The ambulatory teaching site characteristics most valued by clerks and residents are having an adequate number and variety of patients while being supervised by enthusiastic and available preceptors. These characteristics have been identified before and are well summarized by Bowen and Irby [19
]. Little value is placed on having other trainees in the clinic despite social learning theory that suggests this enhances learning. Bowen [20
] and Lesky [21
] suggest that students learn by teaching and may feel less threatened asking questions that reveal a lack of knowledge of a fellow student than of a preceptor. Although what students value may not translate into effective learning, it is still important to understand why something is valued or not valued. Without reliable learning outcome measures perceived learning value is a proxy measure of learning effectiveness. Further studies should assess what learners do not like about having other trainees present.
Computer resources were more valued than books, likely reflecting a generation of learners who are comfortable accessing electronic information. Proximity of the clinic to university campus was unimportant. In contrast to other studies [22
] we found block rotations were valued more than longitudinal rotations. Some programs, particularly Canadian Family Medicine programs, encourage longitudinal rotations to enhance the continuity of care experience. Merenstein et al [25
] however recently reported there to be no difference in continuity of care provided by residents in longitudinal rotations. Exploration of the value of block versus longitudinal rotations is an area for further research.
Valued preceptor behaviours identified in this study are feedback by enthusiastic, open preceptors who are willing to discuss their reasoning processes and delegate responsibility. Recent studies report 3rd
year medical students to also value these preceptor behaviours[26
]. Lesky and Borkan [21
] suggest that pathogenesis and natural histories of disease can be learned from a variety of resources, including books and computers but problem solving, decision making and dealing with uncertainty are learned mainly from preceptors and practice. This study supports students' perceived value of these aspects and suggests them as priorities for teachers in ambulatory settings.
We have confirmed the value of feedback found in most studies [26
] (a study by O'Malley [32
] being the exception). As one respondent commented "constructive and honest feedback in a timely manner is by far the most important (item)". Feedback leads to positive learning outcomes. Cope [33
] demonstrated that giving feedback to residents improved their patient satisfaction scores, which in turn has been correlated with improved patient outcomes[34
]. Unfortunately this teaching behaviour is underutilized. Irby [1
], in a review of studies, reports that feedback is given only 3–6% of the time (range 0–16%). This is an effective teaching behaviour that is valued by students and deserves high priority.
Meaningful feedback about many aspects of students' patient care is best based on direct observation[35
]. Only 61% of our respondents actually value direct observation by their preceptors. Some of the reasons for more not valuing this may be similar to why students do not want to be taught in front of the patient (see next section). Since direct observation is a necessary component of good teaching it will be important to explore further why more students do not value this important preceptor behaviour.
A number of strategies have been suggested to improve efficiency in the ambulatory teaching setting including teaching in the patient's presence and preceptors directing tasks to be covered in the interview [36
]. A significant proportion of our respondents rated reviewing the case and teaching in the patient's presence, structuring the interview by providing patient information background, outlining tasks to be done during the interview and focusing on one teaching theme per clinic not only to be unimportant for learning but detrimental. Kernan similarly found 3rd
year medical students to not value being taught in front of the patient[26
]. Comments from students in this study give some indication why teaching in front of the patient is disliked ("it would undermine a therapeutic alliance with the student", "it gives a tense atmosphere more often than not", "...impairs free thinking of student because student feels inhibition in front of patients", "makes it difficult for students to ask questions, not wanting to scare/worry the patient"). Teaching however occurs within a larger context where providing background information on patients may be necessary for ongoing patient care and safety and to model continuity of care. Teaching in the patient's presence may be necessary for efficiency and maintaining a relationship between the preceptor and the patient.Further studies are needed to determine if explanation or teaching methods can overcome this aversion.
Analysis of the impact of gender, school, level of training or residency on valued site characteristics and preceptor behaviours revealed striking uniformity between the groups. There were some statistically significant differences between the groups, many of which do not appear to be educationally relevant, others which likely are important.
Male and female students rank ordered site and preceptor behaviour factors identically. It is of interest that female students ranked all factors, with the exception of teaching in the patient's presence, as being more important for learning than male students. The literature [39
] suggests that women predominantly emphasize relationship issues, which may partially explain this finding. It would appear however with respect to the items surveyed that there are no gender-based educationally important differences in valued site characteristics and preceptor behaviours.
The five schools also essentially rank ordered the factors identically. One school did stand out from the others in frequently ranking factors significantly higher than the rest. This school is the largest of the five schools with the most trainees and teaching sites. It would be valuable to know the ratio of students to preceptors at the different schools. If this were high at the larger school, perhaps resulting in residents feeling relatively anonymous, it may partially explain why these students there particularly value factors like learning climate, professional role modeling and clinic set up.
Within level of training preceptor interaction is most important for clerks. This is the only group to rank this item more important than patient logistics. This may reflect the clerks' developmental stage of being eager to go beyond textbook lists and start to put clinical decisions into patient context–skills best learned by preceptor interaction. Learning resources are significantly less valued by those at either end of their training–clerks for perhaps the above reason and PGY6's/fellows presumably because they are confident in their theoretical knowledge. Beyond clerkship patient logistic factors usurp preceptor interaction as the highest ranked site characteristic. Becoming an expert clinician involves, in part, connecting disparate units of knowledge into networks [3
]. This encapsulating of knowledge occurs when students learn with patients. The residents in this study recognize this, ranking seeing an adequate and large variety of patients independently as the most important site characteristic for their learning. Having objectives defined with efforts made to meet them was third in importance for most levels, superceding available learning resources, office management skills instruction, and clinic setup items. Office management instruction is relatively more important for PGY2's and those at the end of their training. Subanalysis of the PGY2 data removing family medicine residents who would be at the end of their training and leaving those in the middle of their training significantly decreased the importance of office management and health care system interaction instruction. Teaching these aspects thus seems most important for those at the end of their training. Directing the clinical encounter and teaching in the patient's presence is valued less as residents gain seniority and presumably identify themselves more as the patients' physicians. Increasing desire for autonomy and decreasing potential for undermining their relationship with the patient may be reasons for these trends.
Within almost all residencies patient logistics and preceptor interaction are the most valued site characteristics; feedback, teaching and learning climate the most important preceptor behaviours. Lab/path, radiology and anaesthesia residents value all these preceptor behaviours less than other residents. Arguably these are areas of medicine where decision making is more clear-cut without as much patient input, which may explain these results. Other significant differences between the specialties seem best explained by considering future practice ie: office-based specialties (paediatrics, psychiatry, family medicine) most valuing office management and health care system interaction instruction.
Strengths of this study are the large multi-institutional sample size (n = 1642) encompassing students at multiple levels in all specialties. The response rate (48%) limits the external validity of the result. A confounding factor within the level of training data set may be the variability in residency lengths as suggested by the subanalysis of the PGY2 data. Rather than years from graduation from medical school what seems to influence valued site characteristics and preceptor behaviours more are years from independent practice.