Site Visits in Family Medicine: Stakeholders Perspectives on How Site Visits Can Be Improved to Maximize Preceptor Support and the Quality of Medical Student and Resident Supervision

doi:10.4236/ce.2013.46A006

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Creative Education

2013. Vol.4, No.6A, 29-38

Published Online June 2013 in SciRes (http://www.scirp.org/journal/ce) http://dx.doi.org/10.4236/ce.2013.46A006

Site Visits in Family Medicine: Stakeholders Perspectives on How

Site Visits Can Be Improved to Maximize Preceptor Support and

the Quality of Medical Student and Resident Supervision

Colla J. MacDonald1*, Edward Seale2, Douglas Archibald2,3, Madeleine Montpetit2,

David Tobin2, Michael Hirsh2, Martha McKeen3

1Faculty of Education, University of Ottawa, Ottawa, Canada

2Department of Family Medicine, University of Ottawa, Ottawa, Canada

3Bruyère Research Institute, Ottawa, Canada

Email: *[email protected]

Received April 23rd, 2 0 1 3 ; revised May 24th, 2013; accepted May 31st, 2013

mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, pro-

vided the original work is proper ly cited.

In 2012, the Department of Family Medicine at the University of Ottawa conducted a study to identify

stakeholder’s perspectives of site visits and how they can be improved to support preceptors and provide

the best learning experience for medical students and residents. Two data sources were utilized to address

the research questions: interviews with stakeholders (both focus group and individual interviews) and

online surveys with preceptors. The findings assert that establishing a process for site visits to maximize

preceptor support and the quality of medical student and resident supervision is a complex process. Per-

ceptions of quality site visits for all stakeholders were strongly linked to: 1) having clear expectations; 2)

making site visits a priority and supplying the necessary support and resources; 3) supporting preceptors

to be better teachers; 4) the quality and timeliness of preceptor feedback from residents and medical stu-

dents; 5) involving the medical student and resident in the site visit process; and 6) an integration and

collaboration among curriculum, faculty development and evaluation resources. As researchers continue

to build site visit recipes based on theory and reflection of practical experiences, the resulting insights will

enable all stakeholders in family medicine programs to make more informed decisions to positively im-

pact the quality of the site visit experience, support preceptors in being better teachers and improve the

quality of the supervision of residents and medical students. This study takes one step toward building a

broad base of theoretical knowledge informed by practical experiences on site visits.

Keywords: Site Visits; Family Medicine; Preceptor; Resident; Medical Student; Rural Community Site;

Urban Community Site; Quality Standard

Introduction

As family medicine programs across Canada continue to

grow and accept more medical students and residents in re-

sponse to a shortage of family physicians, finding sufficient

medical educators to provide effective learning experiences has

become an ongoing challenge. As a result, Canadian medical

schools have been expanding both undergraduate clerkship and

postgraduate rotations into rural and community medical of-

fices, clinics and hospital settings. A study by Bianchi, Stobbe

and Eva (2008) demonstrated that medical students and resi-

dents who learn in rural and community environments are in no

way experientially disadvantaged. First, community and rural

medical clinics and offices typically encounter a wide variety of

patients with complex issues and problems and therefore ex-

pose learners to a broad range of patients and rich learning

experiences. Second, students and residents in rural and com-

munity settings claim close relationships with preceptors, a lot

of hands-on opportunities and involvement, and experiencing

continuity of care. Finally, early exposure to rural community

settings during clinical education increases the likelihood that

these learners will stay and practice medicine in these under-

served areas helping to correct the family physician mal-dis-

tribution in rural communities (Bianchi et al.; Curran & Rourke,

2004; Denz-Penhey et al., 2005; Veitch et al., 2006).

Challenges

Supporting community and rural preceptors to ensure they

are well equipped with exceptional clinical and pedagogical

skills to provide excellent learning experiences for medical

students and residents has become a formidable challenge for

academic departments. While many community and rural based

preceptors often find great satisfaction from teaching, super-

vising a learner in these environments can be demanding. The

presence of medical learners can detract from the efficiency of

a physician’s office (Latessa, Beaty, Colvin, Landis, & Janes,

2008; Sargent, Osborn, Roberts, & DeWitt, 1993). Similarly,

Pololi and Knight (2005) outlined challenges preceptors face

*Corresponding author.

C. J. MACDONALD ET AL.

related to the “changing nature of the current health care envi-

ronment” including increased administrative and clinical re-

sponsibilities coupled with “reductions in time and collegial

support for scholarly activity and teaching” (p. 866).

Site Visits Solution

Site visits are one mechanism employed by family medicine

programs to offer support to preceptors and monitor quality

control of the teaching experiences for medical students and

residents in community and rural sites. Suzewits (2002) out-

lined the purpose of the site visit in ten objectives. In summary

Suzewit suggests the site visit process involves 1) the assess-

ment of the learner’s progress in the clinical setting, 2) con-

ducting a tour of the learning environment, 3) providing a fo-

rum for introductions (the preceptor to the departmental staff

and vice versa), 4) educating and informing preceptors of new

teaching methods and tools, 5) supporting ongoing dialogue

regarding preceptors needs and departmental initiatives, 6)

evaluating the resident’s performance and suggest effective

feedback options to the preceptor, 7) providing rotation specific

feedback to the medical student or resident, 8) to obtain pre-

ceptor opinion or feedback concerning departmental policies or

strategies, 9) to find resolution to problems involving a number

of issues including finances, professional or personal issues and

10) career planning. Moser, Dorsch and Kellerman (2004) de-

scribe the site visit process as having the propensity to elimi-

nate the “town-gown syndrome” and build “ivory bridges not

ivory towers”. Thus, a goal of the site visit process is to act as a

mechanism to increase cohesion and promote a sense of inclu-

siveness throughout the entire faculty population.

Stearns, Hemesath and Londo (2000) explain that “for each

precepting experience, the sponsoring department or program

should provide a set of explicit and accomplishable goals, ob-

jectives, and expectations” (161). In addition to relaying im-

portant departmental expectations and policies, the site visit

allows for the development of a mentor-mentee relationship

between the preceptor and the academic staff performing the

site visit. Typically the site visit involves a dyadic mentorship

model (one preceptor with one resident) although some pro-

grams have developed collaborative mentorship models in-

volving groups of preceptors who form a supportive network

where ideas are shared and issues are resolved collaboratively

(Pololi & Knight, 2005). According to Bhagia and Tinsley

(2000) the mentor-mentee relationship is ideally characterized

by support, investment and inspiration. Mentorship can aid

preceptors in clarifying their value as an educator, planning

their academic career, developing useful relationships and

pedagogical skills, and providing incentive to continue in aca-

demia (Pololi et al., 2002). Peer coaching is another effective

form of mentorship that can involve co-teaching and the ena-

bling of independent preceptor learning (Steinert, 2005).

Feedback is an important aspect of mentorship and peer

coaching and a key component of the site visit process. Steinert

et al., 2006 have found evidence suggesting “systematic and

constructive feedback [to preceptors] can result in improved

teaching performance” (p. 519). Elzubeir and Rizk (2002)

called for increased focus on formative approaches to faculty

evaluation that include regular feedback and opportunities for

faculty development and mentoring. Langlois and Thach (2003)

suggested the site visit process cater to many different types of

preceptors with varying levels of clinical and educational ex-

perience. Wilkerson and Irby (1998) define four different stages

of preceptor involvement in educational careers: 1) entry level

teachers who are refining their skills and orienting to academic

values, responsibilities and expectations; 2) teachers with

greater pedagogical skill and content knowledge; 3) educational

leaders who may direct programs; 4) teacher-scholars who ap-

proach educational issues of process and reform. Those who

facilitate site visits must be equipped with an array of skills

necessary to cater to the needs of many different preceptors.

Chew et al. (2003) recommended the development of multifac-

eted strategies while Malik et al. (2007) suggested better train-

ing for site visit facilitators and increased administrative and

financial support to ensure site visits are well planned, efficient

and effective.

Purpose of the Site Visit

Along with expanding Canadian Family Medicine programs

comes the need to develop monitoring processes and protocols

for decentralized teaching environments to ensure quality

learning experiences that meets the College of Family Physi-

cians of Canada’s (CFPC) accreditation standards. Bianchi et al.

(2008) elaborate:

… finding acceptable methods of [continuous quality im-

provement] CQI of community-based teaching opportuni-

ties is a recurring theme in the literature; however, authors

have not described a standardized strategy for program

administrators to design, implement, or monitor the use-

fulness and acceptability of these CQI programs (p. 466).

Although site visits are an accreditation requirement man-

dated by the CFPC, the site visit protocol appears flexible and

left to the discretion of each Department of Family Medicine

(DFM). At the University of Ottawa (U of O) DFM, site visits

are designed to have a faculty representative visit the preceptor

for approximately one hour (usually over lunch), every two

years. The purpose of the site visit is not to ‘police’ the precep-

tor but rather to provide support, resources and teaching strate-

gies so preceptors are equipped to provide the best possible

learning experience to the medical student or resident.

However, the faculty representatives at the DFM at the U of

O expressed concerns regarding the effectiveness of the site

visit. Moreover, faculty reps reported they suspected many

preceptors shared their concerns. Therefore, the purpose of this

research project was to first, document stakeholders perspec-

tives of the state of site visits in the DFM; and second, to solicit

feedback from stakeholders on how site visits can be improved.

By sharing our experiences, we hope that other DFM can draw

from our suggestions and lessons learned.

Methods

The following research question served as a guide to obtain

an understanding of the current state of site visits in the DFM

and how they can be improved, “How can the Department of

Family Medicine urban community and rural community site

visits be improved to maximize preceptor support and the qual-

ity of medical student and resident supervision?” Four sub-

questions assisted in obtaining the answer to the overarching

question:

 How do stakeholders describe the purpose of site visits?

 How do stakeholders describe the strengths of site visits?

C. J. MACDONALD ET AL.

 How do stakeholders describe the shortcomings of site vis-

its?

 How do stakeholders suggest site visits could be improved?

Two data sources were utilized in this research project to ad-

dress the research questions: interviews with stakeholders (both

focus group and individual interviews) and online surveys with

preceptors. Stakeholders were identified by the three faculty

representatives and included the preceptors in urban community

and rural practices, the two co-directors of site visits, the cur-

rent interim chair who formerly was responsible for site visits

in the DFM undergraduate program, and the site coordinator

who is an administrator who supports the organization of the

site visits. All preceptors in this study had supervised post

graduate residents which require supervising a resident for two

years. Some of these residents but not all had also supervised

medical students for one month rotations or clerkships.

Focus Groups and Interviews

Seven interviews were conducted with site visit stakeholders

(three individual and four focus groups) with a total of fourteen

participants. The fourteen participants included ten preceptors

representing both rural and communities teaching sites, two

co-directors of site visits in the postgraduate program, the in-

terim chair of the DFM (who was a former faculty site visit

faculty advisor in the undergraduate program) and the coordi-

nator of site visits. Preceptor experience ranged from two to

twenty years. The three individual interviews lasted an average

of 40 minutes and the four focus group interviews lasted an

average of 60 minutes. All interviews were audio recorded and

transcribed verbatim. For a copy of the interview protocol, see

Appendix.

Surveys

The purpose of the online survey was to obtain preceptors’

perspectives on the research question from a broader population

than the focus group interviews permitted. A brief survey was

developed which included (four demographic questions and 10

open-ended questions). The survey was housed on Survey

Monkey™. All rural and community preceptors (N = 65) were

sent the survey. A total of 14 preceptors completed and re-

turned the surveys representing a response rate of 22%.

A reminder email was sent one week following the first

email. A total of 14 preceptors completed and returned the sur-

veys. There was an even split of urban community preceptors

and rural community preceptors. Ten of the preceptors had five

or fewer years teaching experience and only one had more than

20 years. Eight of the 14 preceptors had supervised five or less

residents in their careers and eight had supervised more than 10

medical students.

Findings from the Focus Groups, Individual

Interviews, and Surveys

Qualitative data analysis was guided by Merriam (1998) and,

Bogdan and Biklen (1998). The interview transcripts were

checked for accuracy by the researcher listening to the audio

recording (mp3 file) and comparing them to the transcribed text.

Open coding of the text was then performed by hand. After a

preliminary list of codes were developed the transcripts were

coded a second time to group common codes together to form

themes. The co ding was reviewed several more times t o ensure

that no new codes emerged from the data. Once the themes

reflected “the recurring regularities or patterns in the study”

(Merriam, 1998: p. 181), and the researcher was satisfied the

themes reflected the needs and views of the participants, the

data were assigned to categories to provide rich, detailed, and

comprehensive information that would answer the research

questions.

Relevant information from the emerging themes were used to

weave a story from multiple stakeholders’ perspectives por-

traying the current state of site visits in the DFM and how site

visits may be revised to support preceptors in providing a posi-

tive learning experience for residents and medical students.

Direct quotations are used throughout this paper to allow par-

ticipants’ voices to be heard and to obtain objective evidence

regarding the participants’ perceptions of the site visits. All

interview participants were provided a copy of the qualitative

data analyses to ensure the interpretation was according to their

intentions and perspective. Interview participants were pro-

vided an opportunity to adapt, remove or elaborate on any

quote or text that misrepresented their perspective. One pre-

ceptor made minor edits to the analysis report.

The findings from the interviews are organized under the sub

research questions purpose of the site visit, strengths, short-

comings and improvements.

Purpose of the Site Visit

The five themes that emerged regarding the purpose of the

site visits were: Teaching Environment; Support, Preceptor’s

Experience, Affirmation and Quality Assurance.

Teaching Environment

When asked about the purpose of the site visit, both

co-directors and the preceptors agreed one purpose is to make

sure preceptors have the right layout and teaching environment

to accommodate a resident or student. There appeared to be a

common understanding among stakeholders that having the

right layout implies the teaching environment is physically and

operationally appropriate and conducive to teaching and learn-

ing. For example, a proper layout would consider the office

layout, patient profile, staff mix, resources available). However,

no clear description of an appropriate layout for effective

teaching and learning currently exists in the program. One

co-director elaborated:

The purpose has been based on what has happened in the

past … visit usually over lunch for approximately an hour.

Inspect the place of work that the resident is in. Then sit

with the preceptor and discuss how things are going with

the resident. We talk to him about what’s happening with

faculty development, new things happening in the de-

partment, how we can help.

Preceptor’s perspective of what occurs during a site visit was

similar to the co-directors.

We tell them how our practice has changed. How many

physicians we work with? Do we offer OB [obstetrics]?

Minor procedures? How many nurse practitioners, dieti-

cians we have? Who we work with? What we offer.

Similarly, preceptors elaborated both in the interviews and

on the surveys that the site visits provide an opportunity to have

fresh eyes review their teaching site and to ensure the sites are

C. J. MACDONALD ET AL.

set-up for teaching residents.

Support

Interview participants agreed creating a liaison between the

DFM and the community and rural teaching sites is one pur-

pose of the site visit. The site coordinator pointed out the site

visit allows for a sense of connectedness between the DFM and

the community and rural practices. “There is a tendency for

community preceptors to feel quite isolated. Having the co-

directors physically visit their different community sites allows

for the preceptors to feel more a part of the department”. Al-

though all interview participants agreed that one of the pur-

poses of the site visits was to liaise, there were mixed percep-

tions from preceptors regarding the amount of support they

receive. An experienced preceptor revealed she felt the DFM

was very supportive when she had a resident in difficulty.

My resident needed more exposure to acute care commu-

nity practice. So I sent the individual to the urgent care

clinic for a month. To pick a colleague with a specific

practice profile or specific learning setting and have our

residents go there to do extra work is very valuable.

Other preceptors felt the support was available from the

DFM if you knew how to access it. One preceptor shared,

“Sometimes the support is very good, but you have to know

how to search it out”. A second preceptor shared, “The support

is not there if you don’t go looking. But it is amazing what they

will do for people”.

Preceptor’s Experience

The co-directors stipulated if the preceptor has never had a

resident or medical student before, or they are inexperienced,

the purpose of the site visit is different than if the preceptor has

years of experience supervising residents and/or students.

Similarly preceptors pointed out that there could be a difference

in the purpose of the site visit if the preceptor has a resident or

student in difficulty or if the preceptor continually receives

poor evaluations from the resident or student. “If they are going

along swimmingly and there is no problem then why bother

them? Whereas Joe Blow with his third sub-par evaluation, the

site visit is a forum for communication”.

Affirmation

For one preceptor a purpose of the site visit is affirmation

that they are doing a good job. Another preceptor explained, “I

didn’t really gain anything from the site visit per se, except for

a confirmation that what I was doing was a reasonable type of

practice and the training I was doing was appropriate”. The

interim chair described the purpose of site visits as:

… part PRs part feedback… validate by showing up,

waving the flag, giving them credit for what they do …

giving feedback; letting them know what is going on at

the university, trying to offer some sort of faculty devel-

opment … There are many differing thoughts in this

statement … needs to abridge to assure desired focus.

Quality Assurance

All stakeholders identified site visits as a quality standard

mechanism to ensure consistency across teaching sites. Simi-

larly, the site coordinator reported that one purpose for site

visits is to safeguard that all residents and medical students

have the same learning opportunities. The site coordinator ex-

plained site visits were also necessary for accreditation and to

ensure quality. “The department via the co-directors need to

have a good understanding of who their preceptors are and the

learning opportunities their residents are exposed to at the var-

ious teaching sites”.

Strengths

Two themes emerged regarding the strengths of site visits:

Communication and Enjoyment.

Communication

According to the co-directors, a strength of site visits is pro-

viding a ‘face’ to the DFM. The co-directors believe preceptors

feel respected and valued when representatives from the DFM

take the time to visit. “There is a sense of mutual respect which

is important to foster relationships”. Similarly, the interim chair

suggested the site visit was, “... personal face-to-face time with

someone from the university so you connect and offer an ele-

ment of feedback [based on learner evaluations]”. One survey

respondent indicated, “[The visit] gives me as a community

preceptor the ability to interact directly with the community

director and give and receive direct feedback”.

The co-directors reported site visits provide a mechanism to

share teaching tips between and among sites. They stated they

pick up effective teaching strategies from one site and commu-

nicate these strategies to other sides. One co-director shared,

“Sometimes we pick up things that are very useful and we can

say ‘we visited so and so and they dealt with your problem this

way’. So actually going there is a good way of passing it on”.

Some preceptors agreed that an advantage of the site visits was

sharing knowledge among sites. In the words of one preceptor,

“It is cross-pollinating knowledge between different sites”.

Enjoyment

When asked why they take residents and students the pre-

ceptors didn’t hesitate to reveal they do it because they enjoy it.

We enjoy it. If I didn’t like it, I would have probably tried

it for two years and then said “I am out”. If my first few

residents were poor then I probably would have bailed

because they could ruin things.

Another preceptor reported she took residents and students

because she loved teaching. She elaborated, “it is fun, chal-

lenging, rewarding and keeps you on your toes”. A third pre-

ceptor stated she took residents because, “… she is a better

physician for having had residents”. Preceptors elaborated that

having a resident or student also provides them with a break

from their routine. “Like anything else even after the challenge,

I think most of us sign on because we enjoy it”.

The interim chair supported that those who consistently take

a resident or student, do so because they enjoy it and love to

teach. “I think the people who have chosen to be full time

teachers … are self-selected. These are people who like to teach,

like the idea of having a resident around, like to be involved

with the university”.

Shortcomings

The eight themes that emerged regarding the shortcomings of

the site visits were: Expectations; Co-directors Role; Scheduling;

C. J. MACDONALD ET AL.

Compensation; Time; Inconsistency, Resources and Preceptor

Assessment.

Expectations

Preceptors pointed out what is not made clear when taking a

resident/student is the amount of paper work and time required

to do evaluations.

What you don’t know going in is all the evaluations re-

quired. You have to go to SOOs [structured office oral

exam]. There is an expectation that you go to ITER

[in-training examination report]. They come and do site

visits, department meetings. That should be told ahead of

time so there are no surprises.

There does not appear to be clarity on expectations for seeing

patients during the resident’s rotations. The resident’s schedule

appears to be organized by the preceptor. Some preceptors re-

ported they see exactly the same number of patients whether or

not they have a resident or student. Other preceptors said they

try to book fewer patients when they have a resident. One pre-

ceptor explained, “I try to book a little less especially when my

resident is on their half-day back”. Other preceptors reported

they set up a schedule for learners to have their own patients.

One preceptor suggested that more direction on how best to

schedule patients while supervising a resident would be helpful.

“One thing they [co-directors] have never asked me and I al-

ways thought they should is how many people I am seeing per

hour and whether there is a volume that might not be the best

for a teaching environment”.

The interim chair pointed out that benchmarks for what resi-

dents and students should know at various points in their pro-

gram are not made available to guide preceptors in their teach-

ing. Preceptors reported they would like to receive a manual or

have a web page they can go to outlining the DFM’s expecta-

tions of them. Another preceptor clarified that she attended an

orientation session but it was six months into the whole process

when she had already been teaching.

Co-Directors Role

The co-directors admitted they sometimes doubt the value of

conducting site visits as they do not perceive themselves any

more knowledgeable or proficient at teaching residents and

students than many of their peers. The co-directors were hum-

ble sharing they are not expert teachers, and other than creating

a liaison with the DFM they too questioned the value of the site

visit. Similar to what the preceptors said, the co-directors re-

vealed that when the preceptor is experienced and has no issues,

the site visits seem a little trite and somewhat superficial. One

co-director stated, “We [the co-directors] feel we are equal to

the preceptors. So there is the imposter syndrome. To fulfill

their [preceptors] needs maybe we are not the right people”.

One of the co-director explained his dilemma with the site vis-

its:

For some I get the feeling it is really good. I have made a

connection and they understand what is going on. For the

ones that have been doing this for a long time, I feel bad

I’m taking their time because I don’t know how much

they are getting out of it.

The co-directors stated the heart of the problem is that the

preceptors are their colleagues. In some instances they have

worked together or were classmates. In most situations, co-

directors didn’t feel they were in a position to help their col-

leagues become better teachers. “When the discussion comes

around to setting learning plans, I don’t know how to do that. I

am absolutely not a resource to them. Some things I can [help],

or I can refer them to somebody”.

Scheduling

When asked what the shortcomings of the site visits were,

the co-directors explained that coordinating schedules was

complicated and pinning down preceptors to commit to a time

for a visit was often a challenge. “I wish they [site visits] were

consistent and scheduled. It always seems like a barrier and I

don’t know on whose part. Scheduling of the site visits needs to

be prioritized if it’s felt to be a priority”. Scheduling issues

were identified by six of the fourteen survey respondents

Compensation

For a few preceptors, one complaint communicated regarding

site visits was that the stipend they receive for having a resi-

dent/student doesn’t cover their costs. One preceptor explained

that she is on salary. She does not receive the stipend but rather

it goes back into the centre. For most preceptors teaching is not

about being remunerated. In the words of one preceptor, “It is

not the compensation. It is the wasted time because the time in

your day is so valuable. It is I can’t believe they have spent an

hour to do this. I sit and go ‘everything’s fine’”.

Time

One of the biggest drawbacks of site visits for everyone in-

volved was the time they demand. The co-directors are physi-

cians who run their own family medical practice. Their director

position is one day a week and during that time they are often

required to attend meetings at the DFM. The co-director’s iden-

tified meetings and administrative responsibilities as a barrier to

conducting site visits.

The meetings get in the way of site visits. Meetings that

have nothing to do with community doctors. Sitting on

advisory committees and executive committees probably

take on average about half the working day.

The co-directors reported they could be doing a better job if

there were fewer meetings and administrative responsibilities

attached to their role. “I would like to be on the phone with

them, out visiting them, seeing how things are going, asking

them if they have problems, reacting if there are problems.

Otherwise they get fed up”.

Some preceptors complained the site visit took time away

from their patients. Others felt that when they did spend time

communicating things that could change, nothing happened. In

the words of one preceptor, “Time consuming if we are just

going through a checklist with no change. Every year we give

them ideas of what needs changing and then nothing happens”.

The surprise for some preceptors was that in addition to eve-

rything else they found out after the fact that they were respon-

sible to supervise a research project. In the words of one pre-

ceptor:

I found out from my resident that they can do a research

project with you and that is more work. That was not in

the contract. I am sitting at home on my computer on Sat-

C. J. MACDONALD ET AL.

urday night doing this online course to get this certificate

to submit to the university so I can supervise him. That is

above and beyond.

Preceptors stated that five years ago the research projects

became “way too big”. A second preceptor agreed and pointed

out that now the research project required the resident to do a

review of literature on top of everything else. Another preceptor

said he didn’t mind the project was big but what she found

frustrating was, “all the hoops they have to jump through now”.

Inconsistency

One issue broached by several preceptors and supported by

the site coordinator and the interim chair was that the commu-

nity and rural preceptors have a very different experience than

preceptors who teach in the units. In the words of the site coor-

dinator:

The first priority of a community physician is their prac-

tice. A resident can detract from their business because

they need to spend more time with the resident. It has an

impact on their finances. Unit preceptors have a different

funding arrangement. It is just a differen t situation.

Preceptors discussed that it is often extremely time consum-

ing to have an International Medical Graduate (IMG). Precep-

tors suggested that IMG residents require a lot of one-on-one

supervision and support they are more likely to receive in the

community than in a unit. “If they [residents] are in a unit with

a group of preceptors things get lost and no one takes owner-

ship or responsibility the way you do one-on-one with your

resident”. One preceptor suggested a reason she devoted so

much time to supervising residents was to ensure her patient’s

safety, “I am just obsessive that they’re going to do something

wrong and hurt my patient”.

Resources

When asked what resources the preceptors are currently re-

ceiving, the co-directors reported they provide the preceptors

with a list of faculty development sessions available, the names

of the people in the DFM who might be helpful to them and

they answer questions based on preceptor needs. “We try and

provide them with that sort of information”. The site coordina-

tor elaborated on the resources provided to Post Graduate full

time preceptors:

Community preceptors get funding annually for profes-

sional development. They can receive funding from the

department for AV equipment. If they have a resident they

are compensated. They are invited to faculty development

sessions, curriculum development events, the faculty re-

treats and dinners. They have funding for attending con-

ferences. There are perks for sure.

All preceptors who have full time residents are eligible to

have video equipment supplied to them by the DFM. One pre-

ceptor had the equipment but admitted he rarely used it because

it required getting the patients permission. Those preceptors

that used the video equipment were adamant that it was a valu-

able teaching tool. One preceptor explained:

It [the video] is a fantastic tool. The minute I am in the

room the dynamic between the resident and the patient

changes. We sit down at the end of the day and review

two or three. They pick up on things they need to change.

The preceptors stated that the video equipment made it easier

to provide the resident with constructive feedback. When the

residents saw their behaviour, preceptors felt they better under-

stood the message they were trying to communicate. One pre-

ceptor shared, “If you just tell them something they can be de-

fensive. When they can actually see it on videotape, you say to

them “do you notice how often you are doing such and such,

what do you think about that?”

Preceptors suggested they needed to share resources and in-

formation about supervising residents and students with one

another. One experienced preceptor suggested, “We need to

share that information to a greater degree”.

Preceptor Assessment

During the site visits, the co-directors provide the preceptors

with evaluations from previous residents and students if they

have any available. However, the evaluations are not made

available to preceptors until a year after the resident graduates.

In reality, this can be up to three years after the evaluation was

completed.

All preceptors expressed their dissatisfaction with the way

they receive feedback from residents and students. Preceptors

all strongly agreed that they do not receive enough feedback

and the feedback they do received comes far too late. “If I have

a deficiency in my office, no one knows it better than my resi-

dent”. One preceptor stated, “I strongly object to it being three

years after the fact … we are adults. We should be getting feed-

back just like we are giving our residents feedback. … Three

years later … it is too late …” A preceptor who had supervised

approximately twenty residents and twenty students over a

twenty year period revealed that during that time she had only

received “I think three [assessments] in my lifetime”. A second

preceptor shared she had supervised thirty residents and twenty

medical students over a twenty year period and reported she

had received “Maybe four or five”.

Several preceptors stated they do not like the one45 evalua-

tion system used by the DFM to assess residents. They ex-

plained that in this system they are required to search for their

resident’s evaluation forms and suggested the forms should be

sent to them automatically. One preceptor pointed out another

issue with the evaluations of residents. “I had a resident who

didn’t pass the exam this time. I hope if there had been red flags

along the way. If there is a 2 out of 4 then the primary preceptor

has to be informed”.

Preceptors’ Recommended Improvements

The final themes of recommended improvements for the site

visits have been summarized in Table 1.

Discussion

All stakeholders agreed that the site visit process was a step

toward overall program quality assurance. Similarly, Malik et al.

(2007) found the site visit process to be an important CQI ini-

tiative with the potential to effectively evaluate distant commu-

nity teaching sites. The findings from the this study also sup-

port Suzewits’ (2002) allocation that a tour of the facilities during

the site visit allows faculty representatives to become familiar

with the types of learning settins that exist outside the large g

C. J. MACDONALD ET AL.

Table 1.

Recommended site vis i t improvements.

Thematic Description Quote

DFM to prioritize site visits … if it is useful let’s put our resources into scheduling it . Setting up the time to

make it value added so there is an educational experience with resources.

DFM to provide clear expectations More time, set agenda according to the site’s needs and the program directors

need to ensure we are following the college requirements. More frequent visits

when a new site is starting up.

DFM to provide support for preceptors to become better teachers I have never really used the CanMeds c urriculum t o either learn or teach. Where do

you start? The obstet r i c population is my practice p r o f i l e. How do I take this large

amount of information when only twenty percent app l ies to me?

Involve residents in the site visit The site visit is now like the pare n t s t alking about the kid s without the kids havi n g

any input. I think during a site v i s it the resident sho ul d be present at the very least”

Alternative Strategies: teleconference and videoconference I like the Skype idea. Everybody has computers. You could talk for fifteen minutes.

Unless it was a new person

Provide one support email for questions When you feel supported you don’t feel isolated. You feel that it is worth the time

and effort you are putting in and that is very pos itive.

Site Evaluations Give advance notice of what will be covered during the visit.

academic centres.

All stakeholders perceive site visits in their current structure

are not as effective as they could be. One of the programmatic

shortcomings that surfaced was that community/rural faculty

members often feel that they are not given adequately laid out

expectations for teaching and that their responsibilities are not

clearly defined at the outset of their preceptorship. Stearns et al.

(2003) identify this as a problem that is prevalent in most aca-

demic medicine community settings. “Vague and global objec-

tives are not helpful and do not maximize the learning opportu-

nity for those involved” (161). Stearns et al. (2000) emphasized

the need for clinical departments to clearly outline their vision

for preceptorship at the outset of an educator’s career.

Despite the finding that some preceptors didn’t find the site

visit to be particularly useful, the University of Ottawa team

found that some preceptors simply appreciated being recog-

nized for their work as educators. This finding is in accord with

Suzewits’, 2002 idea that an important aspect of the site visit is

the opportunity it gives departmental leaders to thank their

educators in person. For the most part, the opportunity for in-

formal discussion was valued as was the opportunity for remote

faculty members to be apprised of issues that emanated from

the urban hub of the program such as curriculum reform, policy

changes etc. This is in line with Moser et al. (2004) findings that

demonstrated that community based faculty members typically

appreciate knowing departmental leaders and staff on a “first-

name basis” (p. 317). Lowenstein et al. (2007) also report that

faculty members often appreciate feeling a part of the institu-

tion with whom they are affiliated and that a failure on the part

of the institution to nurture ties with academic staff can lead to

career dissatisfaction and attrition.

All stakeholders alluded to the idea that site visits should not

be a one size fits all operation. Both the co-directors and pre-

ceptors suggested the purpose of the site visit should and does

change based on the experience and competency of the precep-

tor. Likewise, Malik et al. (2007) noted the importance of cre-

ating teacher specific materials for site visits to ensure there are

relevant for the preceptor involved. The findings of this study

highlight the challenge inherent in running a site visit program

that caters to diversity among the faculty ranks. Wilkerson and

Irby (1998) identified levels of educational careers that require

very different types of professional support and mentoring.

However Pololi and Knight (2005) argued that mentorship and

collegial communication can be extremely valuable “regardless

of status, position, or level of expertise” (p. 868). I would men-

tion the role of collaboration between site visit facilitators and

Fac Dev team.

The co-directors revealed that they have a bit of the “impos-

ter syndrome” because they do not feel they are more qualified

than many of their experienced peers at teaching and were in-

herently uneasy about the perception of site visits being a posi-

tion of power. Malik et al. (2007) also found their site visit

facilitators expressed discomfort with the idea that they were

“policing” their peers. Their solution was to develop a site visit

policy document that described the purpose of and expectations

for the site visits.

The co-directors of site visits reported they would like to see

their role involve fewer faculty meetings so they can devote

more time to supporting preceptors. Moreover, they want the

DFM to put more resources into scheduling visits, prioritizing

and making site visits more effective. Moser et al. (2004) also

identified the freeing up of time for academic faculty to conduct

site visits as well as scheduling with preceptors at distant sites

as being the two main challenges associated with the site visit

process. Similarly, Malik et al. (2007) emphasized the need for

strong administrative and financial support for coordinating site

visits.

Preceptors reported they enjoyed being a preceptor, loved

teaching and the challenge it brought to their practice. This is in

line with Latessa et al. (2008) who reported that community

physicians found the opportunity to introduce learners to work-

ing in the community setting to be particularly satisfying.

Community and rural preceptors often remarked that their

experiences differed from those of unit-based preceptors. The

site visit process must adapt to the needs of the commu-

nity/rural preceptor group in order to be effective. Moser et al.

(2004) state the fixation on the tangible aspects of the site visit

is often ineffective. The solution may be for faculty reps to

focus more on the facilitative skills and methods that depart-

mental leaders utilize in response to the feedback they receive

during the visits so they are prepared with adequate resources to

respond to issues that arise.

C. J. MACDONALD ET AL.

All preceptors were open to having site visits if they were

structured to help them become better teachers. The preceptors

articulated they need to “share information and resources”.

Steinert et al. (2006) cited the importance of collegial support

and the formation of networks for the mutual exchange of in-

formation and ideas as well as the importance of institutional

support for community based faculty through faculty develop-

ment. Moser et al. (2004) cited the importance of delivering

individualized faculty development opportunities for seldom

reached faculty members (p. 318). Similarly, Malik et al. (2007)

called for site visit programs to equip facilitators with the

knowledge and tools to bring faculty development offerings to

dispersed faculty members. Suzewits (2002), Malik et al. (2007)

and Moser et al. (2004) called for the inclusion of faculty de-

velopment in the site visit process as an effective strategy for

reaching distant and often disconnected faculty members.

How and when preceptors receive feedback from residents

were the biggest criticisms preceptors associated with of the

site visit. Lowenstein et al. (2007) found that a lack of timely

and constructive feedback from departmental leaders can have

devastating impacts on the morale of faculty members in aca-

demic medicine. The University of Ottawa data is congruent

with these findings and suggests a need to improve the way in

which community/rural preceptors receive feedback on their

teaching (Steinert et al., 2006).

A few preceptors suggested having the resident involved in

the site visit in some capacity would be an alternative site visit

structure worth exploring. Suzewits (2002) included interac-

tions with learners in his description of the purposes of a site

visit. Similarly, Moser et al.’s (2004) approach to the site visit

process calls for facilitators to provide direct feedback to learn-

ers and also provide individualized faculty development and

professional feedback to preceptors.

Conclusion

The findings from this study highlighted congruency be-

tween and among stakeholder’s perspectives of site visits and

how they can be improved to support preceptors and provide

the best possible learning experience for medical students and

residents. The findings also gleaned results that are in line with

existing literature on the site visit process. In particular, the site

visit process as a mechanism to ensure a programmatic quality

standard in the community setting, to provide opportunities for

faculty development, to disseminate information on depart-

mental and institutional affairs, to promote career development,

to address issues with students or residents and to meet ac-

creditation requirements are all well-established objectives of

site visits as outlined by Suzewits (2002), Moser et al. (2004)

and Malik et al. (2007). The areas for improvement, the

strengths and possible solutions are also in line with current

literature calling for the rationalization of site visit programs to

make them more effective (Malik et al., 2007) and efficient for

stakeholders as well as the call for more inclusion of faculty

development (Moser et al., 2004; Malik et al., 2007; Steinert,

2005) and the shift toward a more interventionist stance (Suze-

wits, 2002) or the involvement of the learner in the process.

The University of Ottawa study demonstrates a need to con-

tinually improve and monitor programs that aim to engage

community and rural faculty members to ensure that they feel a

part of the academic department with which they are affiliated.

Several of the preceptor’s ideas and concerns that emerged in

this study were not specific to how site visit can be improved

but had far broader implications for how the entire DFM pro-

gram could improve. Although all of the issues and ideas raised

by the preceptors affect site visits, they are all encompassing

program interrelated issues such as the evaluation process,

timeliness of receiving feedback from residents, faculty devel-

opment and the orientation process. Some of the concerns and

issues have already been addressed and plans for responding to

several others preceptors concerns are underway. For example,

the site visit co-director’s roles are to facilitate growth and

maintenance of quality through their contacts and networking

with preceptors. Responding to the feedback from this study,

the site coordinators have worked out a system to make better

use of their time so they are available to spend more time re-

sponding to preceptor’s needs. Findings that emerged from this

study have fuel the DFM approach to remediation and bench-

marks for our own internal continual quality improvement.

Standard questions and benchmarks are being created for qual-

ity assurance to ensure preceptors provide residents with direct

observations, feedback well rounded patient profiles, and an

effective teaching/learning environment. In response to precep-

tors feedback, the DFM has created a graded form for site visits

that corresponds with preceptor’s experience (new preceptor

site visit; experienced teaching practice; situation where there is

a learner in difficulty; and using experienced preceptors to

teach others). The co-directors of site visits are also focusing on

getting evaluation back to the preceptors more expediently.

A close working collaboration between the site co-directors

and the co-directors of faculty development has evolved to

address many of the concerns raised by preceptors in this study.

A new tailored orientation has been organized specifically for

the DFM to clearly outline preceptor’s roles and make explicit

procedures, available resources, and expectations. Processes

and mechanisms are being initiated to have preceptors improve

situations by taking ownership and empowering them to com-

municate and offer suggestions and solutions when they per-

ceive a process isn’t effective or effective. Blogs and open fo-

rums for providing feedback constructively and anonymously

are being set up.

A grassroots initiative has been initiated to try to have pre-

ceptors come up with teaching solutions and share ideas and

best practices. One consistent idea communicated by preceptor

was they feel they learn best from one another. As a result one

initiative that emerged as a result of the findings from the this

study is “Teaching Tips at your Fingertips”, where preceptors

describe their tried and true teaching tips in a YouTube video.

The video links are emailed and tweeted to their colleagues in

order to share best practices. Having preceptors become more

involved by sharing their teaching pearls that either link to evi-

dence based practice or that emerged from experience will en-

hance the learning community and support system between and

among the community and rural preceptors.

An Essential Teaching Skills program have been developed

which consists of a series of four hour main pro C accredited

workshops that address several of the teaching related concerns

raised by preceptors in this study (how to deal with a student in

difficulty, how to observe, evaluate and provide a resident with

feedback and issues related to professionalism). Moreover, a

follow-up focus group will take place with the same group of

preceptors that participated in this study two years following the

first focus group to solicit feedback on whether they feel things

have improved and what still needs attention and improvement.

C. J. MACDONALD ET AL.

The findings from this study suggest that effective site visits

involve curriculum, faculty development and evaluation issues

and all components need to work together in an efficient man-

ner if the entire system is to be effective. Supporting preceptors

to be better teachers emerged as a key factor that links these

components into a responsive and relevant situational learning

experience.

Given resource requirements and the degree of collaboration

required to deliver effective site visits, it appears that a profes-

sional approach to site visits is essential. Site visits will not be

effective if simply composed of a list of required ingredients of

success. Rather effective site visits will require a recipe or

framework whereby any site visit program can be carefully

implemented, monitored and supported to succeed (MacDonald,

Stodel, Farres, Breithaupt, Gabriel, 2001; MacDonald & Thom-

pson, 2005; MacDonald, Stodel, Thompson, & Casimiro, 2009).

Research must be ongoing to continually monitor and adapt the

recipe and enable more deliberate application of strategies that

lead to a quality site visit experience.

This study also illustrates the dynamic intersections between

theory and best practices. Theory informs actions, and actions

modify theories so that future actions grow out of what we have

learned by experience and reflection (MacDonald & Thompson,

2005; Thompson & MacDonald, 2005). When preceptors per-

ceive that theory makes good practice and good practice makes

theory, the entire system will be energized. As researchers con-

tinue to build site visit recipes based on theory and reflection of

practical experiences, the resulting insights will enable all

stakeholders in a family medicine program to make more in-

formed decisions to positively impact the quality of the site

visit experience, support preceptors in being better teachers and

improve the quality of the supervision of residents and medical

students. This study is one step in helping to build a broad base

of theoretical knowledge informed by practical experiences on

site visits.

Acknowledgements

The authors would like to thank the busy preceptors who

generously gave their time to participate in this study to im-

prove the site visit program.

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Appendix

Focus Group Interview Protocol

 Use either SI (MKS) or CGS as primary units. (SI units are

encouraged.) English units may be used as secondary units

(in parentheses). An exception would be the use of English

units as identifiers in trade, such as “3.5-inch disk drive”.

 What is your current position?

 How many community/rural clerkships have you experi-

enced/supervised?

 How many community/rural resident rotations have your

experienced/supervised?

 What is the purpose of the site visit?

 What are the strengths of the site visit?

 What are the shortcomings of the site visit?

 When was the last time you had a site visit?

 How often would you like to have a site visits?

 What more could the DFM do to support you in your role as

a community/rural preceptor?

 What more could the faculty rep do to support you in your

role as a community/rural preceptor?

 What resources do you currently receive during site visit?

 What resources would you like to see during the site visit?

 Are you clear on what is expected from you as a medical

student/preceptor/preceptor?

 What is the current protocol for the site visit?

 How could the site visit be improved?

 Do you have any other comments that may be useful to us

in improving the site visit as a mechanism to support you in

your role as a preceptor and ensure the medical stu-

dent/resident have a positive experience?