

teaching students how to break things down into little

segments to memorize. We don't teach them how to

synthesize data as caring individuals.

Familiarity with adult education principles

and practices

Most respondents revealed an acquaintance with prin-

ciples and practices of adult education:

Too many people in medical education know

nothing about education and they really need to

listen to adult learners and adult educators ¼ we're

not dealing with medical students who are 14 years

old.

Some recognized that it is important for teachers to

know the level of preparedness of their learners:

There has to be an understanding of where the learner is.

That's a necessary part of it ¼ starting from a

perception of where the learners are in terms of

their knowledge ¼ and then ¼ listening for points

¼ to enhance.

Others saw the need to identify the speci®c learning

goals from the learners' perspective:

What do they need to get out of this encounter ¼ As

opposed to what I thought they would need.

The learner has skills ¼ or knowledge that they want

to acquire ¼ I'm someone there who is assisting

them in setting goals and checking goals.

Many respondents emphasized the importance of fos-

tering a love of continued learning in their students:

I think the important thing is to know what your

resources are and how to access them ¼ how to do a

literature search, how to get the article you need, or

how to contact some specialist in a different city to

review a case with them. Those skills encourage

lifelong learning.

Appreciation for the bene®ts and drawbacks

of teaching

Most respondents mentioned multiple bene®ts to

clinical teaching. While all respondents mentioned one

or more drawbacks, they indicated that the bene®ts of

teaching outweigh the drawbacks. For many, teaching

was a way to update their clinical knowledge.

Teaching compelled them to learn as much as their

students:

Just the act of teaching and the need to be current with

your knowledge ¼ to be prompted to think about

things, by questions that you hadn't otherwise thought

of, certainly leads you to be a better physician.

Identifying oneself as a teacher · S Stone et al.182


Teaching was also appealing because it was enjoyable

and rewarding:

I enjoy teaching ¼ it's sort of a neat trick to ®gure

out [how] to help someone learn ¼ I like the feeling

that someone's just learned something that I helped

them to learn.

However, they also conveyed some of the drawbacks of

the teaching role. Many noted the time pressures and

inconveniences that teaching adds to their day:

Willingness to take time ¼ willingness to sacri®ce

some of my own time.

Another drawback of teaching identi®ed was the

motivation and developmental readiness of learners in a

particular clinical setting:

When your learner isn't ready, that can be frustrating.

The image of self as teacher

One of the strongest themes from the data was

respondents' view of themselves as teachers and the

multiple perspectives that created the image of teacher.

Most subjects identi®ed an external prompt that trig-

gered a sense of themselves as teachers:

I ®rst felt like a teacher when I was assigned as a team

with an intern and a student to teach and ¼ I

remember ¼ being about to write the orders and

remembering, oh, wait a minute ¼ my role is more

to teach the person, the intern and student.

At the same time, an internal process was described.

Many felt as they progressed along the medical

education continuum, and gained more knowledge and

skills, they had something concrete to share:

There were more people under me who all of a

sudden knew less than I did ¼ I had the opportunity

to share with them what knowledge I had.

For several, this evolving sense of self as teacher

was accompanied by a sense of personal pride and ego

support:

I've had medical students four, ®ve, and six years

later who are ®nishing residencies who have called

me up and told me they chose [my specialty].

This sense of pride was tempered for some, however,

by the recognition that their own knowledge was lim-

ited. While this was characterized as a cause for

discomfort, respondents also expressed the importance

of being open to challenges from students, and the

ability to acknowledge one's own limitations:

There are times when I've had to say you're going to

have to talk with [someone else about that].

There are the questions that the student asked that ¼I have to look at them and say, `I don't know. We'll

talk about it tomorrow', and you go home and you

read on it. And, that happens a lot.

An important common thread that emerged was the

image of self as teacher interwoven with identity as

patient provider; the identities as teacher and doctor

support each other:

I had a patient today ¼ and I sat down with the

patient and explained ¼what hypertension involved.

He looked at me and said, `nobody has ever taught me

before'. Daily, I feel like a teacher with my patients.

Several respondents saw themselves ®rst as doctors:

¼ many physicians that are good, gifted doctors are

not very good teachers because they have forgotten

¼ what the art of medicine is; the picture of Norman

Rockwell, the classic painting of the mother and

father wringing their hands, the child laying very ill in

the bed, and the old country doctor. Medicine at that

time was the art of being with the patient.

Others saw themselves principally as teachers:

I think probably even more than to practice medicine

itself is to teach.

There was a strong tendency to see the images tied

together. The very identity of physician implicitly holds

the identity of teacher:

I've been very successful [as a teacher] because I am,

in the traditional term, a good doctor.

I'm a teacher and a physician and ¼ a lot of my

identity as a teacher is already found in what I am

and what I do.

In summary, the identity as teacher often began with

a speci®c incident involving a learner and evolved as

knowledge and expertise increased. Preceptors

expressed a sense of ego grati®cation and personal

pride, with the drawback that one's knowledge is lim-

ited. Many respondents tied the images of teacher and

physician together.

Discussion

Three issues emerged from our research: the strong

feelings preceptors associated with their identity as

teachers, the lack of association of identity with stu-

dent learning, and the integrated role of doctor and



teacher. One affective component expressed was the

sense of responsibility to give back to a profession that

had given to them. This sense of obligation connects

with the professionalism of medicine and may be

important in the recruitment and retention of precep-

tors. Other affective components included enjoyment

of teaching, respect for the learners and a sense of ego

grati®cation.

The sense of identity among preceptors was not

generally related to any measure of student learning.

Identity was related to observing the learning process as

well as being labelled teachers. The lack of association

of identity with learning outcomes may not be signi®-

cant. Students may learn whether or not teachers name

learning as part of their identity. However, student

learning is a prominent part of identity in other teaching

professionals.20 Learning may not be named as part of

teacher identity in the medical setting because precep-

tors do not have the time or expertise to assess learning.

Preceptors are often assigned students for 3±4 weeks,

and it may be dif®cult to measure learning in that short

period of time. If they were more skilled in setting

objectives that could be attained in 3±4 weeks, they

could better evaluate learner achievements.

The integral aspect of the role of doctor and teacher

was another issue identi®ed. Participants felt that

excellence in one role was necessary for excellence in

the other. They named many characteristics common

to both roles. However, for both the authors and the

participants, this overlap of the roles did not seem

completely de®ned. One could postulate that empha-

sizing to preceptors their existing role as teachers (to

their patients, to their staff) would increase their

con®dence and enhance teacher identity. Research21

demonstrates that skills are best retained when they are

translated from one area to another. This concept has

implications for faculty development. However, more

research is needed to understand the most effective

methods for translating these skills.

An interesting point here is that the faculty in this

study seem to have formed a teaching identity by

creating the elements of identity formation in a non-

traditional ways. Externally, while they could not name

the vocabulary as learning theory, they have adopted

some of the language of education. Participants talked

about having objectives for their learners and assessing

student needs and understanding where the learner is in

the process. They also talked about setting and check-

ing goals, a form of student learning assessment. Many

of these physicians also expressed the feeling of teach-

ing as a calling, not in the sense of primary responsi-

bility but as an ancillary to their role as physician. They

described it as the need to give back to the profession or

the necessity of sacri®cing time and energy. The inter-

viewees did not mention having peers they talked to

regarding education or participating in a community of

like-minded individuals. There is a possibility that these

physicians formed a bond with their students that is

different from the traditional student/teacher relation-

ship. The one on one nature of precepting could pro-

vide an element of the socialization needed to form

identity. More research is needed in the area of pre-

ceptor/student interaction.

The mentoring component was absent in our

discussion with all preceptors interviewed. As stated

earlier, research shows that mentoring in the neophyte

stage is critical to identity formation. This is an element

that needs to be examined. If medical education is to

attract and retain quality clinical faculty, creative

methods of implementation must be explored. Medical

education could promote mechanisms for mentoring

physicians as teachers, and to help them focus on

measuring student learning. This might enhance their

identity as teachers and their commitment to teaching.

Implications for faculty development

Faculty development programmes have traditionally

focused on speci®c teaching skills and behaviours.

Faculty development could play a signi®cant role in

fostering preceptor identity as teacher by addressing

the affective component. Methodologies for accom-

plishing this include asking preceptors to keep journals

on their experiences as teachers or providing group

discussion at faculty development programmes.

Continuity in the training of preceptors is important if

the affective components are to be emphasized.

Preceptors need the opportunities to re¯ect on their

teaching experiences. Programmes could provide

continuity through follow-up workshops, or electronic

or written communication. These components are

powerful and may strengthen satisfaction and commit

ment to teaching.

Preceptors voiced concern over their teaching when

they lacked the clinical knowledge. Faculty developers

need to be aware of this and provide clinical informa-

tion when new areas of the curriculum are presented to

the students. Faculty developers may want to work

with traditional continuing medical education to com-

bine knowledge and skills of teaching with those in a

clinical area. Faculty developers also want to emphasize

learning outcomes and provide preceptors with the

skills to set and measure objectives that ®t the short

time frame.

The implications of faculty development related to

the doctor/teacher connection need to be explored.

Identifying oneself as a teacher · S Stone et al.184


Pointing out the similarities of the roles and applying

skills from one role to the other (e.g. the dif®cult

patient/student) could increase preceptors' skills and

con®dence.

Conclusion

In this study we were able to identify characteristics

excellent preceptors attribute to their teaching identity.

In order to test our next set of assumptions, additional

study is needed to determine whether these attributes

exist with all preceptors, not just those identi®ed as

excellent. Furthermore, research is needed on whether

or not these characteristics are associated with the

desire to teach, satisfaction with teaching, and desire to

improve teaching skills. Although our study subjects

were identi®ed as excellent teachers by both their

learners and peers, increased student learning was not a

criterion in their selection. Since the ultimate goal is

student learning, research needs to determine which of

the characteristics identi®ed in this study, if any, lead to

increased learning.

Acknowledgements

The authors want to thank Dr Bruce Weinstein, who

assisted in the piloting of the interview tool.

Contributors

This was a collaborative project. SS and DQ were

interviewers; RO and JT were coders, and BE and DH

underbook literature research and edited the paper. All

authors participated in the development of the inter-

view guide, conceptualization of the data, and writing

of the paper.

Funding

The project was supported by the Generalist Physician

Initiative of the Robert Wood Johnson Foundation, the

DMS Of®ce of Dartmouth-Hitchcock Medical Center,

and the Community Faculty Development Center at

the University of Massachusetts Medical School.

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accepted for publication 29 March 2001



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Identifying oneself as a teacher: the perceptions of preceptors