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Common concepts in separate domains? Family physicians’ ways of understanding teaching patients and trainees,… Stenfors-Hayes, Terese; Berg, Mattias; Scott, Ian; Bates, Joanna Jun 27, 2015

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RESEARCH ARTICLE Open AccessCommon concepts in separate domains? Familyphysicians’ ways of understanding teachingpatients and trainees, a qualitative studyTerese Stenfors-Hayes1,2*, Mattias Berg3, Ian Scott1 and Joanna Bates1AbstractBackground: Medical education is increasingly expanding into new community teaching settings and the need forclinical teachers is rising. Many physicians taking on this new role are already skilled patient educators. The purposeof this research was to explore how family physicians conceptualize teaching patients compared to the teaching oftrainees. Our aim was to understand if there is any common ground between these two roles in order to supportfaculty development based on already existing skills.Methods: Semi-structured interviews with twenty-five family physician preceptors were conducted in Vancouver,Canada and thematically analyzed.Results: We identified four key areas of overlap between the two fields (being learner-centered; supporting theacquisition, application and integration of knowledge; role modeling and self-disclosure; and facilitating autonomy)and three areas of divergence (aim of teaching and setting the learning objectives; establishing rapport; andproviding feedback).Conclusions: Finding common ground between these two teaching roles would support knowledge translationand inquiry between the domains of teaching patients and trainees. It would furthermore open up new avenuesfor improving training and practice for clinical teachers by better linking faculty development and continuingmedical education (CME).Keywords: Family medicine, Patient, Physician, Qualitative research, Trainee, Faculty developmentBackgroundAround the world, medical education is expanding andmoving into new and more distributed and dispersedcommunities. In Canada, where this study was set, thenumber of students entering MD programs increased by73 % between 1995 and 2009 [1] and regional campusenrollment increased almost five-fold between 2005 and2009 [1]. This expansion means that more regional com-munity hospitals and community practice sites are nowbeing used in undergraduate programs [2–5]. These newcontexts of medical education, together with new modelsof education, such as longitudinal integrated clerkships,are increasingly relying on family physicians as precep-tors. Between 2003 and 2007 the number of part-timefamily medicine faculty members in Canada increased by64 % from 3605 to 5901. In the UK, approximately onethird of general practitioners are now involved in teach-ing undergraduate medical students [6], and Australia isalso projecting significant increases in community-basedgeneral practice preceptors [7].The large recruitment of primary care preceptors [8–10]means that many physicians now find themselves cast intoteaching roles because their practices are located at newlyassigned community education sites. The need for qualifiedpreceptors is often characterized as a major problem for ex-pansion [11] and training to improve teaching skills hasbeen recommended [12–17], especially for community-* Correspondence: Terese.stenfors-hayes@ki.se1Centre for Health Education Scholarship, University of British Columbia,Vancouver, BC, Canada2Department of Learning, Informatics, Management and Ethics, KarolinskaInstitutet, Stockholm 171 77, SwedenFull list of author information is available at the end of the article© 2015 Stenfors-Hayes et al. This is an Open Access article distributed under the terms of the Creative Commons AttributionLicense (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Stenfors-Hayes et al. BMC Medical Education  (2015) 15:108 DOI 10.1186/s12909-015-0397-zbased preceptors [18]. This training is traditionally offeredby units of faculty development linked to the universities.Ongoing primary care redesign is furthermore demandingnew clinical skills of preceptors teaching in complex clinicalsettings [19]. In Canada and elsewhere, regular attendanceat Continuous Medical Education (CME) activities ismandatory for all physicians. These activities addressdisease management, procedural instruction and practicemanagement and may focus on various themes such as acertain diagnostics, optimized chronic disease management,and motivational interviewing. Physicians that need to im-prove their skills in patient education may choose appropri-ate CME activities to meet these needs. However, thenumber and distribution of teachers has increased the diffi-culty of providing and encouraging the attendance of familyphysicians at both faculty development and (CME) events.Most newly recruited family practice preceptors arealready experienced in teaching patients in the contextof clinical care: They explain different treatment optionsto enable the patient to make treatment decisions; helppatients understand possible diagnoses and warning signsof evolving symptoms (e.g., fever of unknown origin or ab-dominal pain); and provide support for self-managementof chronic conditions (e.g., asthma or diabetes). As such,teaching and learning are central parts of the counselinginteractions between physician and patient. Patient educa-tion and communication is also part of the undergraduatetraining to become a physician [20, 21]. It has been sug-gested that educating patients and trainees requires simi-lar skills, and by learning to teach trainees, physicians maybecome better patient educators, and vice versa [22–24].To our knowledge, no empirical data has yet been gath-ered to further explore or support this claim.In this paper we explore how family physiciansconceptualize key aspects of teaching patients and teach-ing trainees and how they identify the similarities anddifferences between them. The findings of our explor-ation may be used to explore the possibility of integratedfaculty development and CME for physicians forimproving their teaching of both trainees and patientssimultaneously, and thereby helping to balance thesecompeting learning needs [25]. We suggest that drawingupon identified similarities, as well as differences be-tween the two fields will improve the effectiveness oftraining in both, as learning theory has shown that sim-ultaneous exposure to a wider array of teaching contextsand situations improves learning [26]. Existing examplesof integrated CME and faculty development do not inte-grate the learning in CME and the faculty development,but rather insert freestanding faculty development aboutseparate issues into the CME event [27]. Clinical exam-ples have successfully been used in faculty developmentfor preceptors [28], but we are not aware of situationswhere the two types of teaching have been comparedand contrasted. Comparing and contrasting is a centralcomponent of an effective learning strategy, but in orderto draw interchangeably from experiences in patientcounseling and clinical teaching, physicians must clarifytheir understanding of the similarities and also the dif-ferences between the two situations [26]. It requires anidentification of existing knowledge and skills as well asthe application of knowledge on a new topic to allowphysician learners to discern the differences and similar-ities between the old and new [29, 30]: in this caseteaching patients and teaching trainees. This study is afirst step towards exploring this possibility.MethodThis was an exploratory study, and as we wanted tofocus on physicians’ conceptions of the phenomena ra-ther than how their teaching is conducted, semi-structured interviews were deemed the most appropriatemethod. The research team consisted of two family phy-sicians (IS and JB), one family medicine resident (MB),and one medical education researcher (TSH). The datacollection was conducted in two phases. First, all thefamily physicians (n = 14) at a family practice teachingunit in British Columbia, Canada, were invited to par-ticipate in the study. The clinic provides teaching forundergraduate medical students and residents in familymedicine. Information about the project was emailed toall physicians inviting them to participate. The studyproposal was approved by the Research Ethics Board atthe University of British Columbia and all respondentsgave their written consent to participating. An initialinterview framework was developed and subsequentlymodified based on two pilot interviews. Since the pur-pose of the interviews was to explore as many aspects ofteaching patients and trainees as possible, most ques-tions were followed by probing and follow up questions[31]. All interviews were conducted by TSH. For the sec-ond part of the data collection an email was sent out toall family physicians in the Greater Vancouver region ofBritish Columbia who were engaged in the teaching ofboth patients and medical learners (n = 34). Twelve phy-sicians were recruited and interviewed by MB using thesame interview guide as in phase one. All interviewswere audio recorded and transcribed. Saturation was de-termined through a preliminary analysis alongside datacollection with discussion across the research team.To ensure that we were not influenced by the descrip-tion of teaching in one domain for the other, two re-searchers (IS and TSH) analyzed all the data from phaseone independently from the perspective of teaching pa-tients, and two researchers (JB and TSH) analyzed itfrom the perspective of teaching trainees. Each re-searcher read all transcripts, but after the first readingthe transcripts were filtered to only include aspects ofStenfors-Hayes et al. BMC Medical Education  (2015) 15:108 Page 2 of 9teaching patients or trainees respectively. The codingprocess was open and iterative. Classification of categor-ies was independent of the frequency with which theywere identified in the transcripts. As well as looking forconvergence, we also sought negative instances to ensurethat the analysis was not too aligned with our emergingnotions of the findings. Each sub team met repeatedlyand refined the coding for the two perspectives usingconstant comparison, where categories were further de-fined, merged, or deleted. We continued this processuntil we reached a negotiated consensus [32]. Once wehad established one set of themes for teaching patientsand another for teaching trainees, TSH synthesized theseand extracted the similarities and differences. TSH didso through an iterative process during which JB and ISregularly provided feedback. The data from phase twowas initially analyzed by MB using the same open andinterpretive coding procedure as described above. With-out having seen the findings of phase one, MB summa-rized the findings of phase two in a synthesized set ofthemes for similarities and differences for teaching pa-tients and trainees. TSH reviewed the findings and basedon the striking similarities between the two sets of find-ings the data was merged. As part of that process TSHreviewed and reanalyzed all the transcripts from phasetwo to strengthen the analysis. JB read all transcriptsfrom phase two to verify the analysis.ResultsTwenty-five physicians agreed to be interviewed: tenmen and fifteen women, between the ages of 30 and66 years. The respondents had been preceptors for 1 to40 years. All respondents were family physicians, andsome also had administrative roles in the medical educa-tion program. All respondents had regular opportunitiesto attend faculty development workshops at their cam-pus aimed at improving their teaching of trainees andCME events focusing on patient communication andcounselling. The extent to which the respondents hadparticipated in these varied, but all were aware of the op-portunities available to them. Preceptors spoke clearlyand thoughtfully about their teaching of patients andtrainees. We found areas of similarities as well as somedifferences in their conceptualization of the two teachingroles. To illustrate the findings, quotes have been se-lected from participants and include examples for bothtrainees and patients.SimilaritiesBeing learner centeredIndependent of whether the learner is a trainee or apatient, physicians try to adapt their teaching to thelearner’s level of knowledge, what they believe theyneed to know, and a way of communicating that suitseach learner.I ask them what they know already, what they’ve read,what they’re comfortable with, what they’re not. Ithink it’s really important to ask what patients arethinking, what their concerns are [about patients].To support the process of learning, physicians alsoemphasize the importance of patient/trainee motivation,and how they engage the patient/trainee if that motivationis missing. Some suggested that motivation among traineesto learn was often higher.I think trainees tend to be engaged or keen. Whereasthe switch is with patients, you need to engage them,you need to find out how motivated they are to learnabout what’s going on with them.Physicians also take the learner’s feelings into con-sideration and support their emotional health throughreassuring patients. They do so by providing informa-tion regarding their disease that is appropriate to theirneeds and providing suggestions for further learningfor the trainee to support their development as aphysician.It just feels like you just have to know where theperson is, and if you don’t know that, then there’s nopoint [about trainees].Physicians described how they incorporated culturaland social background and beliefs into their learner-centeredness in the case of patients, but less so withtrainees. One respondent also differentiated betweentrainees and patients, in that tailoring of education topatients’ needs was more specific to their situation orcontext, whereas medical learner education was tailoredmore to their competency level.With learners – my teaching techniques vary verymuch depending on their level in their educationaljourney. Whereas with patients it very much dependson their situation at the time, their need to know,their desire to know and the emotional situation. It’smore of a situational as opposed to a level of competencethat makes those decisions as to how you teach orapproach.Supporting the acquisition, application and integration ofknowledgePhysicians helped patients and trainees to gain newknowledge, contextualize information, and apply it to aspecific situation. When teaching patients, physiciansStenfors-Hayes et al. BMC Medical Education  (2015) 15:108 Page 3 of 9described how they translate the information thepatient has retrieved from different sources (i.e. theInternet), help break down the information into ‘di-gestible chunks,’ provide the right information at theright time, and help the patient to contextualize andapply the information to their own situation. Fortrainees, physicians help them to contextualize theirknowledge and apply it to a specific patient, and to in-tegrate knowledge from textbooks and preclinicaltraining with clinical experiences.A translator of the information (that the patient hasbrought) and what that means to the patient.Working through what that is, or an interpreter ornavigator [about patients].For the students it’s teaching them about integratingtheir medical knowledge and using it to explorecommunity resources and a realistic plan, not just atheoretical plan for investigation and management[about trainees].Physicians accomplish this in the context of the pa-tient or trainee (learner centeredness) as our first themedescribed, by building on the patient/trainees’ previousknowledge.So we just have to recognize the level that they’re at andrecognize where to challenge them [about trainees].The tools of good communication are the same forboth trainees and patients:I think the principles of how you communicate withsomeone are the same: Thoughtfulness, respect,clarity, pitching things at the right level and invitingquestions.However, physicians expressed that the process ofchecking for understanding with the learner may be afine balance to not intimidate them or to know whetherthey are answering honestly.But I don’t know that the patients would honestlysay, “No, I didn’t understand a word of what yousaid. It was way too complicated.” They’ll just say,“Oh, yeah, no, that make sense.” ‘Cause again,there’s a power dynamic and they don’t want tooffend me. And there’s a social desirability bias andall that stuff at play [about patients].I do try and get trainees to think about it (the answerto a question) first. And try and, in a way, you know,not to humiliate them or anything [about trainees].Many use the same pedagogical approaches and teach-ing techniques (illustrations, case descriptions, Socraticquestioning etc.) for both patients and trainees. Onephysician however suggests that with trainees one maybe using more specific teaching techniques (such asquizzing) than with patients.Role modeling and self-disclosurePhysicians draw on their own actions and experiences toprovide examples for both patients and trainees to learnfrom and to normalize patients’ and trainees’ experiences.With patients this role modeling and self-disclosure ap-pears to also be about gaining legitimacy in the patient’seyes and building rapport.Sometimes I’ll say, “When my kids were sick, thishappened.” Or, “I found with my kids with eating,this happened” and I think it helps the patient seethat you understand the challenges that they’rehaving because you had similar challenges. So it’snormalizing their challenges. And by me saying,“I’m a parent and this is what I think is going on.”Or, “This is what I’m recommending,” it may helpthem feel more comfortable in the recommendationI’m making [about patients].With trainees, the physicians also role model both as aperson and as a professional with the role modelingbeing both explicit and implicit with a significant focuson work life balance, patient care, and lifelong learningtechniques.Sometimes I know the answer, but I say, “Let’s lookthis up,” because I want to model kind of– let’s see ifwe can find this [about trainees].I think the job description for physicians are that theyneed to be self-motivated. Continually assessing theirown knowledge base and learning for the rest of theirlives. And so I want to model that and sort of inspirethem, you know [about trainees].Facilitating autonomyPhysicians showed support for the autonomy of bothtrainees and patients and strove to teach them how tomanage their problem (whether their own illness or apatient problem) independently through techniques suchas how to find relevant information and how torecognize when further help is needed. Physicians helpedboth patients and trainees to function “in the real world”(either by enabling patients to navigate successfullythrough the health system, or enabling trainees to prac-tice medicine effectively in the community). Physiciansdescribed that the patients need to be able to manageStenfors-Hayes et al. BMC Medical Education  (2015) 15:108 Page 4 of 9their illness effectively on their own, while trainees needto experience autonomy in order to develop as inde-pendent physicians.It’s the patient who needs to really identify what he orshe needs. And it is really important to, again, that’swhy it takes a bit of time, it’s to really try andunderstand what the needs are, help the patientarticulate that and then help the patient sort of figureout what’s the best course of action [about patients].You have to be comfortable letting go of the reins andallowing the residents to work through things [abouttrainees].Let them figure things out, guide them through thatsort of reasoning process and be there as a backup ora reassurance that nothing’s going to fall through thecracks. But allow them to experiment and figure outas best they can and learn from that process [abouttrainees].DivergenceAim of teaching and setting the learning objectivesPhysicians reported that in teaching both patients andtrainees, knowing their objectives was core to goodteaching. Physicians described the aims of teaching pa-tients in terms of helping them to improve their healthand quality of life and to slow the progression of dis-ease. The patient thereby brings crucial expertise tothe consultation as they are the experts in themselvesand the way they experience their health. Physiciansexplained that with patients the focus of teaching ison the patient’s questions, interest and own perceivedneed to understand their disease or to change their be-haviors and what they want to achieve. Physicians de-scribed the aims of teaching trainees quite differently:the trainees are there to learn to be physicians, whichmeans that the physician is supporting their profes-sional development and training them to be able tojoin a professional workforce. Thus, trainee learningoutcomes need to align with formal and informal cur-ricula, and licensing requirements.I have expectations on trainees. I cannot demandpatients to come up to certain level.If the patient doesn’t want to know, they don’t have toknow. They just have to know maybe to take theirmedication.Many physicians seem to have a ‘gold standard’ forwhat they want the trainee to achieve and the physicianmore clearly sets the agenda and the learning outcomesfor the trainees.Although I know we’re supposed to teach clinicalskills, I still think that it’s just so important for themto learn communication skills [about trainees].Establishing rapportThe importance of ‘connecting’ with patients was acentral concept in teaching, as was establishingrapport and trust. Less importance was ascribed toconnecting with trainees, while some physicians feltthat in their work with trainees ‘a connection’ wasestablished naturally through regular interaction. Theimportance that physicians attached to trainees con-necting with patients also highlights the importance ofthe issue of physicians establishing rapport withpatients.So if you want your patients to become healthier andif you want them to live healthier lives, then you haveto communicate with them and connect with themaround where we’re going with this. And I think it hasto be done together [about patients].[On teaching the importance of establishing rapport]:I always look at it from the point of view of what didyou learn from the patient. And if you just learn somefacts you’re probably not going to get very far.Because you take, you know, a 60 year-old womantalking to a 25 year-old resident, this woman’s lived inthe world for a long time; she’s not going to take theadvice of a 25 year-old person unless that person hascreated an alliance.Physicians often described trust as the core of a goodrelationship with a patient. One reason for the emphasison trust was the patients’ freedom to choose anotherphysician:It’s the patient who has to approve you for them tostay with you. So I think probably the most importantthing from their point of view is trust [aboutpatients].Providing feedbackPhysicians did not report giving overt feedback to patients,even if the physician had established clear objectives witha patient. However, giving constructive feedback wasdescribed as a central part of being a preceptor. Physicianfeedback to trainees was given in a variety of ways: uponrequest, during debrief after a patient encounter, or spon-taneously, for example during a case presentation.Stenfors-Hayes et al. BMC Medical Education  (2015) 15:108 Page 5 of 9Recognizing their strength and weaknesses and beingable to reflect back on what they’ve done and say, thisis what’s changed, this is what hasn’t changed, this iswhat you’ve learned [about trainees].Some physicians did report feeling hesitant to providenegative feedback to trainees.We’re pleasers and we don’t always want to criticizetrainees when they’re not doing a particularly goodjob [about trainees].Reciprocal learningPhysicians described their relationships with both pa-tients and trainees as rewarding and satisfying. With pa-tients the longitudinal aspects were especially cherishedas many followed their patients and their families for30 years or more. With trainees the ability to followtheir professional growth was also valued. Additionally,physicians expressed that there was reciprocal educa-tional value in what they could learn from their medicaltrainees.It’s always surprising what you learn from residents. Ialways manage to learn something from them [abouttrainees].The other big value is trainees keep you up to date.They ask you questions and they give you someconfidence that you’re maintaining your abilities[about trainees].Discussion and conclusionsOur analysis shows examples of both similarities and dif-ferences in the way physicians conceptualized theirteaching of patients and trainees. We found four keyareas of overlap: first, we identified learner-centerednessas a key concept. Physicians described this orientationwith both trainees and patients in similar ways, such asfocusing on understanding the trainee or patient as awhole person with individual needs and expectations tobe integrated in the learning situation as described. Thisperspective has been described in both medical educationand patient education literature [33, 34]. Our second simi-larity is that with both trainees and patients, physicianstried to facilitate the acquisition, integration, and applica-tion of knowledge as well as emphasize the importance ofproviding information at the right time. Both medical edu-cation and patient counselling have developed theoreticalframeworks that outline the process of learning in theirdomain. In the higher education literature, the concept ofteaching in the zone of proximal development describesthe importance of understanding what the trainee knowsand does not yet know, and focusing the teaching in thezone just beyond their current knowledge [35]. In thepatient education literature, behavioral change modelsemphasize the process that patients undergo whenmoving through changing their health habits [36]. Thesemodels include the patient’s readiness for change, and theimportance of presenting information when the patient isready to use it. Theoretical frameworks in use in bothdomains use the key concepts of assessing the learner’sreadiness to learn, and ensuring that the right level ofinformation is presented and support provided to thelearner at the right time. Although the language is differ-ent, there are clearly similarities between theoreticalframeworks in use in the two domains.Physicians were aware of their implicit role modelingwith trainees and patients. With trainees, the physiciansalso used explicit role modeling. Such role modelinghas been shown to support trainee learning and devel-opment [37, 38]. However, role modelling is not onlyabout clinical competence as one respondent suggestsbut also about good teaching ability and personalattributes [39]. Physicians also used self-disclosure toprovide insights for their learners drawn from the phy-sician’s experience and to help build rapport with thepatient and to normalize the patient’s challenges. How-ever, the value of self-disclosure as a clinical tool is notclear [40, 41]. Finally, we also found that physiciansaimed to support the autonomy of both trainees and ofpatients. Autonomy is also a way of enhancing self-efficacy [42], which is the belief an individual holds re-garding her ability to succeed in a specific situation[43]. In clinical education, new models focus on traineeinitiative and emphasize self-directed and self-regulatedlearning to help develop independency [44–46]. In patienteducation, self-management and self-care are key concepts[47]. Self-management can be supported by patient em-powerment which focuses on their right and ability tochoose by and for themselves [48]. Although under differ-ent names and techniques, the aim in both clinical educa-tion and patient education is to increase the learners’ability to ‘manage on their own’. We believe that the areasidentified by the respondents are well in line with what isvalued in medical trainee education today.One area of difference we identified was that whenteaching trainees, physicians take a much more activerole in setting the objectives for learning. This may berelated to the perceived difference in the goals of eachgroup. With patients, the goal of teaching was to im-prove patient health and well-being, and patient healthbehaviors, with patients naturally bringing greater know-ledge of their illness experience to the patient-physicianconsultation. With trainees, the goal of teaching was tofacilitate trainee development into competent physicians(i.e. ‘the gold standard’). While physicians have more ex-pertise in what it means to be a competent physicianStenfors-Hayes et al. BMC Medical Education  (2015) 15:108 Page 6 of 9than the trainees they are teaching, the emergence ofcompetency based curricula may shift this divergence, astrainees may take on a larger role in determining theirown needs to achieve a set of competencies.Our second area of difference was related to buildingrapport and trust and this differential was linked to theimportance of establishing a ‘connection’ with patients.The physician’s ability to establish rapport also affectsthe level of trust established [49, 50] with both traineesand patients. With patients, continuity of care facilitatesthe development of a trusting relationship [51]. Effectiveteaching of trainees also requires such a relationship[52–54]. The difference between these two relationshipsis that the physician has the power of expertise overboth trainee and patient but the physician also holds le-gitimate power over trainees in the formal assessment ofthem [55]. Our interview findings reflect the emphasison the ‘connection’ between patient and physician, whilstthe importance of a similar connection with trainees wasnot described by the physicians. The importance ofestablishing such relationships is increasingly empha-sized in medical education [56] and supported throughthe development of longitudinal clerkship programs [57]and mentor programs [58]. These new programs demon-strate the importance of continuity of relationship be-tween preceptors and learners [59]. However, none of therespondents in the current study were participating in lon-gitudinal medical education innovations which may be areason for the lack of emphasis among them in this field.The third area of divergence focuses on the role offeedback in learning. Physicians we interviewed spoke atlength about feedback to trainees but never mentionedfeedback to patients. Clinical teaching models emphasizethe need for constructive feedback as a learning tool,and many efforts in both assessment and faculty devel-opment are aimed at promoting effective feedback totrainees [60–63]. If feedback is such a learning tool fortrainees, conceptualization of physician feedback onpatients’ learning and behavioral change might improvethe development of their self-management skills. However,it may be that physicians use other techniques such astracking of health indicators such as blood pressure,weight, or blood sugar to provide feedback and to achievethe suggested changes. Our findings also showed howeducating patients and trainees is considered rewarding,but in somewhat different ways. For both types of teachingthe physicians enjoy the longitudinal aspects of followinggrowth and development, whether personal or profes-sional. With trainees the physicians also felt they learned alot from the trainees regarding current medical practice.Limitations of studyThis study is based on interviews with family practicepreceptors from one university, with various clinicalpractices. We did not explore differences among physi-cians with respect to the level of the trainees they usuallysupervised, i.e. if they were undergraduates or residents.This may be an interesting question to pursue in furtherresearch. All respondents had extensive experience inteaching both trainees and patients and most of them hadalso practiced and taught in more than one setting. Theresponse rate for the study was high in phase one and datasaturation suggests that the number of interviewees wasacceptable. Because phase one of our research took placein a family medicine academic teaching unit, we might ex-pect these physicians to be thoughtful about teaching inboth domains. Our second dataset, however, indicates thatthese findings hold true in other contexts. Trustworthi-ness of the findings has been strengthened by local andinternational presentations and discussions of the results[64, 65].Implications for practiceThe need for improved teaching skills among physicianshas been advocated by many, yet the difficulty of provid-ing family physicians both faculty development andCME events has increased. We therefore propose amerging of these two domains: teaching patients andtrainees. We suggest that some aspects of faculty devel-opment be reframed to make better use of physicians’existing knowledge and experience drawn from patientcare and to facilitate transfer of knowledge and skillsfrom one domain to the other. Thus we can imaginesupporting physician CME at faculty development eventsand supporting faculty development at CME events. How-ever, in order to draw interchangeably from experiences inpatient counseling and clinical teaching, physicians mustunderstand the similarities and also the differencesbetween the two situations [26].Faculty development activities are highly valued by theparticipants [66] and may lead to personal growth andfor participants to become more critically reflectiveteachers [39]. Perhaps this increased level of reflectiveteaching can be transferred to patient education as well?We can anticipate that increased knowledge about thesimilarities and differences of the two domains may leadto new understanding of each of these domains. Anincreased awareness on the importance of building rap-port with trainees can be created from our experiencesin patient education, and we can bring what we knowabout feedback into our patient encounters. Finally, ourstudy also showed that being a preceptor was consideredan important way to maintain one’s medical knowledge.With our work we propose a way of approaching facultydevelopment to meet the needs of increasing numbers ofpreceptors in community-based settings. We would like toinvite discussion regarding how a more synergistic under-standing of the teacher role (of both trainees and patients)Stenfors-Hayes et al. BMC Medical Education  (2015) 15:108 Page 7 of 9may lead to an increased capacity for teaching the nextgeneration of physicians as well as benefit patient care. Inthis paper we have explored how family physiciansconceptualize their teaching of trainees and patients re-spectively. While the language and context in the two do-mains (teaching patients and teaching trainees) may differ,some of the underlying concepts and meanings are simi-lar. We believe that an increased integration of the over-lapping aspects of the two domains of teaching patientsand trainees in the training of physicians and others maygradually lead to the emergence of a shared language, andmay help advance the education, research, and practice ofphysicians independently of whether the learner they areseeing is a trainee or a patient.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsTSH and JB conceived of the study, TSH and MB carried out the interviews,all authors (TSH, JB, IS and MB) contributed to the analysis of the data. TSHwrote the first draft of the paper, with contributions from JB and IS onsubsequent versions, all authors read and approved the final manuscript.Authors informationTerese Stenfors-Hayes is assistant professor at Karolinska Institutet and Dir-ector of the Evaluation Unit, at the time of data collection, she was a post-doctoral research fellow at University of British Columbia.Mattias Berg is a family physician and fellow of emergency medicine at theUniversity of British Columbia.Ian Scott is associate professor, Department of Family Practice, and directorof undergraduate family medicine programs at the University of BritishColumbia.Joanna Bates is professor, Department of Family Practice and director of theCentre for Health Education Scholarship at the University of British Columbia.AcknowledgementsThis project was supported by the BCCFP Research Awards Fund, theResearch & Education Foundation and Faculty Development Initiatives GrantProgram at University of British Columbia and Royal College/AssociatedMedical Services CanMEDS Research and Development Grant. The authorswould like to thank research assistant Wendy Hartford for her assistance inthe revisions of the manuscript.Author details1Centre for Health Education Scholarship, University of British Columbia,Vancouver, BC, Canada. 2Department of Learning, Informatics, Managementand Ethics, Karolinska Institutet, Stockholm 171 77, Sweden. 3Department ofEmergency medicine, University of British Columbia, Vancouver, BC, Canada.Received: 12 December 2014 Accepted: 19 June 2015References1. AFMC: Mapping undergraduate distributed medical education in Canada.The Association of Faculties of Medicine of Canada (AFMC) 20102. Nutter D, Whitcomb M: The AAMC project on the clinical education ofmedical students. Association of American Medical Colleges (AAMC) 20013. Mallon WT. Medical school expansion: deja vu all over again? Acad MedJ Assoc Am Med Coll. 2007;82(12):1121–5.4. Strasser RP, Lanphear JH, McCready WG, Topps MH, Hunt DD, Matte MC.Canada’s new medical school: the northern Ontario school of medicine:social accountability through distributed community engaged learning.Acad Med J Assoc Am Med Coll. 2009;84(10):1459–64.5. Howe A, Campion P, Searle J, Smith H. New perspectives–approaches tomedical education at four new UK medical schools. BMJ.2004;329(7461):327–31.6. Wass V. Growing your own. Educ Prim Care. 2005;16:215–6.7. Thistlethwaite JE, Kidd MR, Hudson JN. General practice: a leading providerof medical student education in the 21st century? Med J Aust.2007;187(2):124–8.8. AFMC: Canadian medical education statistics. The Association of Faculties ofMedicine of Canada (AFMC) 2012, 34.9. Krupa LK, Chan B. Canadian rural family medicine training programs. CanFam Physician. 2005;51:852–3.10. Bunton S, Sabalis R, Sabharwal R, Candler C, Mallon W: Medical schoolexpansion: challenges and strategies. In Association of American MedicalColleges (AAMC); 2008.11. AAMC: results of the 2009 medical school enrollment survey report to thecouncil of deans. In Association of American Medical Colleges (AAMC);2010.12. Frank J: The CanMEDS 2005 physician competency framework. Betterstandards. Better Physicians. Better Care. Royal College of Physicians andSurgeons of Canada; 2005.13. Ross MT. Learning about teaching as part of the undergraduate medicalcurriculum: perspectives and learning outcomes. Edinburgh: The Universityof Edinburgh; 2012.14. Liason Committe in Medical Education Accreditation standards andexplanatory annotations [https://www.meded.umn.edu/lcme/documents/LCME_Accred_Stds_for_retreat_cases.pdf]15. GMC. Tomorrow’s doctors: outcomes and standards for undergraduatemedical education. London: General Medical Council; 2009.16. Teherani A, O’Brien B, Masters D, Poncelet A, Robertson P, Hauer K. Burden,responsibility, and reward: preceptor experiences with the continuity ofteaching in a longitudinal integrated clerkship. Ac Med. 2009;84:s50–3.17. Daly M, Perkins D, Kumar K, Roberts C, Moore M. What factors in rural andremote extended clinical placements may contribute to preparedness forpractice from the perspective of students and clinicians? Med Teach.2013;35(11):900–7.18. Cook DA: Study of clinical teachers in canadian faculties of medicine.Association of Faculties of Medicine of Canada AFMC 2009.19. Eiff MP, Waller E, Fogarty CT, Krasovich S, Lindbloom E, Douglass AB, et al.Faculty development needs in residency redesign for practice in patient-centeredmedical homes: a P4 report. Fam Med. 2012;44(6):387–95.20. Von Fragstein M, Silverman J, Cushing A, Quilligan S, Salisbury H, Wiskin C.UK consensus statement on the content of communication curricula inundergraduate medical education. Med Ed. 2008;42(11):1100–7.21. Aspegren K: BEME Guide No . 2 : Teaching and learning communicationskills in medicine -a review with quality grading of articles. MedicalTeacher. 1999; 21(6):563–570.22. Dandavino M, Snell L, Wiseman J. Why medical students should learn howto teach. Med Teach. 2007;29(6):558–65.23. Cohen S, Dennick R. Applying learning theory in the consultation. ClinTeach. 2009;6:117–21.24. D’Ivernois JF, Albano MG. Therapeutic patient education: a new deal formedical education? Med Teach. 2010;32(12):945–6.25. Walters L, Greenhill J, Richards J, Ward H, Campbell N, Ash J, et al.Outcomes of longitudinal integrated clinical placements for students,clinicians and society. Med Educ. 2012;46(11):1028–41.26. Marton F. Sameness and difference in transfer. J Learn Sci.2006;15(4):449–535.27. Karg A, Boendermaker PM, Brand PL, Cohen-Schotanus J. Integrating continuingmedical education and faculty development into a single course: effectson participants’ behaviour. Med Teach. 2013;35(11):e1594–7.28. Langlois JP, Thach SB. Bringing faculty development to community-basedpreceptors. Acad Med J Assoc Am Med Coll. 2003;78(2):150–5.29. Marton F, Pang MF. On some necessary conditions of learning. J Learn Sci.2006;15(2):193–220.30. Van Merriënboer JJG, Sweller J. Cognitive load theory in healthprofessional education: design principles and strategies. Med Ed.2010;44(1):85–93.31. Cousin G. Research learning in higher education. London: Routledge; 2009.32. Wahlström R, Beermann B, Dahlgren LO, Diwan V. Changing primary caredoctors’ conceptions - a qualitative approach to evaluating an intervention.Adv Health Sci Educ Theory Pract. 1997;2:221–36.33. Laine C, Davidoff F. Patient-centered medicine. JAMA. 1996;275(10):152–6.34. Weston WW. Patient-centered medicine: a guide to the biopsychosocialmodel. Fam Syst Health. 2005;23(4):387–92.Stenfors-Hayes et al. BMC Medical Education  (2015) 15:108 Page 8 of 935. Vygotsky L: Mind in society: The development of higher psychologicalprocesses. In., edn. Edited by Cole M, John-Steiner V, Scribner S, SoubermanE. Cambridge, MA: Harvard University Press; 1978.36. Prochaska JO, DiClemente CC. Stages and processes of self-change ofsmoking: toward an integrative model of change. J Consult Clin Psychol.1983;51(3):390–5.37. Wright S. Examining what residents look for in their role models. Ac Med.1996;71(3):290–2.38. der Jochemsen-van Leeuw HGR, Van Dijk N, Van Etten-Jamaludin FS,Wieringa-de Waard M. The attributes of the clinical trainer as a role model:a systematic review. Ac Med. 2013;88(1):26–34.39. Balmer DF, Richards BF. Faculty development as transformation: lessonslearned from a process-oriented program. Teach Learn Med.2012;24(3):242–7.40. Mcdaniel SH, Beckman HB, Morse DS, Silberman J, Seaburn DB, Epstein RM.Physician self-disclosure in primary care visits. Arch Intern Med.2013;167:1321–6.41. Beach MC, Roter D, Rubin H. Is physician self-disclosure related to patientevaluation of office visits? J Gen Intern Med. 2004;19:905–10.42. Andersson R, Funnell M. Patient empowerment: myths and misconceptions.Patient Educ Couns. 2009;79:277–82.43. Bandura A. Self-efficacy: toward a unifying theory of behavioral change.Psych Rev. 1977;84(2):191–215.44. Ten Cate O, Snell L, Mann K, Vermunt J. Orienting teaching toward thelearning process. Ac Med. 2004;79(3):219–28.45. Bowen J. Educational strategies to promote clinical diagnostic reasoning.New Eng J Med. 2006;355:2217–25.46. Stickrath C, Aagaard E, Anderson M. MiPLAN: a learner-centered model forbedside teaching in Today’s academic medical centers. Ac Med.2013;88(3):13–6.47. Lorig K, Holman H. Self-management education: definition, outcomes andmechanism. Ann Beh Med. 2003;26(1):1–7.48. Aujoulat I, d’Hoore W, Deccache A. Patient empowerment in theory andpractice: polysemy or cacophony. Patient Educ Couns. 2007;66:13–20.49. DiMatteo M. A social-psychological analysis of physician-patient rapport:toward a science of the art of medicine. J Soc Issues. 1975;35:12–33.50. Tate P. The doctor’s communication handbook. 6th ed. Oxon: RadcliffePublishing Ltd.; 2009.51. Ogle KD, Boulé R, Boyd RJ, Brown G, Cervin C, Dawes M, et al. Familymedicine in 2018. Can Fam Physician. 2010;56(4):313–5.52. Goertzen J, Stewart MA, Weston WW. Effective teaching behaviors or ruralfamily medicine preceptors. Can Med Assoc. 1995;153(2):161–8.53. Neighbour R. The inner apprentice: an awareness-centred approach tovocational training for general practice. 2nd ed. Abingdon: RadcliffeMedical Press; 2004.54. Evans DE, Alstead EM, Brown J. Applying your clinical skills to students andtrainees in academic difficulty. Clin Teach. 2010;7(4):230–5.55. Raven BH. The bases of power and the power/interaction model ofinterpersonal influence. Anal Soc Issues Public Policy.2008;8(1):1–22.56. Hodges B, Albert M, Arweiler D, Akseer S, Bandiera G, Byrne N, et al. Thefuture of medical education: a Canadian environmental scan. Med Educ.2011;45(1):95–106.57. Hauer KE, Hirsh D, Ma I, Hansen L, Ogur B, Poncelet AN, et al. The role ofrole: learning in longitudinal integrated and traditional block clerkships.Med Ed. 2012;46(7):698–710.58. Sambunjak D, Straus SE, Marusic A. A systematic review of qualitativeresearch on the meaning and characteristics of mentoring in academicmedicine. J Gen Intern Med. 2010;25(1):72–8.59. Hauer KE, O’Brien BC, Hansen LA, Hirsh D, Ma IH, Ogur B, et al. More isbetter: students describe successful and unsuccessful experiences withteachers differently in brief and longitudinal relationships. Ac Med.2012;87(10):1389–96.60. Ramani S, Krackov SK. Twelve tips for giving feedback effectively in theclinical environment. Med Teach. 2012;34(10):787–91.61. Norcini J. The power of feedback. Med Ed. 2010;44:16–7.62. Holmboe E, Yepes M, Williams F, Huot S. Feedback and the mini clinicalevaluation exercise. J Gen Intern Med. 2004;19:558–61.63. Norcini J, Burch V. Workplace-based assessment as an educational tool:AMEE Guide No. 31. Med Teach. 2007;29:855–71.64. Stenfors-Hayes T, Scott I, Bates J: Family physicians’ ways of understandingthe two solitudes of clinical teaching [abstract]. Quebec: CanadianConference on Medical Education (CCME); 2013.65. Stenfors-Hayes T, Scott I, Bates J: Doctors teaching patients and trainees:finding common ground [abstract]. Prague: Association of MedicalEducation in Europe (AMEE); 2013.66. Sorinola OO, Thistlethwaite J. A systematic review of faculty developmentactivities in family medicine. Med Teach. 2013;35(7):e1309–18.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitStenfors-Hayes et al. 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