Strategies for Teaching Medical Students: A Faculty Development Workshop for Pediatric Preceptors in the Community Setting.

Introduction: An increasing number of medical students complete clerkships outside of traditional university-affiliated medical centers despite little faculty development geared specifically for the community preceptor. Moreover, the community setting presents a unique set of challenges, including fewer educational resources, greater expectation of clinical productivity, and a wide geographic distribution of preceptors.
Methods: This 90-minute workshop provided pediatric community preceptors with effective teaching strategies that could be used in their setting. First, participants identified opportunities and challenges for medical student education in the community setting. Then, participants discussed approaches to strengthen the students' learning experience in small-group breakout sessions. Finally, workshop leaders emphasized specific teaching resources and methods to empower participants.
Results: This workshop was presented at three national pediatric conferences and had at least 57 participants (40 total respondents). Over the three iterations, participants consistently rated this workshop as highly effective and engaging, with the small-group breakout session rated most engaging. Over time, modifications to the workshop included lengthening breakout sessions, shortening didactic materials to enhance audience discussion, and expanding content to include the outpatient setting. In later iterations, participants identified a specific medical education challenge at their institution and committed to using a technique they learned from the workshop. Discussion: This workshop targeted inpatient and outpatient pediatric preceptors to address the community-based faculty development gap. After completing the workshop, community preceptors can enhance the medical education experience by optimizing invaluable opportunities in the community setting and applying targeted strategies and resources.

Educational Objectives

By the end of this activity, learners will be able to:

Identify opportunities and challenges for medical student education in the inpatient and outpatient community setting.

Discuss approaches and resources to strengthen the students' learning experience at a clinical teaching site.

Adapt a tool or strategy to solve a specific medical education challenge at a clinical site.

Introduction

Clinical training at community sites is an important part of medical student education since the majority of US health care services take place outside of traditional university-affiliated medical centers.[1] Community sites offer educational opportunities for student learning by reinforcing management of common high-yield medical conditions in settings where this care is most often provided. From community hospitals to community health centers and primary care practices, most US medical students receive part of their training in the community setting.[2] From an educational perspective, the community hospital inpatient setting allows medical students to learn about the typical presentation and treatment of common diagnoses in generally healthy children.[3] Community-based outpatient medical training can similarly expose learners to the treatment of common primary care conditions, as well as provide a high level of educational continuity between the medical student and preceptor. As the number of medical schools and the size of classes continue to grow, so too does the demand for community-based training sites.[4] In fact, the Association for American Medical Colleges found that a large proportion of allopathic medical schools had difficulty identifying clinical training sites for their students, with 55% of schools describing barriers to finding pediatric clinical sites.[5]

In particular, teaching pediatrics at community-based sites presents a unique set of challenges. Being structurally separate from the traditional university-affiliated medical center often results in a lack of faculty mentorship, educational resources, support staff, and established didactic infrastructure for both students and preceptors. Many community preceptors have decreased their commitment to medical student teaching due to time limitations, financial burdens to productivity, barriers created by electronic health records systems, and a shift to training other health professional students.[6,7]

Despite the need for community clinical educators and the well-known challenges involved with recruiting preceptors and ensuring quality teaching, there are significant gaps in the resources available for community-based faculty development.[4,8] Educational leaders such as clerkship directors may therefore struggle to both recruit and maintain community preceptors.[8] The Liaison Committee on Medical Education requires medical schools to provide ongoing faculty development for community-based teachers.[4] In 2017, a task force of the Association of Medical School Pediatric Department Chairs (AMSPDC) and the Council on Medical Student Education in Pediatrics (COMSEP) identified faculty development of community preceptors as a key priority.[7] Although some shared faculty development conferences and tools exist, most materials are geared toward the preceptor in the university-affiliated medical center. These do not always translate well to the unique challenges facing the community preceptor. MedEdPORTAL contains hundreds of faculty development publications; however, when narrowed specifically to the community preceptor, only one active reference remains. MedEdPORTAL has partially addressed this gap by introducing podcasts for the community-based preceptor, but there is no known published material specifically targeting the unique needs of community preceptors in a workshop format.[9] Our workshop aims to fill the existing gap in faculty development for the pediatric community preceptor. The literature supports time constraints and financial pressures as the most challenging aspects of precepting in the community, and therefore, these issues are specifically addressed.[8]

Methods

As facilitators, we drew upon our experience in medical education and leadership in the community and university settings to promote community preceptor partnerships, introduce practical educational resources, and develop effective teaching strategies in the midst of providing patient care. We used case-based small-group facilitated discussion to increase participant engagement, draw on a collective expertise, and encourage problem solving. We expected that by completing the workshop, participants would learn new strategies to engage students and maximize the many invaluable opportunities that the community setting offers.

We initially designed this workshop for community and university pediatric hospitalists, clinical site administrators, and educational leaders at the Pediatric Hospital Medicine 2016 annual meeting.[10] Based on positive feedback, we returned the following year and presented the workshop with small modifications based on audience evaluations.[11] Most recently, at the Pediatric Academic Societies Meeting in 2018,[12] we expanded the workshop to include both outpatient and inpatient preceptors. The audience required no prerequisite knowledge beyond experience in a clinical setting and an interest in medical student education. The number of facilitators needed to run a session varied depending on the size of the audience—with the minimum being enough to lead small-group, roundtable discussions (ideally no more than five to eight participants per table). We designed the session to last 90 minutes, but the workshop could be adapted to fit within a 60- to 120-minute time frame.

Introductions, icebreaker, and facilitated large-group discussion: 10 minutes.

Breakout sessions (small group): 65 minutes total.

Instructions: 5 minutes.

Cases—three vignettes presented using the following format:

Small-group discussion: 10 minutes.

Facilitated, large-group discussion during which a table reporter summarized the small-group discussion. Afterward, one of our workshop facilitators elaborated upon specific tools and strategies using slides: 10 minutes.

Facilitated large-group discussion to introduce additional strategies and reinforce take-home points: 10 minutes.

Individual participant reflection, workshop evaluation, and a commitment to adopt a tool/strategy: 5 minutes.

Workshop Outline

We assembled the room with a computer, projector, and screen at the front and circular tables seating six to 10 participants throughout. We used the screen to project the PowerPoint (Appendix A). When we knew prior to the start of the workshop the size and composition of the audience, we labeled tables as community pediatricians, community hospitalists, and educational leadership to allow entering participants to self-select their table. If we did not know the composition of the audience prior to the session, we either encouraged the participants to move to tables with participants from similar settings at the start of the breakout sessions or encouraged them to work in mixed groups. We found that teams with similar backgrounds seated at the same table benefited from tackling a problem with similar underpinnings, whereas teams with different backgrounds benefited from unique perspectives. We made copies of the vignettes, workshop evaluations, resource sheets, and commitment sheets (Appendices B, E–G) in different colors and distributed them to each table before the start of the workshop. We positioned flip charts and markers at the front of the room to allow a facilitator to record ideas generated during the large-group debrief.

We began the workshop by introducing ourselves, the objectives, and the time line for the workshop using PowerPoint (Appendix A). In part, the success of the workshop relied on establishing a shared experience with the participants. Therefore, we emphasized our personal experience in working with learners in the community.

Depending on audience size, we asked participants to identify their specialty, their university or community affiliation, and the type and number of learners at their site through either personal introductions, a show of hands, or an audience response system. Our intent with this exercise was to help our participants identify collaborators and to allow us to gauge the makeup of the audience in order to focus the discussion to the groups' needs.

We asked participants to identify challenges that they faced (or could envision facing) when working with learners at their site. Our approach encouraged participants to draw upon their personal experience in order to normalize struggles such as patient volume, variable preceptor schedules, limited teaching resources, and competing demands. Next, we requested that the participants identify the advantages of community-based medical student education. This discussion was effective in building enthusiasm within our audience. Finally, we referenced literature explaining how teaching medical students at their community sites could add value.[13] In this way, we met our first objective of identifying opportunities and challenges for student education in the community setting.

We created three vignette-based, small-group, facilitated discussions with large-group reports to tackle common dilemmas related to (1) orientation and expectation setting, (2) clinical teaching methods, and (3) feedback and assessment (Appendix B). One of the facilitators introduced the case while another managed the time. We each joined a table to facilitate small-group discussion. We distributed the handout with the three vignettes and recruited a note taker and reporter from each small group. We allotted 10 minutes for each small-group discussion. In the event that participants were quiet, we used additional prompts from the facilitator's guide to encourage discussion (Appendix C). We reconvened as a large group and debriefed, asking the reporter from each table to summarize solutions generated. One of us recorded the solutions on a flip chart while the facilitator who initially introduced the vignette managed the discussion. The same large-group facilitator also wrapped up the report-out using PowerPoint to highlight specific tools and strategies (Appendix A). The second and third vignettes followed the same format. The second vignette included a brief skit emphasizing the 1-minute preceptor model, which was incorporated into the specific tools and strategies discussion (Appendix D).[14]

Toward the end of the workshop, we led a large-group discussion and introduced a few final resources and strategies. We concluded with a summary of the workshop's take-home points. In the final 5 minutes, we distributed workshop evaluations and a compilation of workshop resources (Appendices E and F). We encouraged participants to identify a barrier at their site and commit to adopting an educational strategy within the next 3 months (Appendix G). Participants were asked to take a photo of their commitment and save it as a reminder. We collected evaluations and commitment forms. Within the next 2 weeks, we sent each participant an individualized email to remind the participant of the barrier identified and his or her plan to adopt an educational strategy.

Our evaluation form (Appendix E) was designed by workshop facilitators and modified with each iteration of the workshop. We evaluated the success of the workshop with satisfaction scores. Initially, we evaluated the introduction, each of the breakout sessions, and the resource discussion on a 5-point Likert scale (1 = not at all effective, 5 = highly effective). For the most recent version, we asked participants to evaluate our success in meeting the educational objectives and in presenting relevant content. We encouraged narrative comments by asking several open-ended questions related to session strengths and opportunities for improvement. We also asked participants to identify a strategy, skill, or resource that would be useful at their site.

Results

We presented three iterations of this peer-reviewed workshop at national conferences. We collected anonymous evaluation data with each presentation and used the feedback to modify the workshop to reach its current form. There were at least 57 participants in total. The majority of attendees at the first two presentations described their role as being, at least in part, community hospitalists (87% of participants in 2016, 73% in 2017). More than half of the responding participants at the third presentation in 2018 practiced in the community as inpatient or outpatient providers (63%).

Workshop 2016

The first iteration of this workshop, presented at the 2016 Pediatric Hospital Medicine conference, had 33 attendees, with just under half returning evaluation forms at the end of the session (16 responses, response rate: 48%).[10] The evaluation form used a 5-point scale (1 = not at all effective, 5 = highly effective) to assess the perceived efficacy of each section of the workshop (Table 1). The breakout sessions were rated as most effective, and the section on establishing a pediatric student education program was the lowest-rated section.

Table 1.

2016 Pediatric Hospital Medicine Conference Workshop Evaluations (n = 16)

Statement	Ma
Introduction: challenges and opportunities	4.1
Establishing a pediatric student education program	3.6
Breakout sessions	4.3
Large-group report-out and discussion	4.1
Role of university-affiliated hospital	4.2
Developing a pediatric rotation in the community	4.1
Overall	4.1

aScores are based on a 5-point Likert scale (1 = not at all effective, 3 = neutral, 5 = highly effective).

Workshop 2017

The following year, based upon participant feedback, we updated the workshop for the 2017 Pediatric Hospital Medicine conference.[11] We made the breakout sessions the focal point of the workshop and removed the lower-rated portion on establishing a pediatric student education program. We shortened and interspersed didactic materials to enhance audience engagement. We obtained responses from 15 participants. We do not know the total number of attendees, and therefore, the response rate cannot be determined. We updated the evaluation form to reflect the reorganization of the workshop but otherwise utilized the same 5-point scale (1 = not at all effective, 5 = highly effective). Results are presented in Table 2. Additionally, Table 3 includes responses from 15 participants through the conference's online evaluation platform using a similar 5-point scale. Participants rated the workshop as highly effective at meeting learning objectives.

Table 2.

2017 Pediatric Hospital Medicine Conference Workshop Evaluations (n = 15)

Statement	Ma
Introduction	4.4
Breakout sessions
Orientation and setting expectations	4.5
Teaching techniques for variable census	4.7
Strategies for feedback	4.6
Additional resource discussion	4.9
Overall	4.6

aScores are based on a 5-point Likert scale (1 = not at all effective, 3 = neutral, 5 = highly effective).

Table 3.

2017 Pediatric Hospital Medicine Evaluations Provided by Online Conference Evaluation Platform (n = 15)

Statement	Ma
Content of presentation	4.5
Appropriately met the learning objectives	4.7
Quality and effectiveness of resources and references tools	4.6

aScores are based on a 5-point Likert scale (1 = not at all effective, 3 = neutral, 5 = highly effective).

Workshop 2018

Finally, we modified the workshop to its existing 90-minute version, which was presented at the 2018 Pediatric Academic Societies Meeting.[12] We lengthened the breakout sessions, included more examples of teaching methods, and broadened the scope to encompass all community providers, including those preceptors working in outpatient, inpatient, and newborn nursery settings. All nine participants completed the evaluation forms, which we updated to reflect the changes in breakout session topics but otherwise utilized the same 5-point scale (1 = not at all effective, 5 = highly effective; Table 4). Four participants completed the conference's online evaluation platform using a 5-point scale (1 = needs improvement, 5 = outstanding) and rated the workshop an average of 5 in answer to the question about whether the information was relevant and met objectives.

Table 4.

2018 Pediatric Academic Societies Workshop Evaluations (n = 9)

Statement	Ma
Introduction	4.8
Breakout sessions
Orientation and setting expectations	5.0
Clinical teaching methods	5.0
Feedback and assessment	5.0
Additional resource discussion	4.8
Overall	4.9

aScores are based on a 5-point Likert scale (1 = not at all effective, 3 = neutral, 5 = highly effective).

Narrative Feedback

Narrative comments were collected with each version of this workshop. Seventy-nine percent of respondents (11 of 14 respondents) from the first workshop identified the breakout sessions as the portion of the presentation during which they were most engaged. Additionally, many respondents commented that the teaching resources were valuable. Participants of the second workshop volunteered that the breakout sessions were most engaging (six of 11 respondents). One respondent said, “Small groups were great—awesome hearing different strategies from others in the group”; another mentioned that “excellent tools/ideas [were] discussed.” Narrative comments from the third workshop highlighted that participants were again most engaged during breakout sessions (seven of eight respondents).

There were fewer narrative comments regarding areas for improvement. Themes from the first workshop included a desire to hear about other teaching methods. Feedback from the second workshop included one comment to “welcome more specific examples of teaching methods” and another to “define each participant's exact teaching roles ahead of the discussion.” There were no narrative comments regarding areas for improvement from the third presentation of this workshop.

In the third iteration of this workshop, participants identified a specific medical education challenge at their clinical site and committed to using a strategy or tool from the presentation to address it. Examples of the commitments made by the participants as a result of the workshop included utilizing the 1-minute preceptor, incorporating the online educational resources into their group's teaching approach, and creating a standardized orientation for medical students to the community hospital rotation. Immediately following the session, we sent participants an individualized email reminding them of the barrier and change in practice they had identified. Six months after this workshop, we sent a follow-up email to participants asking about their progress. Among the nine participants, four responded to the email, all of whom had already started enacting a change. The respondents reported creating an orientation email for residents, incorporating online resources into the existing educational structure, and establishing a standard community hospital orientation for trainees.

Discussion

Preceptors teaching in the community face different barriers and often lack the educational support of their university-affiliated colleagues, necessitating faculty development materials specifically geared toward providing effective techniques to precept in the community setting. This workshop pulled from existing literature on medical education in a variety of settings and focused on providing specific resources and strategies for community preceptors. The workshop topics also aligned with the AMSPDC/COMSEP Task Force recommendations for community preceptor faculty development, such as rotation goals and objectives, orienting learners to a rotation, giving feedback, and working with challenging learners.[7] Participants with varied practice settings, institutional affiliations, and years of clinical experience added to the richness of the discussion and diversity of proposed solutions. Over the three iterations, participants consistently rated this workshop as highly effective and engaging.

After each presentation of this workshop, breakout sessions were lengthened, with short bursts of didactics interspersed. This was based upon participants' feedback and done in an effort to accommodate principles of adult learning focusing on problem-based learning about topics immediately applicable to participants' work. We placed an emphasis on reflection and encouraged participants to identify a barrier within their institution and a strategy that they could employ to address it. The resource sheet remained highly rated and was also tailored over time to include high-yield tools to improve education at community sites.

One limitation of our data was our small audience at each presentation. A more accurate interpretation of this workshop's successes or shortcomings would be possible with a larger sample size of various types of community providers. Despite the small number of participants at each presentation, we were able to gather a large amount of feedback over time. In addition, although this workshop was developed and presented by pediatricians in the community setting, the approaches discussed can be easily adapted to other medical specialties. Future work may consider expanding the scope to other specialties and other learners, such as residents, advanced practice provider students, or nurses.

The dissemination of this workshop is one way to facilitate faculty development for pediatric community preceptors and may be useful to educational leadership when recruiting new staff or providing support for existing preceptors. However, we recognize that many community providers may not have the ability to attend such conferences. Based on the success of this workshop with audiences of various sizes and participants with different practice settings, we hypothesize that it could be adapted to the needs of presenters who travel to individual practices. Furthermore, making this workshop available online and accessible to community preceptors for use on their own time may be helpful in cultivating teaching skills for individuals within their unique community setting.[8] However, we acknowledge that the efficacy of this workshop as an online individual resource or practice-based small-group session has not been evaluated. Future directions could include evaluating the modification and subsequent use of this workshop in other settings such as in smaller practices or as a reconfigured online module for preceptors to complete independently.

Our workshop evaluations reported satisfaction-level data. We recognize our limited success in gathering higher-level evaluation data when inquiring whether preceptors had implemented a new tool or strategy learned in this session. In the second and third workshops, we asked participants to commit to adapting a tool or strategy and attempted to evaluate this commitment and practice change in the third iteration. In the future, our evaluation process could go one step further by asking participants to outline a plan for achieving their proposed change and by offering incentives for sharing their progress, successes, and barriers in implementing their proposed change with the facilitators. Additionally, decreasing the interval of time for subsequent follow-up to 3 months and sending reminder emails may improve the response rate and the number of participants who follow through on their plan to change practice.

Overall, this workshop addresses a gap in faculty development by specifically targeting pediatric preceptors who teach medical students in the community. Its value lies in providing efficient strategies and resources for these preceptors in an enjoyable, engaging, and solution-driven format. Despite the small audience size at each presentation, over time this workshop had both a sizable number of participants and feedback, allowing it to be honed into a very effective learning tool.

A. Workshop PowerPoint Presentation.pptx

B. Breakout Session Vignettes.docx

C. Breakout Session Facilitator Guide.docx

D. Skit for Teaching Methods.docx

E. Workshop Evaluation.docx

F. Suggested Educational Resources.docx

G. Commitment to Practice Change.docx

All appendices are peer reviewed as integral parts of the Original Publication.