Primary Care Perspectives on Education Scholarship: A Qualitative Synthesis

Family medicine physicians play critical community-based roles in providing and coordinating interdisciplinary care, health promotion, and patient advocacy. Many also take on additional scholarly responsibilities, such as teaching, mentorship, and research. In fact, scholarship is formally recognized as a significant component of family physicians’ core professional competencies. ^{1, 2} This strength is acknowledged in the Four Pillars for the Primary Care Physician Workforce model proposed by the Council of Academic Family Medicine (CAFM) and since adopted by the broader primary care community. ^3-5

In 1990 Ernest Boyer introduced a model elaborating on the traditional meaning of scholarship—a model that goes beyond the usual primary focus on research and publication. ⁶, ⁷ Boyer suggested that scholarship involves actively engaging with one’s work, considering it in broader contexts, and going beyond the basic duties of a faculty member. He proposed four key domains (Table 1): the scholarship of discovery (formal research), integration, application, and teaching (education scholarship). ⁶ The scholarship of teaching challenges the historical view that teaching is a priority secondary to research and publication, or something that is done as an adjunct to research and publication. In this model, teaching is described as a scholarly enterprise: carefully planned, continuously examined, and involving the transformation of teaching practices to stimulate active learning. ^{6, 7}

A significant portion of undergraduate medical education as well as primary care residency programs takes place in primary care settings. Accordingly, much of the teaching responsibility falls on faculty primarily trained as family medicine clinicians. While these clinicians take on acknowledged academic teaching roles, their backgrounds in clinical education can vary widely from introductory faculty development to a formal postgraduate degree. ⁸ Medical schools are accountable to rigorous accreditation standards, and the influence of clinician teachers on learners is important to recognize. These clinician teachers embody the delivery of the formal (eg, lectures), informal (eg, ad hoc clinical teaching), and hidden (eg, role-modeling and mentorship) curricula. High-quality teaching by clinical faculty in family medicine is critical to the success of medical students and to the legitimacy of associated institutions. ^{9, 10}

While scholarship and teaching as core competencies in family medicine are well documented in the literature, understanding how clinician teachers integrate education scholarship in practice is not. We asked this research question: What are the experiences of primary care physicians regarding clinical teaching, and how do their practices relate to education scholarship based on Boyer’s definition? Our review aims to provide a fuller understanding of the qualitative literature on the key facilitators, barriers, and experiences of primary care physicians’ implementation of education scholarship in their clinical teaching practices.

We based our study on the premise that we would find applied grounded theory in medical education in the perceptions and activities described by primary care clinical educators. ¹¹ We conducted a qualitative data synthesis using a meta-ethnographic approach. This interpretive method involves comparison of primary studies to obtain a clearer theoretical understanding of a particular phenomenon. The final objective of a meta-ethnography is to develop novel interpretations and conceptual insights based on the primary data. ¹² The method involves a literature search, abstract selection, quality appraisal, data extraction, and synthesis of key concepts and themes. ^{13, 14} The research team consisted of a family medicine physician and clinical teacher, an education scientist, and a medical student.

We conducted an electronic database search to identify primary qualitative studies involving primary care clinician teachers. Developed with guidance from an education librarian, the search strategy captured four main search concepts: primary care, clinician teachers, professional competencies, and qualitative research (Appendix 1). The overlap of these four concepts best describes our area of focus for this synthesis. In August 2020, one reviewer (L.L.) searched the following databases: PubMed/Medline, Scopus, ERIC, and Web of Science. Medical Subject Headings (MeSH) and text word synonyms were used with Boolean operators to combine the four main search concepts.

One reviewer (L.L.) screened the retrieved abstracts for relevance. Then the full article texts of selected abstracts were retrieved and reviewed (by L.L.) for potential inclusion based on specific criteria (Figure 1). Articles with the following key concepts were included: primary care (family medicine, community pediatrics, ambulatory internal medicine) physicians and residents, and perspectives on clinician teacher roles. Due to the subjective, experiential nature of our study objective, we focused on studies reporting qualitative results.

We excluded articles if they lacked qualitative results, were not original research (ie, reviews, commentaries), unavailable in full text articles (eg, conference abstracts), or focused on other health care professions, medical student perspectives, or topics other than clinical teaching in primary care. We lacked capacity to assess non-English articles. We searched literature published after the year 2000, 10 years after Boyer proposed his concept of education scholarship, ⁶ to allow time for dissemination, acceptance, and possible implementation of his concept. A total of 1,454 articles were retrieved in the initial search in 2020, of which 30 met inclusion criteria. The search was repeated in 2021, resulting in three additional articles. Ultimately, 33 articles were retained for inclusion in the synthesis (Figure 1 ).

Data extraction and critical appraisal of full text articles were done by two reviewers (L.L. and B.C.) independently. We used the Critical Appraisal Skills Programme (CASP) tool for qualitative studies to evaluate the quality of the included studies. We chose the CASP tool because it provided a systematic process for critical appraisal and focused on assessing the study validity and relevance of the results to our study questions. One reviewer (L.L.) used the CASP tool to evaluate the quality of each selected study. No articles adhering to the inclusion criteria were rejected based on the CASP tool. ¹⁵ Data were extracted using a data extraction tool we developed based on the Cochrane Collaboration Qualitative Methods Group guidelines. We piloted the tool on five articles, and we discussed discrepancies among reviewers until consensus was reached. ¹⁶ The following information was extracted from each article: bibliographic information, study objectives, design and data collection methods, sample size, participant characteristics, inclusion and exclusion criteria, and qualitative data. We extracted primary data, as well as the primary studies authors’ conceptual interpretations, in the synthesis because the latter offered additional descriptive and conceptually rich data relevant to the aim of our synthesis.

Our thematic analysis involved inductive coding of the primary study concepts and comparison of the codes across articles. We used codes generated from previously reviewed articles to aid in the extraction of similar codes. Related codes were organized into groups to generate overarching themes. To preserve the structure and context of the qualitative data, data were extracted verbatim. Qualitative data were considered to be study findings as well as all text labeled as “results” or “findings.” ¹⁷ Discrepancies related to coding and theme generation were resolved through team discussion until reaching consensus. The diversity of the research team enabled potential alternative interpretations in the synthesis of the aggregated results.

We compared themes and concepts across articles. We found similarity across article themes, and no contradictory concepts were identified in our synthesis. We did not conduct a refutational synthesis because no concepts were strongly contested across papers.

A total of 33 articles were included. About half were conducted in North America (33.3% United States [n=11], 15.2% Canada [n=5]), 18.2% in the United Kingdom (n=6), 15.2% in Africa (n=5), and 18.1% in other countries (Asia, Australia, New Zealand, Sweden, South America [n=6]). The majority (69.7% [n=23]) used semistructured interviews for data collection. Focus groups were used in 18.2% (n=6) and qualitative questionnaires in 12.1% (n=4).

Table 2, Table 3, Table 4 display the four main themes from the synthesis and illustrate selected narrative data from both the primary study authors and participants. Table 2 illustrates the themes that represented a commonality among multiple articles. The majority of articles studied the perspectives of attending primary care physicians, with only a minority focused on residents. Themes pertaining to attending and resident clinician teachers were similar, with one exception. Residents felt they had additional responsibilities (eg, exams) and were formally evaluated on their teaching performance.

Instructing medical students was perceived as a skill to be continuously developed, though some studies reported a lack of confidence in teaching abilities. ²⁹, ⁴¹ While some articles investigated residents’ clinical teaching experiences, many described practicing physicians who started teaching only when they became attending physicians. ^{31, 40} Without prior experience or formal teacher training, many reported acquiring the skills by learning experientially. ³⁶ A need for resources for teacher development was identified, and workshops were considered particularly useful. However, to access such professional development, participants reported, they had to take the initiative to seek opportunities while balancing other clinical responsibilities. ⁵⁰

Many reported that clinical teaching competency often was presumed by institutions. ^{20, 23, 27} Primary care clinicians practicing at academic centers, as reported, were expected to take on learners, regardless of their formal background in teaching or precepting trainees. Some studies that focused on residents made a different claim because residents who took on teaching roles were supervised and evaluated on how well they could teach. ^{25, 34}

Studies described the lack of formal institutional recognition and value perceived in teaching compared to other academic pursuits (eg, published research). ^{19, 20, 29} Some institutions reported having criteria for academic promotion on the basis of teaching or education scholarship, but the specific steps were not as established as they were for research. ⁹

A strong focus on learner-centered clinical teaching existed across the articles, with learning objectives being heavily influenced by trainee needs, knowledge gaps, and level of training, making the process relatively personalized to each student.

Clinician teachers’ educational approaches and teaching strategies were diverse. ^{23, 41, 39} Informal or ad hoc teaching was frequently used to address student-directed learning objectives. Some taught with an observation-and-feedback approach, in which students were given autonomy and subsequently were evaluated on their performance. Didactic teaching was rarely discussed.

Role modeling was one of the most discussed clinical teaching techniques. ^{26, 27, 43, 36} While described as intentionally modeling a skill or behavior for the learner, clinician teachers were aware that role modeling often occurred passively. It was described as an inherent part of being a clinician teacher due, in part, to the hierarchical structure of medicine. Many clinician teachers reported to have learned through role modeling. The enterprise of clinical teaching appears to be as much about transmitting the culture of medical training as an apprenticeship. As such, certain skills, behaviors, and teaching techniques have trickled down the medical hierarchy.

Building longitudinal mentor-mentee relationships was considered important for effective teaching. Mentorship often was multimodal across domains and included developing clinical skills competencies, career planning, well-being, and creating a collegial environment. ²⁵, ⁴⁵, ³⁴ Near-peer teaching and mentorship by resident teachers were uniquely valued. Residents were considered more relatable to, and cognitively and socially congruent with students, thereby enhancing the learning experiences of a mentor-mentee relationship. ^{25, 45, 30, 36}

A common benefit of clinical teaching is that it is often a shared learning experience. Attending physicians appreciated a wider range of perspectives and updated knowledge as well as an opportunity to reflect on their practices through student feedback. ^{20, 32} Residents noted that teaching can help them become better learners themselves because teaching reinforces one’s knowledge, skills, and knowledge gaps. ³⁰ Resident teachers are evaluated by their supervisors and thereby gain invaluable feedback on their teaching skills. ^{25, 34}

Clinical teaching experience was perceived to positively impact physicians’ career trajectory. ⁴⁵ While teaching contributions were not perceived to hold the same prestige in academic institutions compared to publishing, teaching was still viewed as a professional asset because it was a means of networking and forming professional relationships. ^{28, 48, 39}

Clinical teaching was reported to be personally rewarding. ^{45, 27} The majority of included studies involved participants personally interested in teaching, wherein teaching was protecting them from burnout. ³³ Other studies cited altruism as a reason for enjoying teaching; it was a way to give back. ^{30, 33, 40} Much satisfaction was taken from seeing students improve. Having enthusiastic trainees boosted morale in the clinical environment. ^{33, 34}

Inadequate time, often due to competing clinical demands, was a common challenge cited for clinical teaching. Some study participants reported taking more time with patients if they had a student, resulting in decreased clinical productivity and financial losses. ²³ Also, ensuring safe practice while teaching was reported as time-consuming. Some attending physician participants noted that near-peer teaching by residents reduced their clinical teaching burdens. From the residents’ perspective, they also faced the challenge of time constraints. ^{45, 30}

Other clinical teaching challenges were the learning objectives and competency expectations of the teaching institution. ²⁰ Those expectations were often broad, and a lack of communication with the students’ academic institutions was a key barrier. ³¹ Clinician teachers often expressed concern that there was too much content to cover. In practice, learning objectives mainly were directed by the students themselves. ²⁴

Logistical barriers in the clinical environment included lack of space in a practice for students as well as practice patterns that limited teaching (ie, use of electronic medical records during patient interactions). ^{22, 38} Lack of funding for adequate compensation for clinician teachers’ instructional time was also of concern. ²³

This qualitative synthesis explored the experiences and perspectives of primary care clinician teachers regarding teaching and education scholarship in the clinical setting. Four main themes emerged from the literature: perceptions of clinical teaching, clinical teaching strategies, benefits of clinical teaching, and challenges of clinical teaching.

Primary care clinician teachers often lacked formal training in precepting, as well as confidence in their teaching abilities. Studies reported physicians having learned their teaching methods through role modeling by their former preceptors ^{43, 36} while others described teaching as an experiential skill that they accrued once they became attending physicians. ^{27, 41} As such, the most common teaching techniques were informal or ad hoc because those approaches were perceived to be intuitive and flexible. ^{23, 46} While the literature described a desire to become skilled clinician teachers, logistical barriers existed, such as time constraints, lack of compensation, and lack of direction from the academic institutions themselves. Clinician teachers also perceived that academic institutions tended to presume teaching competency while simultaneously holding other scholarly pursuits, such as research, in higher esteem. Excellence in clinical teaching was not viewed as an effective route for achieving academic promotion. ²⁸

Our findings showed that primary care clinician teachers recognized the potential for career satisfaction derived from clinical teaching, in part related to the networking and collaborative aspects of this role. Clinician teachers often reported having a personal interest in teaching and being keen to contribute to students’ learning. Contributing to curriculum development and otherwise engaging in the research or innovation of clinical education rarely were cited as advantages of clinical teaching. The research revealed an overall lack of awareness of education scholarship as a complement to practical teaching experiences.

A disconnect seems to exist between the experiences and perceptions described in the literature and Boyer’s definition of education scholarship, which described teaching practices informed by educational theory, peer-review, and advancement of the field. ⁶ Addressing this disconnect requires support to build the skills and confidence of clinician teachers. Primary care clinician teachers, particularly those based in community settings, possibly have limited opportunities to advance their diverse skills and teaching experiences. A first institutional step may include increasing awareness of education scholarship as an opportunity to study and improve existing teaching practices, which in turn would benefit both learners and patients. ²⁸ Support may include providing formal education scholarship training, compensation, and protected time to participate in faculty development, as well as institutional recognition for clinician teachers as scholars. Institutions can leverage the existing desire of clinician teachers to improve their skills to develop the capacity to advance teaching practices and educational theory. This synthesis highlighted a need for institutional support in the development of strong education scholars, which could include effective leadership, allocation of resources, and a strong commitment to education scholarship.

Our synthesis had limitations. Education scholarship is currently an underdeveloped area of study in medical education, and few existing articles directly address the issue of education scholarship and Boyer’s framework in primary care. As such, we included geographically diverse studies and recognize that primary care clinical education may vary among sites. Our approach did, however, permit greater applicability of our conclusions across different primary care settings. We included articles that studied clinical teaching in both undergraduate and graduate medical education because the teaching skill set applied to teach clerks and residents is similar but with a graduated difference in the level of responsibility and autonomy. ⁵¹ While study inclusion criteria were determined by team consensus, only one author completed the abstract review for final inclusion in the study. We did not supplement our database searches by directly searching relevant journals and reference lists. We did not review articles in chronological order, as is commonly done in meta-ethnographic reviews. ¹², ¹³ A strength of this synthesis was the multidisciplinary research team; each author brought a different perspective in the realm of clinical education, which enhanced the richness of our synthesis and conclusions.

This is the first known synthesis of the qualitative literature on the experiences and perspectives of primary care physicians on clinical teaching. Our research revealed a perceived lack of guidance, resources, and awareness of education scholarship in clinical teaching settings in primary care. Findings from this synthesis could support the development of interventions tailored to address the needs of family medicine clinical teachers. To this end, the implementation of a sustained source of education scholarship support would be an asset to most family medicine departments. Establishing stronger linkages between community-based and academic clinician teachers may be one strategy, as well as bringing opportunities and expertise in education scholarship into the clinical teaching environment. In our own context, we are studying the impact of embedding a part-time medical education scientist (JNY) in the clinical environment of the Women’s College Hospital Academic Family Health team. ⁵² This education scientist role supports local family medicine clinical teacher engagement in education scholarship by providing individually tailored faculty development mentorship and support in areas such as program development and evaluation, and writing skills. Such contextually tailored institutional responses could be an essential part of ongoing efforts to support the scholarly pursuits of family medicine clinical teachers as they strive to meet the education challenges of their clinical teaching roles and advance their engagement in education scholarship.