Empowering rural educators: Strategies for overcoming barriers in clinical teaching

Abstract

Equitable access to health services is fundamental to achieving universal health coverage, a principle underscored by both the Institute of Medicine in the United States¹ and the World Health Organization (WHO).² As a result, medical students in many parts of the world are mandated to undergo extended clinical training in rural or underserved areas to better prepare for practice and effectively serve community patients. Such requirements, however, create challenges given that the shortage (or unequal distribution) of community-based clinicians means there is necessarily a shortage (or unequal distribution) of community-based preceptors.³ With that in mind, we commend Alexandraki et al.'s⁴ efforts to investigate the motivators and barriers to teaching experienced by individuals serving as community preceptors. Their use of social cognitive career theory (SCCT) leads to conclusions that usefully draw attention to existing gaps and adversity supporting rural community preceptors' clinical teaching and career advancement. Their findings also underscore the importance, more generally, of enhancing clinical education in rural areas, emphasising that there is a necessity for stakeholders in underserved communities and medical schools to collaborate in establishing an inclusive educational environment and faculty development programme aimed at improving clinical teaching practices.

Alexandraki et al.⁴ highlight the disconnect between rural community preceptors and medical schools, attributing it to insufficient financial support, restricted access to resources, inadequate guidance and a sense of undervaluation. As a result, rural preceptors in their study reported needing to devise their own teaching strategies, tailored to their unique context, enabling them to overcome challenges and excel in their dual roles as both practising physicians and educators. As we reflect on these findings, we are struck by how many of the challenges rural preceptors can face that derive from social isolation. Graven et al.'s⁵ theory of social learning posits that professional development is inherently a social enterprise. O'Sullivan and Irby's⁶ model of faculty development goes further, emphasising that clinical preceptors are embedded in two communities of practice (CoP): the first comprises a community of educators involved in faculty development initiatives, while the second is the teaching practice community within preceptors' respective work settings (i.e., the workplace in which teaching occurs). O'Sullivan and Irby emphasise that inquiry into faculty development should focus on the interaction of elements within the two CoPs because one's engagement in each community so deeply impacts upon their activities within the other. Working in a community with fewer people, as rural preceptors do by definition, makes it harder, however, to find one functional community of practice (CoP) let alone two.

The importance of finding such social connection as a means of overcoming barriers is reinforced by Alexandraki et al.⁴ emphasising the considerable influence teaching attendings, and the vicarious learning that is offered by role models, has on community preceptors' readiness for teaching and their subsequent career decisions. Opportunities to interact with other people with similar interests contribute to the growth of self-efficacy, enhancing resilience and the ability to cope with adversity. Rural preceptors can harness these experiences when they are able to find mentorship, active participation in medical education communities and engagement in skill development programmes. Through coaching, scaffolding, interaction, assessment and reflection in authentic contexts, Wenger-Trayner and Wenger-Trayner⁷ argue that change is enabled within social learning spaces by enhancing expertise and capacity for the individual themselves but also benefiting other key stakeholders beyond the participant. Therefore, medical schools will benefit from more than simply gaining a single new preceptor if they collaborate with rural or underserved communities to co-create a social learning environment and facilitate sustainable learning among community preceptors.

Far from being a tale of inevitable struggle, optimism can be gained in this regard from the success stories reported by the authors. Despite the challenges in work–life balance and communication with medical schools, conducting clinical teaching in rural and underserved communities clearly remained a commitment for some rural clinical preceptors. Alexandraki et al.⁴ highlight that such individuals reported that feeling valued and supported was more important than monetary compensation, suggesting that social rewards may serve as stronger motivators than external ones. However, their career decisions may not always be enduring, as even the most motivated may experience professional exhaustion and burnout if they lose a strong sense of purpose or value-based motivation. This prompts us to consider the importance of shaping the professional identity of future physicians, illustrating the personal meaning that can be derived from teaching and helping them to appreciate the value brought to the educational system by community preceptors.⁴ Identity, after all, spans a continuum from individual traits to relational dynamics. Understanding the process through which rural community preceptors develop their teacher identity may provide learners with profound insight into how they navigate adversity in clinical education in ways that can not only inform the design of faculty development curricula but might also help better position the next generation to pay forward the benefits they have gained. Current conceptions of teacher identity suggest that it is neither fixed nor static but, rather, is fluid and evolving, continually shaped by an interplay between the individual's inner self and the surrounding social, political, cultural and institutional contexts.⁸ Developing a robust teaching identity that enhances job satisfaction and promotes professional growth is likely to require regular reminders of the value one is providing to learners and their future patients. Thus, medical schools and rural communities should collaborate to create clinical and educational environments that support integration between personal, clinical and teacher identities.

In sum, while incorporating rural clinical training and placement into training programmes significantly enhances the preparedness of medical students for primary care,⁹ overcoming systemic and structural barriers to integrating rural or underserved communities into the medical CoP is challenging. It is crucial that we overcome such barriers by thoughtfully pursuing social opportunities that reinforce rural physicians' identities as teachers and highlights the value they provide to their students if we are to build the workforce to the point of ensuring equitable access to health services. Establishing an inclusive educational environment to nurture the formation of teacher identities among rural community preceptors and aiding their transition to clinician-educators in their clinical settings yields mutual benefits for both rural or underserved communities and medical schools.

Chia-Yu Hu: Conceptualization; formal analysis; writing—original draft. Yu-Che Chang: Conceptualization; formal analysis; supervision; writing—review and editing.