Identifying Barriers to Precepting Health Professions Learners During the COVID-19 Pandemic

Experiential clinical training is recognized as essential to learning the critical thinking skills¹ necessary to produce competent providers.² However, primary care has faced a shortage of clinical preceptors³ because providers have perceived negative impacts to productivity, including low patient flow,^4,5 reduced income and increased working hours,⁶ increasing workload expectations, and self-perceived lack of qualification.^7,8 The COVID-19 pandemic exacerbated these challenges, affecting experiential learning for health professions trainees.^9–11

Many medical practices stopped accepting students into their facilities, shifted in-person care to telemedicine,⁹  and saw temporary decreases in volumes. Virtual care drawbacks from a learning perspective included reduced student engagement and loss of assessment.² Although early evidence has shown that preceptors believe they can deliver high-quality instruction in virtual environments;^12,13 students are dissatisfied with virtual clinical learning.¹⁴

In response to the pandemic, Emory Healthcare restricted clinical rotations from March through May 2020 and implemented mandatory vaccination for all employees and students in fall 2021. In fall 2020, Emory University’s doctor of medicine (MD), physician assistant (PA), and nurse practitioner (NP) primary care clerkship programs faced increased challenges in recruiting and retaining preceptors. Thus, the Emory Primary Care Consortium (EPCC), a collaborative group of family medicine (FM), general internal medicine (GIM), and geriatrics providers, undertook an investigation of their preceptors’ barriers. The EPCC found scant peer-reviewed literature describing actionable barriers faced by preceptors of health professions trainees. Thus, the objective of this study was to characterize the general and new pandemic-related barriers to precepting health professions learners.

Qualtrics was used to survey primary care providers eligible to precept health professions learners (PA, NP, and MD) to determine their current precepting status, their barriers to precepting, and whether they would be interested in receiving training materials to assist in incorporating learners in telehealth visits.

For initial content validity,¹⁵ the EPCC members (including precepting Emory faculty, and clerkship and residency directors) compiled a list of barriers they expected to resonate with preceptors. These barriers formed a nine-question, 5-minute, nonincentivized multiple-choice survey. For face validity,¹⁵ the survey was pilot tested for usability and readability in January 2021 by FM and GIM residency preceptors and fielded from February 3, 2021 through March 1, 2021.¹⁶ The pilot testing resulted in minor edits to the wording of the barriers presented and the addition of two barriers. The survey invitation and reminder at 2 weeks were emailed to approximately 450 primary care providers via a physician listserv, NP and PA program community preceptor lists, and internal social media pages. We used Stata (StataCorp LLC) to compute descriptive statistics of our results. The Emory Institutional Review Board determined this was not human subject research.

Of 72 survey respondents (16% response rate), 61 were physicians and 11 were NPs or PAs (Table 1). Overall, 41 respondents were currently precepting students: 29 precepted only MD students, 2 MD and PA students, 7 NP students only, and 3 PA students only. Of the remaining 31 respondents who were not precepting students at the time of the survey, 4 had never precepted, 21 had precepted before March 2020 and not since, 5 precepted both pre- and during COVID but not at the time of the survey, and 1 had begun precepting after March 2020.

Of the 21 respondents with precepting experience who had not resumed precepting since March 2020, 5 reported barriers to precepting of productivity decreases, 2 low patient volume, 2 lack of comfort teaching virtually, 3 increased external pressures, 2 practice not open/uncertainty of practice sustainability, and 18 other. Those who responded “other” reported their barriers as preparing for retirement, pressure to maintain clinical volume, decrease in clinical time, high COVID rates in their facility, increased demand for resident rotations, reduced time for students, inconsistent scheduling, lack of staffing, and physical distancing/spacing issues.

Of the 30 respondents reporting challenges to precepting that started with the COVID pandemic, low patient volume was cited by 12 respondents, lack of comfort teaching in a telehealth setting by 7, increased external pressures by 8, uncertainty of practice sustainability by 1, and other reasons by 11. The “other” barriers identified included inconsistent clinical schedules, students’ lack of physical exam skills due to lack of in-person experiences, increased workload, patients being more complicated post-COVID, fewer in-person patients, the need to provide personal protection equipment (PPE) for students, social distancing requirements, and workspace availability.

Overall, 20 respondents were interested in receiving training on how to incorporate students into the telehealth clinical workflow (Table 2), 13 in training on how to teach and provide feedback remotely, 9 in mentorship by providers experienced in precepting in telehealth, and 5 in training on the use of telehealth.

The COVID-19 pandemic placed additional burdens on preceptors due to uncertainties associated with telehealth, PPE supply, and viability of the practice. Based on our survey results, Emory provided training for preceptors on how to incorporate students into virtual visits and provided student training on virtual visits and virtual physical exams. Emory also designed preceptor and medical learner workflows to help increase preceptor efficiency and enable preceptors and students to evaluate the patient together.

The survey was fielded at a single health system. Thus, results might not be generalizable across the United States. Also, the level of nonresponse bias was not assessed, and recall bias might have led to reporting immediate barriers instead of barriers related to COVID-19. Additionally, although the response rate of 16% was low, our survey was not incentivized, was fielded during a pandemic, and eligible respondents were volunteers. Therefore, our response rate is realistic for this real-world setting of unpaid work.¹⁷ Further, because this was a one-time survey, we were unable to conduct reliability tests of our results.¹⁵

A structured approach to address the needs of preceptors would allow a tailored response. This approach could entail ensuring that the skills of learners included use of telehealth, offering proactive educational sessions for preceptors on teaching in a telehealth environment, and developing strategies to improve efficiency and workflow with learners. Broadly sharing examples of how to best incorporate learners may help to address preceptors’ concerns.