Training in Medical Residency: the preceptors’ view

Aderval de Melo Carvalho Filho1,2,3 iD Almira Alves dos Santos1 iD Rozangela Maria de Almeida Fernandes Wyszomirska1,2 iD Juliana Holanda de Gauw3 iD Iandara Maria Sampaio Ribeiro Soares Gaia4 iD Ricardo Macedo Houly2 iD adervalfilho@hotmail.com almira_alves@yahoo.com.br rozangelaw@yahoo.com.br julianagauw@hotmail.com iandaramgaia@hotmail.com drhouly@hotmail.com Formação na Residência Médica: visão dos preceptores


INTRODUCTION
First appeared in Brazil in the 1940s, Medical Residency (MR) is a type of training for physicians 1 . After approximately 30 years of its implementation, it has been duly regulated by Decree n. 80.281/77 2 , which defined: Medical Residency is a modality of postgraduate education aimed at physicians, constituting a specialization course, characterized by in-service training on an exclusive dedication regimen, carried out in health institutions, in a university environment or not, under the guidance of physicians with high ethical and professional qualifications 2 .
The resident, usually a recently graduated professional and/or with little professional experience, has the chance to obtain theoretical and, above all, practical experiences in the different specialties offered at the MR. As it is a practical training, MR is usually so impactful that it can be considered as the stage of personal and professional life that most affects the profile of young physicians 3 .
According to Pessoa and Constantino 4 , it is "the best way to improve and specialize in Medicine". This idea is reinforced by Trindade 5 , who states that there is "no doubt that MR is still the best way to train medical professionals, with their learning based on in-service training and under the supervision of a preceptor". It is also considered the gold standard, a reference for training specialist physicians in Brazil 2 , attaining relevance and a huge degree of responsibility for having this characteristic of continuing medical training after graduation.

The preceptor of medical residency and their importance
The preceptor is essential for the quality of the resident's training and must stimulate the development and gain of technical skills and ethical sense 1, 6 , despite the difficulties that may exist in practice environments. They represent a type of interlocutor between the academy (educational world) and health services (care world) 7,8 , with the simultaneous tasks of working in the training of the students, in addition to providing quality assistance to the health care users 9 . Their objective must be the comprehensiveness of the practices, which is one of the fundamental principles that guide SUS 10 .
For the success of the MR program, assistance and educational actions must always be the priority in relation to bureaucratic activities, aiming to train professionals that are closer to the reality of health systems 7 . From this point of view, the residents must gradually mature their reasoning, thus requiring them to be constantly evaluated during their training by the preceptor, working and learning in the same environments where they develop care activities 1 .
In 2006, the minimum requirements for the Medical Residency Programs (MRP) operations were established, in addition to specific guidelines on the development of theoretical-practical activities, equipment, theoretical schedules for each year of training, suggestions for carrying out internships and complementary courses for each medical specialty, among other recommendations 11 .
However, the activities of the preceptor with the resident still tend to be very poorly organized (in the most varied contexts and environments of MR practices), therefore depending on the determinations of the services and hospital institutions 12,13. Overall, a lack of conceptual adequacy regarding their pedagogical competence is observed, where the preceptor is considered as a type of technical reference, having competence in their specialty 12,13 .
Recent national policies to expand the number of MRPs and the increase in vacancies for new graduates have substantially increased the responsibility of the preceptor's role 14 , in addition to the existing challenges. This has demanded increasingly more competence and pedagogical training from the preceptor, in addition to a high level of technical training in their specialty, which may be represented by their participation in courses, stricto sensu programs or pedagogical training. Blue et al 15 reinforced the value of pedagogical training, declaring that teachers with pedagogical skills tend to enhance their students' learning.
In general, preceptors begin their pedagogical tasks in MR with little or no preparation or training to teach 16 . A low percentage of preceptors with some type of pedagogical training has been reported, as well as the knowledge of active teaching methodologies in this type of environment 17 .
Despite this unfavorable scenario, there is an understanding by the preceptors regarding the importance of carrying out some training to better develop their tasks in the context of the MR 12,13,17 . The use of educational resources and their potential for disseminating information 18 can offer educational support 19 , being important to contribute to these preceptors' training. Some are already available, in an attempt to meet these deficiencies [20][21] .
Once the importance of the preceptor and preceptorship has been evidenced, there is a growing need to understand this environment for the training of specialists, which is a subject that requires further studies. Therefore, this research aims to analyze the experiences and detailed perceptions of preceptors in the educational process in the MR in the city of Maceió, state of Alagoas (AL), Brazil.

METHODS
A descriptive and quantitative study was carried out, developed at Universidade Estadual de Ciências da Saúde de Alagoas (Uncisal).
There are approximately 450 preceptors in the city of Maceió, AL. The population of the present study was obtained by convenience, consisting of 300 MR preceptors, of both genders and from all age groups. This sample is considered representative of this universe. Specialist physicians who performed pedagogical together with assistance activities 12 with their resident physicians, in a MEC-accredited MRP in Maceió, AL, were considered preceptors. Preceptors who were on leave from their teaching duties were excluded.
Data collection was carried out using the same procedure and the same instrument, in two different moments: in-person (September 2019 to March 2020); and remote (due to the Covid-19 pandemic), between July and August 2020. Even though it was necessary to carry out two approaches for this collection, no difficulties or obstacles were observed that deserved to be recorded for the data analysis.
The invitation to participate in the study was sent personally (in-person collection) and through a message exchange application (remote collection). After acceptance, the filling out of the questionnaire was scheduled for the in-person collection, in which the participants received clarifications about the stages of the study, its purpose and relevance. Data confidentiality was also observed. Afterwards, the Free and Informed Consent form (FICF) was verified for acceptance and subsequent signature. As for the remote format, information was sent to the participants about the study, in addition to the informed consent form, by e-mail or through a messaging application. After signing the FICF, access to the online questionnaire was made available.
The data collection instrument used in the study was developed and validated by Girotto 13 , in her Master's Degree thesis, after an extensive literature review and consensus of experts in preceptorship and health education. Its purpose is to promote a more detailed analysis of preceptorship, focusing on the preceptors' observation and opinion about their activities in the training of specialists, in addition to the structure in the institutions where preceptorship is carried out 13 .
This questionnaire has a total of 35 statements related to the preceptors' view of their role in the educational process, in addition to the practice scenarios. The answers to the statements were constructed using a five-point Likert scale: Totally Agree (TA), Partially Agree (PA), Indifferent (I), Partially Disagree (PD) and Totally Disagree (TD). A value (score) was assigned to each of the responses: 5=TA, 4=PA, 3=I, 2=PD and 1=TD. For the statements that represented negative concepts about preceptorship, their scores were inverted for the purpose of the analysis of the results 13 . It was explained to the interviewees that they had to interpret the term "student", found in the questionnaire, as "resident".
When analyzing the results of his questionnaire, Girotto 13 grouped the answers, in which a Positive Perception (PP) was considered for the respondents' answers "TA" and "PA" regarding the statement. In turn, the answers "I", "PD" and "TD" were included in a second group, considered as a Negative Perception (NP). The answers were later analyzed through the obtained percentages of PP and NP, in each statement. Therefore, this same methodology validated by the author of the questionnaire 13 was accurately followed in this study.
Girotto, based on the analysis of the information (when validating her questionnaire), identified five domains 13 . Each statement belongs to one of these five topics below:

Ethics Committee
The study was submitted to the Research Ethics

Analysis of results
After the collection, the information was structured into spreadsheets using the Microsoft Excel Program. For the inferential analysis of the statements, the percentages of perceptions (positive or negative) were calculated, in addition to the averages and standard deviations.

RESULTS
The results presented herein derive from a sample of 300 physicians, MR preceptors belonging to five hospital institutions in Maceió, AL: a federal public university institution, a state public university teaching institution and three private hospitals.
Regarding the sociodemographic data, the preceptors'

Preceptors' perception of the preceptorship
Data related to Domain 1 are detailed in Table 1. There was a predominance of PP by the preceptors. Statements 22, 24 and 25 obtained a PP of 98.67%, 96% and 98.33%, respectively. The answers obtained for statements 11 and 21 also obtained a predominance of positive perception (88.67% and 87%, respectively).
Regarding the statements present in Domain 2, the means and percentages of the PP were lower in relation to the first factor. Only statements 7 and 10 showed a positive perception above 70%. Statement 32 obtained a PP of 64%. On the other hand, statement 9 obtained only 28% of PP ( Table 2).
In Domain 3, the statements that obtained the highest percentages of PP were statements 5 and 8, with 91.34% and 90.66%, respectively. Statement 30 had the lowest percentage of PP (44.34%). The results are detailed in Table 3.
In Domain 4, statements 18 and 20 attained the highest percentages of PP (85% and 84.67%, respectively), as shown in Table 4.    of board-certified professionals in the country (approximately 45% of the specialists) 14 .
Regarding the five domains of the questionnaire created and validated by Girotto 13 , in Pedagogical Competence, the results suggest that the participants of this study recognize the importance of their competences in the educational process of MR. They also claim to be aware of the importance of scientific updating and continuous improvement to perform their tasks in MR with quality.
The concept of competence, as well as its importance In general, these preceptors feel prepared to develop their teaching activities (statement 11, Pedagogical Competence), suggesting that they feel secure both in their assistance (attending their patients) and teaching functions (accompanying their residents), in their commitment to the residents.
Regarding teaching, it is important to highlight that those teachers/preceptors who have a greater aptitude for teaching will have an enormous potential to positively influence their students. Otherwise, students who have contact with tutors with little teaching skills may demonstrate lower rates of significant learning 15 . Thus, the preceptor who is technically and pedagogically prepared for preceptorship will have a greater chance of having tools that will help them in their task of teaching. Hence the importance of carrying out pedagogical training by the preceptor to better perform their teaching activities.
In response to statement 34, it was shown that preceptors are interested in teaching, with 55% of PP for this statement. One possibility that may explain this finding is the fact that the teaching career (in the context of undergraduate school) is yet another professional option, considering the expansion of medical courses across the country 14 . It can also constitute one more sign of the preceptors' interest and commitment with medical education. However, a factor that can negatively influence the interest in teaching is the low remuneration, according to Barbosa 26 , especially when compared to other higher education professions. Finally, Girotto 13 described a similar finding to this study, when reporting a predominance of PP for the identification of their needs to prepare for preceptorship (statement 25), even considering themselves mostly adequate for this activity (statement 11).
In the Educational Support and Resources domain, the results showed that in general the preceptors claim to be in an appropriate physical space and structure for MR activities.
Therefore, when concerning aspects such as support and physical structure, they consider that the fact they have the necessary means to carry out their educational practices (predominance of PP in statement 7) means the acknowledgement of the importance of their activity in MR. They also claim they have adequate physical space (PP predominance in statements 32) and that they receive adequate support from their managers and the institutions that regulate the MRP (PP predominance in statements 10, 13 and 17).
This means that Maceió has preceptors in the MRP who have the appropriate structure for the efficient running of MR activities, in addition to the necessary support from their managers and the hospital institution, which even appreciate them as educators. This is a strong sign that there is a commitment by these other actors, who are also fundamental for MR, aiming to promote quality in their MRPs. pedagogical activities with their residents. Therefore, the presence of the residents themselves in the service already has the potential to cause positive impacts on its physical structure, reflected in the acquisition of new materials and improvements in general.
Nevertheless, attention was drawn to the topic of pedagogical training, which showed a proportion of 72% of NP in statement 7. This can be explained by the low number of training courses for preceptorship, which is a matter of concern, as it is important to invest in these preparatory courses. Marins 16 emphasizes this concern, noting that in most health professions there is no tradition in pedagogical training.   In addition to the MR context, the relationship between preceptor and student is also important in undergraduate school and should be considered as important as the relationship between physician and patient. In this environment, the preceptor is responsible for the professional initiation of the future physician.
Nevertheless, studies with divergent results were found. The possible work overload was also reported 13 , where the preceptors demonstrated that the students had a negative influence, overloading their activities. This pressure can mean the preceptor's unpreparedness, as they start to accumulate functions, becoming at the same time a service provider (with an increasing work demand) and an educator 22 .
Regarding the impact of residents on health users and on the service, the present study reported that their presence However, on the contrary, a study 13 described a negative perception of preceptors, who, in general, reported that the presence of residents was displeasing to users, even with the potential risk of compromising their safety. However, the study did not explain the cause for these results.
In this study, only a minority of preceptors mentioned being paid to carry out their educational attributions, whose justification may be related to the scarcity of scholarships or financial aid for preceptorship in Maceió. This is a sign of alarm and devaluation of preceptorship, which can cause dissatisfaction at work and low self-esteem, given the commitment and responsibility the preceptor has in the training of the resident physician. It is worth mentioning that the issue of negative impacts resulting from low or absence of remuneration is well evidenced in the literature, such as discouragement, learning difficulties and drop in performance 27 .

FINAL CONSIDERATIONS
The results disclosed that most preceptors state they are included in a socially pleasant and suitable environment to carry out pedagogical activities with residents and care for their patients. They report the improvement in their quality of professional life with the company of residents. They also have an adequate physical structure, in addition to the due recognition and support of their respective managers and the institution for carrying out this activity in the MR. The preceptors also reported having a commitment to the stages of the educational process of their residents. They stated they are prepared to be preceptors, being aware of their own needs for pedagogical training, since the vast majority did not receive preparation to develop teaching activities in preceptorship, a fact that can be of concern. They are aware of the benefits that this type of preparation can bring.
It was also verified that the preceptors have curricular knowledge of the MRPs of which they are part, reporting they have the necessary freedom to define teaching proposals, in addition to seeking to carry out an adequate integration between teaching and service, including the resident into this entire context. However, they drew attention to two points that could be improved. The preceptors, in general, are not conducting research with their residents and are not being adequately paid, which may negatively impact their teaching activities in the MR.
As implications of this study, we suggest the adoption of measures to encourage pedagogical training, the establishment of a remuneration for preceptorship (aiming at professional valorization), in addition to the implementation of measures to encourage research within the scope of the MR.
The data obtained from this study are representative of the preceptors of the city in which this study was carried out; however, it is not representative for the universe of MR preceptors in Brazil. Undoubtedly, the presented data help to elucidate several aspects of this very relevant topic and could be the basis for future studies where an analysis of the power of the study can be carried out, or we suggest a national study involving MR preceptors, with the application of this questionnaire created and validated by Girotto. Additionally, this knowledge can be considered as the basis for future analyses of other populations of preceptors, in addition to other studies on preceptorship, provided that possible population and regional particularities are considered.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

SOURCES OF FUNDING
The study was funded by Universidade Estadual de Ciências da Saúde de Alagoas.