Abstract
Objective To explore the experiences and recommendations for recruitment of family physicians who practise and teach primary care obstetrics.
Design Qualitative study using in-depth interviews.
Setting Six primary care obstetrics groups in Edmonton, Alta, that were involved in teaching family medicine residents in the Department of Family Medicine at the University of Alberta.
Participants Twelve family physicians who practised obstetrics in groups. All participants were women, which was reasonably representative of primary care obstetrics providers in Edmonton.
Methods Each participant underwent an in-depth interview. The interviews were audiotaped and transcribed verbatim. The investigators independently reviewed the transcripts and then analyzed the transcripts together in an iterative and interpretive manner.
Main findings Themes identified in this study include lack of confidence in teaching, challenges of having learners, benefits of having learners, and recommendations for recruiting learners to primary care obstetrics. While participants described insecurity and challenges related to teaching, they also identified positive aspects, and offered suggestions for recruiting learners to primary care obstetrics.
Conclusion Despite describing poor confidence as teachers and having challenges with learners, the participants identified positive experiences that sustained their interest in teaching. Supporting these teachers and recruiting more such role models is important to encourage family medicine learners to enter careers such as primary care obstetrics.
Family physicians are withdrawing from primary care obstetrics practice in the United States1–4 and Canada.5–8 This trend adds to the challenges in recruiting family medicine graduates to long-term obstetric practice.2,9,10 Some reasons for this withdrawal include concerns about adverse outcomes, effects on lifestyle, and office disruption.11,12
As maternity care providers move away from performing deliveries, it is likely that even fewer family medicine residents will cultivate career paths that include intrapartum obstetric care.1 To engage this group, family medicine residency programs must implement strategies to recruit faculty role models who provide obstetric care as part of their work as family physicians.13,14
Family physician role models in obstetrics are important13 and have been considered influential as teachers.11 Family physician role models for obstetric care encourage new family medicine graduates to consider obstetric practice.15 Such role models have been difficult to recruit,16,17 particularly if there were few faculty delivery providers at the recruiting institution. Several strategies have been employed to attract family physicians providing obstetric care to family medicine residency programs.16 These efforts are considered worthwhile because these new faculty members might help to encourage learners to pursue obstetric practice.
Similar challenges are experienced in the Department of Family Medicine at the University of Alberta in Edmonton. Most Edmonton family physicians who include primary care obstetrics as part of their practices do so in shared-call groups and enjoy practising within them.18 These physicians have been recruited by the University of Alberta urban family medicine residency training program as teachers. Family medicine residents are taught by these physicians in clinical settings (ie, in prenatal clinics and on call) and are well positioned to receive positive role modeling from them. This subgroup of family physicians’ experiences as educators has not previously been explored, nor has their potential to advance interest in family medicine learners for providing obstetric care. These learners might require support in this area.11 Therefore, the purpose of this study was to examine family physicians’ experiences as primary care obstetrics teachers, and to seek their recommendations for recruiting new family medicine graduates to provide obstetric care.
METHODS
Sample recruitment
Potential participants were invited to participate via e-mail invitations from the principal investigator (S.K.). As this was a purposeful sample,19 invitations were only sent to those family physicians in Edmonton who practised primary care obstetrics and regularly taught family medicine residents as part of their practices.
Data collection
Before each interview, participants provided consent and confidentiality was assured. The semistructured interviews were conducted between September 2007 and March 2008. Representative questions from the interview guide included the following:
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How is teaching done in your primary care obstetrics group?
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How do you feel about your teaching role?
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What do you like most and least about teaching?
Each interview was audiotaped and then professionally transcribed verbatim. Identifying information was removed to ensure confidentiality.
Data analysis
The investigators independently reviewed the data, and then analyzed the transcripts together. Iterative thematic analysis was used to elicit important themes.20 The emergent themes were categorized into a coding template. The coding template was modified following each subsequent interview and was stable upon saturation at the 12th interview. Finally, the investigators refined the analysis and interpreted themes.
Trustworthiness and credibility
Trustworthiness and credibility of the study were assessed through verbatim transcription of the interviews to ensure accuracy and honesty of the data. Investigator bias was also addressed: 2 of the investigators were family physicians who practised and taught obstetrics (S.K. and J.M.J.). The other investigator (J.B.B.), who was a doctoral researcher, balanced this bias and ensured a thorough study design and analysis.
This study received ethics approval from the Health Research Ethics Board at the University of Alberta.
FINDINGS
Final sample
The final sample consisted of 12 participants, all of whom were Edmonton family physicians practising obstetrics in groups. They were involved in teaching obstetrics to family medicine residents at the University of Alberta, although none taught in an academic centre. All participants were women, which was reasonably representative of primary care obstetrics providers in Edmonton. The participants ranged in age from 30 to 54 years, with a mean age of 41.4 years. The participants had started practising obstetrics in groups as early as 1993 and as recently as 2005. These family physicians practised in urban settings, with experience ranging from 5 to 29 years, with a mean of 14.9 years.
The participants were members of primary care obstetrics groups (groups A to F) as described in Table 1. Groups A, B, and C functioned similarly. Patients could refer themselves or be referred by other physicians, and were seen at outpatient clinics. Each physician took call on a consistent day each week, and alternated weekends on call.
Characteristics of primary care obstetrics groups
Group D saw pregnant patients from their own practices and prenatal patients who were self-referred or referred from other physicians. Pregnant patients were not seen at a dedicated prenatal clinic, but rather at a family medicine clinic. This group of physicians also conducted separate, dedicated prenatal clinics 1 half-day per week at a public health centre. They took call for their own patients on weekdays, and alternated weekends on call. Patients were not necessarily encouraged to meet every physician in the group before delivery as the patients of the other groups were.
Groups E and F saw patients who were self-referred or referred by other physicians; patients were seen in prenatal clinics twice per week. Each physician took call 1 week at a time and alternated weekends.18
Overview of findings
Themes identified in the results of this study include lack of confidence in teaching, challenges of having learners, benefits of having learners, and recommendations for recruiting learners. While participants described insecurity and challenges related to teaching, they also identified positive aspects, and offered suggestions for recruiting learners to primary care obstetrics.
Lack of confidence in teaching
Most participants expressed limited confidence in their teaching abilities and many questioned if they were adequately passing on knowledge to their trainees: “I think sometimes … I do not have the knowledge or the education to teach them appropriately.” Another participant who continued to perceive herself to be in a learning role felt ill-equipped to teach trainees: “I feel like I’m still a learner, so in some respects I feel like I don’t always have all the tools to help them.” Others were concerned about how to impart information that was considered almost instinctive: “I really don’t know how I do it. I mean, the mechanics of some things are so second nature.”
Participants described how most teaching was done “on the run” or opportunistically based on the patients seen: “We do more discussing of things as they come up.” They provided very little didactic teaching and contemplated whether to provide more: “I worry that they’re not getting out as much as they should … if I should be a more formal kind of instructor.”
Challenges of having learners
Participants also described challenges teaching primary care obstetrics. For example, when participants perceived learners as lacking independence or having insufficient knowledge, frustration could ensue:
I expect them to know more than they do when they get [here]. I find it frustrating that I can’t leave them to do something like sew up a small tear without me being there to guide them … I feel that they should be a little bit further along [with] their skills.
Another challenge was that teaching could interfere with physicians’ connections to patients: “It interferes with flow and sometimes I don’t get as much time with the patient that I’d like to, to really understand what their needs are.”
Participants also described how learners’ lack of interest in obstetrics made them more difficult to teach: “[A] lot of times you have [learners] who aren’t interested in what they are doing and don’t show a lot of initiative. So I think that is challenging at times.”
Benefits of having learners
In spite of lacking confidence in teaching, and describing challenges related to teaching, participants described benefits of having learners: “I like having the [learners] because I figure they’re at the peak of their knowledge … a lot of them will give me a lot of information that I’m outdated on. I really enjoy having them.”
If learners expressed interest in practising obstetrics, participants found teaching to be even more rewarding, as learners gained knowledge and became more independent:
I like seeing the [learners] that are interested in practising obstetrics later learning new skills and feeling at the end of the month that they can actually manage a whole labour, instead of just a delivery.
When learners were excited about new learning opportunities, it was also a positive teaching experience:
It can make the clinic more interesting because you are sort of seeing things through somebody else’s eyes for the first time. So something that maybe didn’t seem that interesting, once you start talking about it, you realize that it probably is interesting for them.
Teaching was gratifying when learners displayed interest in the topic. Witnessing learners’ success was satisfying to participants:
I like seeing someone else be passionate about what I am passionate about. I like seeing them enjoy it and especially if you can teach them and the first time they do something well, and just that sense of accomplishment ... and knowing that you really helped them with what they need to learn.
Some participants emphasized that teaching was often reciprocal. The teaching relationship was often beneficial for the family physician preceptor:
The [learners] actually teach you stuff too, which is good. It keeps you current … often they will ask you a question and I’ll say, “I don’t know; we’ll have to look it up,” and so we’ll look something up together. The [trainees] often know things that you have no idea of.
Such experiences contributed to collaborative learning, which participants perceived as another benefit of precepting:
Rather than it just being something where I teach and the other people learn, it is much more collaborative than that … I’m learning all the time from the people that I work with, and a number of them happen to be learners.
Recommendations for recruiting learners
Participants identified perceived barriers for their learners in considering a career in primary care obstetrics. To overcome these barriers, they had recommendations for learners, as well as for themselves and their colleagues.
Perceived barriers to recruitment
Participants suggested that one recruitment barrier was lack of early exposure to family physicians during medical training, a missed opportunity to steer them toward obstetrics before their final career decision: “I would like to see more students going through. Because a lot of the [learners] have already made up their mind[s] what they are planning to do.”
Another barrier to recruitment described was learners’ reluctance to practise obstetrics owing to their perception of obstetrics as interfering with their lifestyle. Participants were concerned that many learners thought obstetrics involved “70 hours a week and not [getting] any sleep and not [having] time with their families.” Another substantial recruitment barrier preceptors perceived was the existing structure in labour and delivery units: “I think it takes a lot of confidence in your skills, or just a lot of self-confidence in general … to become part of that [labour and delivery] team.”
Recommendations for learners
All participants had taught trainees who they considered competent and had encouraged them to pursue obstetrics in their future careers: “If they are interested in it, I would tell them to stay as keen as they can to get the experience.” Participants also believed learners should work with family doctors who practised obstetrics to gain more exposure: “Having them spend … some time with a group of family doctors that have a high volume of low-risk obstetrics would certainly be helpful.”
Participants suggested that if learners emphasized positive aspects of obstetrics, more of them would consider careers in the field: “They shouldn’t necessarily look at barriers, they should look at rewards, because if they like the area and they find it very rewarding, then the barriers won’t be so large.”
Recommendations for family physicians who teach obstetrics
Participants believed that recruiting family medicine graduates could be achieved by providing advice on how a primary care obstetrics group could facilitate obstetrics careers and help facilitate a balanced lifestyle: “I tend to blow our horn a little bit with the way we manage obstetrics and let them know that it really does lend to a good lifestyle and it adds to more satisfaction … in my work.”
Furthermore, participants recommended that exposing learners to primary care obstetrics groups would aid recruitment. Mentorship from group members would make new graduates feel welcome and supported: “… [For] anyone who is considering it, supporting them and knowing that they have that support [is important] if they decide to go into it.”
Participants expressed that assuring learners of support once they began practising primary care obstetrics might be worthwhile. Informing learners of opportunities to enhance skills through courses, meetings, mentorships, and call-group interaction could also be reinforcing.
There is a role for learning and gaining more experience once they have started practising … that was my biggest factor to overcome. [It] felt like I didn’t have the practical experience or the knowledge [but] there was backup and I knew that I could get help if I needed it, and I didn’t have to know everything as soon as I graduated.
Participants believed that displaying their enthusiasm for primary care obstetrics could influence learners positively: “We try to tell them to leave it open as an option and … let them know how much we enjoy it … [and] how rewarding it is.”
DISCUSSION
In this setting, where there was potential for more faculty role models in primary care obstetrics and where family physicians increasingly chose not to provide obstetric care, the participants presented multiple perspectives as teachers of this discipline. They included lack of confidence in teaching abilities, challenges of having learners, benefits of having learners, and recommendations for recruiting learners into the field.
Lack of confidence in teaching abilities
A prominent finding was the participants’ lack of confidence as teachers. This insecurity stemmed from feeling unsure of their credibility as teachers and feeling uncertain about whether their teaching methods were successful. Kornelsen acknowledges that “teaching with presence” requires preceptors to have confidence, which has been found to improve with continued teaching experience.21 The participants did not describe any faculty development strategies being used to support their teaching. Faculty development efforts such as tools for clinical teachers, and reinforcing the value of clinical teaching, might improve confidence.
Challenges of having learners
Participants expected family medicine learners to have more obstetric knowledge and independence than what they actually had when entering residency. This might point to a gap between undergraduate and postgraduate training at the University of Alberta. Improved communication between these programs and amendments to training might be helpful.
Participants also found teaching to be challenging when learners lacked interest and when teaching interfered with interactions with patients. This confirms previous findings by Burns et al, who recognized that reconciling patient care and involving learners could be difficult for teachers.22
Benefits of having learners
Despite these challenges, participants derived satisfaction from witnessing learners’ success, felt rewarded when activating learners’ interest, and enjoyed contributing to learners’ knowledge and skill development in providing obstetric care. They also benefited from collaboration and reciprocal learning, whereby family physicians learned from trainees as well. Positive experiences such as these appeared to bolster the participants’ motivation to continue teaching.
Recommendations for recruiting learners
Participants’ experiences teaching primary care obstetrics were mixed. They provided specific recommendations for how to recruit new graduates, such as role modeling systems of obstetric care (such as shared-call groups) that were of benefit to them,18 and accentuating the positive features of providing obstetric care. Participants also suggested that recruiting learners early in training, actively welcoming learners in primary care obstetrics settings, and providing them with support would also be effective recruitment strategies.
Limitations
The results of this study cannot be extrapolated to all family physicians who teach primary care obstetrics, nor can they be assumed to be comparable to the experiences and recommendations of male family physicians, as the final sample consisted of only women. The study occurred in 1 urban centre; therefore, the results cannot necessarily be applied to smaller communities or rural and remote areas. Perspectives of patients receiving care in primary care obstetrics teaching practices were not elicited in this study. Further research is required to address these issues.
Conclusion
Interest in primary care obstetrics could be sustained in part by family physician role models who practise, teach, and support learners in this field. Despite describing limited teaching confidence and experiencing challenges with learners, the participants identified motivating factors that sustained their educational interests.
Supporting these teachers requires faculty development to accentuate the benefits of teaching identified by the study participants. Faculty development also has potential to manage teaching challenges. It would also be in the best interests of primary care obstetrics groups and their supporting departments of family medicine to consider the participants’ recruitment strategies in order to encourage family medicine learners to practise full-service obstetric care.
Notes
EDITOR’S KEY POINTS
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Interest in primary care obstetrics could be sustained in part by family physician role models who practise, teach, and support learners in this field.
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Despite describing limited teaching confidence and experiencing challenges with learners, the participants identified motivating factors that sustained their educational interests.
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Supporting these teachers requires faculty development to accentuate the benefits of teaching and to manage teaching challenges. The participants’ suggested recruitment strategies should be considered in order to encourage family medicine learners to practise full-service obstetric care.
POINTS DE REPÈRE DU RÉDACTEUR
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Ce sont les médecins de famille qui font de l’obstétrique de première ligne et qui agissent comme modèles de rôle en formant et en encadrant des étudiants dans cette discipline qui sont susceptibles de contribuer à maintenir l’intérêt pour ce domaine de la pratique.
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Même s’ils étaient conscients de leurs limites comme enseignants et des défis qu’ils rencontraient avec les étudiants, les participants identifiaient certains facteurs de motivation qui les encourageaient dans leur intérêt pour l’enseignement.
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Il faudrait des mesures facultaires pour que ces enseignants bénéficient davantage de leur enseignement et soient mieux préparés pour faire face aux défis qu’ils y rencontrent. Les participants étaient d’avis qu’on devrait envisager certaines stratégies de recrutement pour inciter les résidents en médecine familiale à dispenser des soins obstétricaux complets.
Footnotes
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This article has been peer reviewed.
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Cet article a fait l’objet d’une révision par des pairs.
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Contributors
All authors contributed to the concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.
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Competing interests
None declared
- Copyright© the College of Family Physicians of Canada
