How preceptors develop trust in continuity clinic residents and how trust influences supervision: A qualitative study

Abstract

Introduction To advance in their clinical roles, residents must earn supervisors’ trust. Research on supervisor trust in the inpatient setting has identified learner, supervisor, relationship, context, and task factors that influence trust. However, trust in the continuity clinic setting, where resident roles, relationships, and context differ, is not well understood. We aimed to explore how preceptors in the continuity clinic setting develop trust in internal medicine residents and how trust influences supervision. Methods In this qualitative study, we conducted semi-structured interviews with faculty preceptors from two continuity clinic sites in an internal medicine residency program at an urban academic medical center in the United States from August 2018–June 2020. We analyzed transcripts using thematic analysis with sensitizing concepts related to the theoretical framework of the five factors of trust. Results Sixteen preceptors participated. We identified four key drivers of trust and supervision in the continuity clinic setting: 1) longitudinal resident-preceptor-patient relationships, 2) direct observations of continuity clinic skills, 3) resident attitude towards their primary care physician role, and 4) challenging context and task factors influencing supervision. Preceptors shared challenges to determining trust stemming from incomplete knowledge about patients and limited opportunities to directly observe and supervise between-visit care. Discussion The continuity clinic setting offers unique supports and challenges to trust development and trust-supervision alignment. Maximizing resident-preceptor-patient continuity, promoting direct observation, and improving preceptor supervision of residents’ provision of between-visit care may improve resident continuity clinic learning and patient care.

Learning in Tension: A Case Study Examining What Internal Medicine Residents Learn in the Ambulatory Care Setting

“…For instance, ignoring barriers to care in the moment, such as food insecurity, will hamper residents' learning and indicate that this is not an important area of concern for patient care. As seen from this work, relationships and point-of-care learning with their supervisors is critical to residents' learning, so faculty development regarding socially complex patients is critical [33,34]. These findings suggest that either the system needs to be aligned with the experience of training or we, as medical educators, need to align our learning environments to the system.…”

Internal Medicine Residents’ Perceptions of Their Continuity Clinic Training

“…Although some studies found that resident satisfaction with CC increased with the change to an X + Y schedule, Jantea et al identified that residents’ satisfaction and stress levels at one program did not improve 17 . These studies identified several facets of CC training that predicted satisfaction, including patient characteristics, preceptor quality, and clinic operations 18 . Notably, none of these studies focus on residents’ personal experiences with CC compared with their inpatient IM rotations, and this is of interest because it is unclear whether these factors influence the decision to pursue a career in primary care.…”

“…17 These studies identified several facets of CC training that predicted satisfaction, including patient characteristics, preceptor quality, and clinic operations. 18 Notably, none of these studies focus on residents' personal experiences with CC compared with their inpatient IM rotations, and this is of interest because it is unclear whether these factors influence the decision to pursue a career in primary care. Understanding differences in residents' perception of training in these settings can shed light on reasons that IM residents are preferentially pursuing careers in inpatient general IM.…”