Initial Testing of an Instrument to Measure Teacher Identity in Physicians

Transcription

1 Initial Testing of an Instrument to Measure Teacher Identity in Physicians Susan Starr Department of Pediatrics Heather-Lyn Haley Department of Family Medicine and Community Health Kathleen M. Mazor Meyers Primary Care Institute Warren Ferguson Department of Family Medicine and Community Health Mary Philbin Department of Medicine Mark Quirk Department of Family Medicine and Community Health Background: A previous study described 7 elements of teacher identity: intrinsic satisfaction from teaching, knowledge and skill about teaching, belonging to a community of teachers, receiving rewards for teaching, believing that being a doctor means being a teacher, feeling a responsibility to teach, and sharing clinical expertise. Purpose: To conduct the initial testing of an instrument to measure the 7 elements of teacher identity in clinical educators and to consider the potential applications of such an instrument. Methods: A 37-item questionnaire was mailed to 153 preceptors of preclinical students. Categories reflected the elements of teacher identity listed here. Demographic data were collected. Means, alphas, ANOVAs, and paired t tests were calculated. Results: Of 153 preceptors, 127 (83%) completed the questionnaire. Cronbach s alpha for the overall scale and several subscales were high. Salaried physicians and those who had completed a faculty development program scored significantly higher on several subscales than physicians who volunteered to teach or who did not have faculty development. Conclusions: This study provides preliminary evidence that teacher identity can be measured and that preceptors do not respond as a homogeneous group. Assessing The authors acknowledge Rebecca Spanagel, MD, for her help identifying the sample population. Correspondence may be sent to Susan Starr,, Benedict Building Room A3 122, 55 Lake Avenue North, Worcester, MA 01655, USA. [email protected] 117

2 STARR ET AL. teacher identity may be helpful to medical schools looking to identify and support physicians who teach. Teaching and Learning in Medicine, 18(2), Copyright 2006 by Lawrence Erlbaum Associates, Inc. Medical schools are finding it increasingly difficult to recruit and retain physicians willing to teach students and residents. 1 Yet studies conclude that (a) teaching enhances the enjoyment of patient care, 2,3 (b) participation in educational activities can improve clinician retention and job satisfaction, 4,5 and (c) at least some preceptors experience a joy of teaching. 6 It may be that difficulties with recruitment and retention of preceptors are related to physician dissatisfaction with the practice of primary care medicine. Several studies have suggested that physician frustration is up and morale is down, largely because of practice management and compensation issues. 7 9 In this unsettled practice environment, medical schools are searching for ways to enhance the recruitment and retention of primary care preceptors. We postulate that the probability that a physician will teach varies with his or her self-identification as a teacher. This article describes the initial validation of an instrument to measure teacher identity and discusses how it might be used to identify and measure support for clinical educators. In a previous study, we identified seven elements that contribute to physicians identity as teachers: (a) feeling intrinsic satisfaction from teaching, (b) having knowledge and skill about teaching, (c) belonging to a group of teachers, (d) feeling a responsibility to teach, (e) sharing clinical expertise with learners, (f) receiving rewards for teaching, and (g) believing that being a physician means being a teacher. 10 The purpose of this study was to develop an instrument that would measure the strength of each of the elements of teacher identity. Our experience as medical educators told us that a tool that measures how physicians think about their teacher identity could give medical schools important information about how to recruit, retain, and provide support for physicians who teach. A review of the literature revealed no existing measures of teacher identity in medical education that might be used as a gold standard for a validity study. Therefore, we looked for other accepted sources of evidence for validity, including (a) evidence that the content of the items was representative of the construct being measured, (b) evidence that scores for subgroups of preceptors would vary in predictable ways (e.g., preceptors who completed a faculty development program would have stronger teacher identity scores than those who had not participated), and (c) evidence that all sources of error associated with questionnaire administration and responses were controlled to the maximum extent possible. We also assessed internal reliability, and test retest reliability, that is, consistency over time. 11,12 Methods Item Representation of Constructs Seven elements that comprise teacher identity had been previously identified by physicians in the focus group study described earlier. Using a Delphi technique to select items, 13 we developed an initial 32-item questionnaire, in which 4 items related to each of the seven elements; the remaining 4 items asked about Global Teacher Identity. Each of the eight 4-item sets of questions is referred to as a subscale. The questionnaire asked preceptors to indicate agreement with items on a Likert scale (1 = strongly disagree to5= strongly agree; see Table 1). Two additional steps were taken to ensure that item content was representative of each element being measured. First, the 32-item questionnaire was pilot tested on 49 attendees at a faculty development program given by the UMass Community Faculty Development Center. After completing the questionnaire, respondents listened to a presentation that described teacher identity and the questionnaire and were divided into focus groups to discuss their reaction to the concept and questionnaire. Participants confirmed that items reflected the eight subscales describing teacher identity. However, they noted that five items reflected realities of teaching that were beyond their control. For example, one item was The medical school rewards my teaching. Therefore, five new corresponding items were added to reflect respondents desired outcomes in the same clinical teaching situations, bringing the questionnaire to 37 items. For example, the item I would like to be rewarded for teaching was added. Second, one author (MP) conducted three 45-min cognitive interviews with physician teachers at various stages of their teaching careers to refine the quality of the items. 14 Quality is the degree to which an item measures what it is expected to measure; therefore, item quality is related to item validity. 12 One interviewee had taught for more than 20 years, receiving multiple teaching awards; one had taught for a few years and was actively pursuing a career as a clinician educator with a new position at a medical school; the third had taught in the office setting for several years. The interviewees were asked to state 118

3 Table 1. Descriptive Statistics Test Test Retest Mean SD Alpha Correlation p Global TI *** I see myself as a teacher I would miss teaching if I stopped doing it I truly enjoy the role of teacher I have looked for opportunities to teach Feeling intrinsic satisfaction from teaching *** Working with students and/or residents has its costs, but it s worth it I find satisfaction watching my students and/or residents progress Teaching makes my job more rewarding It is important to me to work in a teaching practice Having knowledge and skill about teaching *** I feel skilled as a teacher of students and/or residents It is important to develop my teaching skills Students and/or residents regard me as an effective teacher I read journals about medical education, e.g., Academic Medicine Belonging to a group of teachers *** I frequently talk to colleagues about teaching I feel part of a community of teachers It is helpful to be able to discuss the progress of students and/or residents with colleagues. I enjoy sharing ideas about teaching Believing that being a doctor means being a teacher *** I do a good job teaching patients about their health I use similar skills to teach patients and students and/or residents I enjoy teaching patients Teaching patients is essential to being a good doctor Feeling responsibility to teach *** All physicians have an obligation to teach the next generation of doctors I consider teaching to be a personal responsibility It s important to contribute to medical education I find it satisfying to think that I am contributing to the profession by teaching Sharing clinical expertise ** Primary care preceptors give students and/or residents an important perspective on medicine. I am good at teaching students and/or residents to form relationships with patients I teach the importance of developing long term relationships with patients I am a role model for students and/or residents who want to work in primary care Receiving rewards for teaching *** The medical school rewards my teaching (e.g., monetary rewards, a parking pass, library privileges). Teaching has contributed to my career advancement It is important that the medical school and residency program recognize my teaching in some way. I enjoy the recognition I get as a teacher Desired outcomes *** I would like to be a more skillful teacher I would like to be part of a community of teachers I would like to be a better teacher for my patients I would like to spend more time teaching students and/or residents about primary care. I would like to be rewarded for my teaching Total for all items *** Note: N = 127. Scale ranges from 1 (strongly agree) to 5 (strongly disagree). 119

4 STARR ET AL. aloud what thoughts or ideas went through their minds as they read and answered each item and how they decided what number on the scale to circle. They also were asked to comment on their understanding of the question to ensure that their understanding was comparable to the authors. A sample question was given (I think I am a good teacher.), and the think-aloud process was modeled. ( Well, I m not entirely sure what a good teacher is what makes one teacher better than another. My students say I m a good teacher, though, so I guess I am. I agree. ) If the interviewer felt the explanations were not clear, follow-up or probing questions were asked. Transcripts of the audiotapes were reviewed by the authors. The results confirmed that most of the questions were qualitatively satisfactory; some questions were reworded for clarity. Discriminating Among Responders A critical step in evaluating the instrument was to examine the extent to which scores or subscales differentiated between groups of preceptors in predictable ways. To that end, we selected a sample that would represent a range of preceptor teaching. The sample consisted of 154 preceptors of preclinical students who participated in a Longitudinal Preceptor Program (LPP). This is a required introduction to clinical medicine course for first- and second-year students in our institution. Most students are paired with a primary care physician in family medicine, internal medicine, or pediatrics; the sample consisted of responders who identified themselves as being in the departments of medicine, family medicine, or pediatrics. Course directors noted that some physicians eagerly agree to teach, whereas others accept the role with great reluctance. Some of the LPP preceptors also teach third-year students and residents; some limit their teaching to the 12 LPP sessions required per year. LPP preceptors also vary in their practice and past teaching experience, as well as in their participation in faculty development. These faculty include physicians employed and salaried by the medical school, physicians employed by community-based organizations that are teaching affiliates, and physicians in private practice. In the latter two groups, the faculty members may receive a small stipend or they may volunteer to teach. Thus, in addition to the 37 items on the questionnaire, LPP faculty were asked to report their age, gender, discipline, years of practice, years of teaching, faculty development training, and faculty status (salaried, stipend, volunteer). Sample groups representing these categories are referred to in this article as subgroups. We predicted that preceptor scores would vary in a number of ways. We postulated that some subscales, such as Receiving rewards for teaching, would vary more than others, primarily because several items in that subscale measured forces outside of the preceptors control. We also postulated that scores would differentiate between subgroups of responders, for example, between those who participated in faculty development programs and those who did not. We examined the range and standard deviation of responses to each item and calculated item and subscale means. To test for significant differences between subgroups completing the survey, a one-way analysis of variance (ANOVA) was used. ANOVAs were chosen over t tests for subgroup comparisons because there were sometimes more than two subgroups being compared. A paired-samples t test was used to determine differences between some sets of items, specifically those measuring the realities of teaching versus desired outcomes. For example, we compared I feel part of a community of teachers and I would like to be part of a community of teachers. Questionnaire Administration The questionnaire was administered using tailored design procedures described by Dillman. 14 Questionnaires and stamped, self-addressed envelopes were mailed to the sample, along with a $2.00 bill that recipients could keep whether or not the questionnaire was returned. An explanatory letter described the rationale for the study and gave detailed instructions for completing and returning the questionnaire. After 1 month, preceptors who had not responded received follow-up letters and questionnaires. Reliability As a measure of internal reliability, we looked at Cronbach s alpha for the questionnaire as a whole and for each subscale. Finally, to estimate test retest reliability, a convenience subsample of respondents was sent a second questionnaire approximately 2 months later. The names of repeat responders were entered into a raffle for a gift certificate to a bookstore. This study was reviewed and approved by the Institutional Review Board at the University of Massachusetts Medical School Results Sample One hundred twenty-seven of the 153 (83%) preceptors completed the questionnaire. Responders described themselves as follows: 30 (24%) were pediatricians, 47 (37%) were internists, and 50 (39%) were 120

5 TEACHER IDENTITY IN PHYSICIANS family physicians. Fifty-six percent of the responders were male, and 44% were female. Age distribution was as follows: 18% < 35 years; 33% = years; 38% = years; and 12% > 55 years. Years in practice and years in teaching showed similar ranges that were evenly divided from less than 3 years to more than 20 years experience. Forty-three percent were graduates of an extensive faculty development program. Of the 26 nonresponders, 3 (11%) were pediatricians, 12 (46%) were internists, and 11 (42%) were family physicians; 54% were male, and 46% were female. Forty-six percent participated in an extensive faculty development program. We do not have data on age, years in practice, or years in teaching for nonresponders. Differences Between Items and Subscales The mean score for overall teacher identity for the sample of 127 preceptors was Means for subscales ranged from receiving rewards for teaching (3.55) to sharing clinical expertise with learners (4.35). Item means ranged from I read journals about medical education, e.g., Academic Medicine (2.70) to primary care preceptors give students and/or residents an important perspective on medicine (4.83). The subscales with items showing the greatest standard deviation were belonging to a group of teachers (.86) and receiving rewards for teaching (.70). Standard deviations for individual items ranged from primary care preceptors give students and residents an important perspective on medicine (.47) to I read journals about medical education, e.g., Academic Medicine. (1.27, see Table 1). Paired t tests indicated significant differences in means between items reflecting realities of teaching and preceptors desired outcomes. The largest difference was between the medical school rewards my teaching and I would like to be rewarded for my teaching (t = 10.22; p =.000). An interesting difference was also found between I feel part of a community of teachers and I would like to be part of a community of teachers (t = 5.59; p =.000; see Table 2). Differences Between Subgroups There were no significant differences in mean scores in overall teacher identity or subscale scores by discipline, years in practice, or years in teaching. Women scored higher than men on one subscale: being a doctor means being a teacher (F = 4.54, p =.035). Women also reported higher mean scores than men on the total of items in the desired outcomes section. None of the individual items in the subscale being a doctor means being a teacher or in the four items in desired outcomes reached statistical significance when comparing women to men. Salaried physicians scored significantly higher than physicians who received stipends or volunteered on global teacher identity, intrinsic satisfaction, knowledge and skill, belonging to a group, and receiving rewards (see Table 3). Graduates of the faculty development program scored significantly higher on total teacher identity, global teacher identity, and five of the seven elements (see Table 4). Reliability Cronbach s alpha for the overall scale was.95. Alphas for four of the subscales were relatively high: global teacher identity.86, feeling intrinsic satisfaction.81, belonging to a group of teachers.88, and feeling a responsibility to teach.78. Four subscales had lower alphas: knowledge and skill about teaching.62, belief that being a doctor means being a teacher.51, sharing clinical expertise.61, and receiving rewards for teaching.58 (see Table 1). Examination of correlation matrices between subscales showed that all the subscales were highly correlated. Correlations ranged from.358 between feeling a responsibility to teach and sharing clinical expertise to.877 between global teacher identity and feeling intrinsic satisfaction from teaching. Table 2. Differences Between Realities of Teaching Experience and Desired Outcomes Item Pairs (Realities in Bold) Mean SD t p I feel skilled as a teacher of students or residents I would like to be a more skillful teacher I feel part of a community of teachers ** I would like to be part of a community of teachers I do a good job teaching patients about their health * I would like to be a better teacher for my patients The medical school rewards my teaching (e.g., monetary rewards, a parking ** pass, library privileges). I would like to be rewarded for my teaching *p <.05. **p <

6 STARR ET AL. Table 3. Mean Scores and Analysis of Variance Between Salaried and Nonsalaried Preceptors Teacher Identity Scores Salaried (N = 50) Nonsalaried (N = 70) Scale Mean SD Mean SD F p Total score (37 items) ** Global teacher identity *** Feeling intrinsic satisfaction from teaching ** Having knowledge and skill * Belonging to a group of teachers *** Receiving rewards for teaching ** Desired outcomes * *p <.05. **p <.01. ***p <.001. Table 4. Mean Scores and Analysis of Variance by Faculty Development Participation FD Participants (N = 55) FD Nonparticipants (N = 72) Scale Mean SD Mean SD F p Total ** Global teacher identity * Intrinsic satisfaction *** Skill and knowledge Belong to a group * Being a doctor ** Feel responsibility ** Clinical expertise Receive rewards ** Would like ** *p <.05. **p <.01. ***p <.001. Test Retest Reliability Twenty-six of the 40 (65%) preceptors who were sent the retest returned the questionnaire a second time. The correlation between test and retest scores on overall teacher identity was.923. The correlations on subscales were as follows: global.906; feeling intrinsic satisfaction from teaching.907, having knowledge and skill about teaching.795, belonging to a group of teachers.912, feeling a responsibility to teach.786, sharing clinical expertise with learners.504, receiving rewards for teaching.941, and the belief that being a physician means being a teacher.766. Discussion/Conclusions Although the sample of teachers in our Longitudinal Preceptor Program was selected to represent a range of interest in teaching, almost half of the respondents had completed an extensive faculty development program, one indication of a commitment to teaching. This faculty development program, organized by UMass under a Health Adminstration and Services Resources grant, is open to primary care physicians from 15 medical schools in New England and New York. The program requires participants to attend three weekend overnight workshops, with approximately 40 hr of education on educational theory and methods. The relatively high mean scores on each item and subscale were probably skewed by the half of the responders who were committed teachers. Construct validity draws an inference from scores on a questionnaire to a psychological construct. 15 A Cronbach s alpha score of.95 for the total questionnaire indicates that the 37 items measured a construct, in this case teacher identity. Although we believe that the four subscales with lower alphas contained items that related to the elements in the first study, we could not confirm them as separate unified constructs. Differences Between Subscales and Individual Items The teacher identity questionnaire differentiated preceptor responses to the seven elements or subscales that had been identified in a previous study as contributing to teacher identity. Results also indicated considerable variation on individual items. This variation in scores confirms studies reporting that preceptors are 122

7 TEACHER IDENTITY IN PHYSICIANS not a homogeneous group. 2,6 It also demonstrates that the questionnaire is sensitive to responder differences, one source of evidence for validity. In our study, preceptors varied most and had the highest standard deviations on the items in receiving rewards for teaching and belonging to a group of teachers. This confirmed our assumption that teacher identity scores vary more on those elements that depend largely on outside forces rather than on one s own attitudes. Studies in the professional literature point to external forces, such as rewards and professional group membership, as important sources of professional identity. 16 Differences Between Subgroups We found no significant differences in responses based on discipline, years in practice, or years in teaching. Others have found that older physicians had higher levels of work satisfaction and less stress. 2 A recent study found that residents, the youngest teachers, were less likely than faculty members to describe themselves as having characteristics of ideal teachers. 17 Teacher identity appears to be independent of discipline and years in practice and teaching. One study found that female physicians were 60% more likely than male physicians to report burnout. 8 Women in our study reported greater differences than men reported between their desired outcomes and how things actually were, a factor that might be related to burnout. Subscale scores discriminated between faculty who were salaried for teaching and faculty who received a stipend or volunteered. This raises questions about the relationship between salary and one s identity as a teacher. A body of literature from the social sciences suggests that monetary and other extrinsic rewards are crucial for maintaining one s identity in a profession. 16 By contrast, the medical literature suggests that preceptors vary in their desire for monetary rewards. Several previous studies reported that, although monetary compensation was important to some preceptors, others were satisfied with faculty appointments and library privileges. 2,3 Our study suggests that salaried preceptors have stronger teacher identity. Medical schools may want to assess preceptor needs and reward them appropriately for teaching activities with salary or other benefits if they want to nurture a cohort of physicians who think of themselves as teachers. Scores in overall teacher identity also discriminated between those who had completed the faculty development program and those who had not participated. This suggests that faculty development programs contribute to one s identity as a teacher. Although we might assume that faculty development increases the knowledge and skill element, our data did not support that assumption. Curiously, we found that, at least in this sample, knowledge and skill and sharing clinical expertise were the only subscales that did not demonstrate significant differences between the faculty development completers and nonparticipants. One possible explanation is that community faculty who volunteer to be long-term preceptors already feel skilled as teachers. Another explanation may be that faculty development programs are perceived by preceptors to influence them in ways other than increasing knowledge and skill. Faculty development programs provide opportunities to strengthen teaching satisfaction, reaffirm responsibility for teaching, and create a sense of group camaraderie, and, for some people, are a reward in itself. One study demonstrated that interacting with colleagues, even during break times, contributes to learning and is perceived as very satisfying. 18 These findings suggest that the content of faculty development programs may not be the important factor in increasing teacher identity; many different kinds of programs might yield similar responses. The high correlation between responses on initial and retests indicates that the items would generate the same responses on retesting. Potential Applications of the Questionnaire The teacher identity questionnaire is not an assessment or a test. A high or low total score does not represent an evaluation of the responder s ability to practice or teach medicine. Rather, it is primarily a self-report of attitudes. A score on the teacher identity questionnaire is an indication of the responder s sense of himself or herself on the seven elements we identified as important for establishing teacher identity. A high score on any item should represent a stronger identification as a teacher; therefore, a high score is good to the extent that we want physicians to identify as teachers. We postulate that a stronger identification as a teacher makes it more likely that the physician will agree to teach. Physicians who feel a responsibility to teach, for example, or who derive intrinsic satisfaction from teaching are more likely to precept. Conversely, physicians who do not feel rewarded for teaching or who do not feel they have the knowledge or skill to teach will be less likely to seek out or respond to teaching opportunities. Medical schools may be able to use the teacher identity questionnaire to identify those elements that preceptors identify as strengths and weaknesses. For example, if a group of actual or potential preceptors score lower on belonging to a community of teachers, the school may want to establish a face-to-face or on-line teaching community. 123

8 STARR ET AL. The questionnaire generates important data about the 37 individual items and the 7 elements that make up teacher identity. It would be misleading to equate numerically equal scores that have very different subscores. Although the high correlations between subscales may prompt one to conclude that some subscales can be eliminated, we believe that information from subscales may lead to different interpretations. Scores can be analyzed for both individuals and groups of physicians. For example, scores for one preceptor or a group of preceptors on having knowledge and skill about teaching may provide information about their confidence or about the value of providing individual skill remediation or group faculty development activities. Review of the response distributions for individual items suggests that most respondents would like to be more skillful teachers, part of a community of teachers, and rewarded for teaching. One interesting article reported that physicians decisions to teach correlated with their prior experience with students. 19 To the extent that prior experience affects individual factors such as intrinsic satisfaction, we posit that experience with precepting contributes to teacher identity. There were several limitations to this study. This is a first in a series of studies to validate the teacher identity questionnaire. The sample was too small for confirmatory factor analysis that would have helped determine the validity of all subscales. The study used a convenience sample of preceptors who were involved in teaching first- and second-year medical students. Although the sample was varied in gender, age, years in teaching, and years in practice, further study of the instrument with physicians who do not teach would be useful in determining whether the items differentiate between respondents. The test retest sample was not random. The retest was sent to physicians we thought were sympathetic to research studies and therefore more likely to return it. Although it is a convenience sample, we have no reason to believe that this sample was more likely to remember or otherwise bias the second completion of the survey. Future studies will focus on expanding the number of respondents, validating the subscales, and identifying appropriate uses for the questionnaire. Animportantstepwouldbetoincreasethenumberof respondents to a sufficient sample size to confirm validity of the items and subscales using factor analysis. This also may allow us to shorten the questionnaire. A teacher identity questionnaire that offers clues to specific preceptor needs may help medical schools recruit and retain faculty. The value of the data about the preceptors in the sample of our Longitudinal Preceptor Program will help us develop interventions tailored to their needs. We expect to share the results with the preceptors and offer a menu of options to address the variety of concerns. For example, based on the responses to our questionnaire, we are exploring a New England Preceptor Network that would offer advanced workshops, a newsletter, online teaching modules, and opportunities to be involved with educational research. It would be useful to faculty developers to explore whether there is a correlation between teacher identity and faculty development programs. We are currently engaged in a longitudinal study to assess change after a yearlong faculty development program. A correlation between participation in a faculty development program and increasing teacher identity scores would assist medical schools in two ways. First, it would lend support to the idea that schools could offer faculty development as a method to increase teacher identity. Second, teacher identity questionnaires could be administered to participants before and after faculty development programs to determine whether the program increased participants sense of themselves as teachers, creating an outcome measure of faculty development programs. Finally, the teacher identity questionnaire offers important information about preceptor needs. Reports on physician burnout suggest that it is crucial that medical schools actively promote physician well-being. It has been argued that well-being is enhanced by increasing the extent to which physicians experience meaning in their work. 8 If rewarding and supporting physicians to teach is a way to increase meaning and job satisfaction, both faculty and medical schools would emerge as winners. References 1. Quirk ME, Haley HL, Hatem D, Starr S, Philbin M. Primary care renewal: Regional faculty development and organizational change. Family Medicine 2005;37(3): Baldor R, Brooks WB, Warfield ME, O Shea K. A survey of primary care physicians perceptions and needs regarding the precepting of medical students in the offices. Medical Education 2001;35: Kollisch DO, Frasier PY, Slatt L, Storaasli M. Community preceptors views of a third-year family medicine clerkship. Archives of Family Medicine 1997;6: Ogrinc G, Headrick L, Boex J. Understanding the value added to clinical care by educational activities. Academic Medicine 1999;74(10): Fulkerson PK, Wang-Cheng R. Community-based faculty: Motivation and rewards. Family Medicine 1997;29(2): Ullian JA, Shore WB, First LR. What did we learn about the impact on community-based faculty? Recommendations for recruitment, retention and rewards. Academic Medicine 2001;76(4, Suppl):S78 S Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressures and physician job satisfaction. Journal of General Internal Medicine 2000;15: Spickard A, Gabbe S, Christianson J. Mid-career burnout in generalist and specialist physicians. 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9 TEACHER IDENTITY IN PHYSICIANS 9. Kaiser Family Foundation. National survey of physicians part III: Doctors opinions about their profession. Menlo Park, CA: The Henry T. Kaiser Family Foundation, Starr S, Ferguson W, Haley H, Quirk M. Community preceptors views of their identities as teachers. Academic Medicine 2003;78(8): Downing S. Validity: On the meaningful interpretation of assessment data. Medical Education 2003;37: American Educational Research Association (AERA), American Psychological Association, National Council on Measurement in Education. Standards for educational and psychological testing. Washington, DC: AERA, Passmore C, Dobbie A, Parchman M, Tysinger J. Guidelines for constructing a survey. Family Medicine 2002;34(4): Dillman D. Mail and Internet surveys: The tailored design method. New York: Wiley, Yu, CH.(1998). Educationalassessment: Reliabilityandvalidity of assessment. [Online] Available at: Accessed January 14, Snyder E, Spreitzer E. Identity and commitment to the teacher role. Teaching Sociology 1984;11(2): Morrison EH, Hitchcock MA, Harthill M, Boker J, Masunaga H. The on-line clinical teaching perception inventory: A snapshot of medical teachers. Family Medicine 2005;37(1): Tipping J, Donahue J, Hannah E. Value of unstructured time (breaks) during formal continuing medical education events. The Journal of Continuing Education in the Health Professions 2001;21: Single PB, Jaffe A, Schwartz R. Evaluating programs for recruiting and retaining community faculty. Family Medicine 1999;31(2): Received 14 April 2005 Final revision received 19 October

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