Catherine F. Pipas

Ambulatory Care Education: How Do Academic Medical Centers, Affiliated Residency Teaching Sites, and Community-Based Practices Compare?

Purpose Little is known about how different ambulatory sites compare as clinical educational settings. The authors used students’ log data to compare the educational content and processes in academic medical center-based clinics (AMCs), affiliated residency teaching sites (ARTs), and local community-based practices (CBPs) at one medical school. Method Students recorded their experiences with symptoms, counseling, procedures, and common medical conditions as well as characteristics of the learning process during a required eight-week third-year ambulatory clerkship in family medicine. Descriptive statistics, chi-square for differences in categorical variables, and analysis of variance and multivariate analysis of variance for differences in continuous variables were used to compare the educational settings. Results Over 9,000 encounters were analyzed; 29.7% occurred in AMCs, 14.8% in ARTs, and 55.5% in CBPs. The proportion of continuity visits was lowest in the AMCs and highest in CBPs (13% versus 22%, respectively; p < .01). Students saw almost 57,000 symptoms and conditions. Of 19 symptoms compared, seven differed significantly among the three settings: back pain, cough, dyspnea, ENT (ears, nose, throat problems), fatigue, knee pain, and vomiting. All but one of these were least likely to occur in ARTs. Procedures were performed more frequently, whereas counseling skills were called upon less frequently in CBPs. Students reported being more likely to work unobserved while conducting physical examinations in ARTs and CBPs. Amount of feedback provided on clinical skills did not differ, but students reported receiving more teaching about patient management in ARTs and AMCs versus CBPs (74%, 72%, and 66% of encounters, respectively; p < .01). Conclusions Academic and community settings can complement each other as learning sites for an ambulatory clerkship in family medicine, and common curricular expectations can be achieved. Settings’ differences and similarities should be taken into account when developing, implementing, or revising clerkship programs and should be considered with students’ interests and previous clinical experiences before assigning students to a teaching site.

An Encounter-Based Analysis of the Nature of Teaching and Learning in a 3rd-Year Medical School Clerkship

Background: Much of medical education has shifted from the hospital to ambulatory settings where each student works with a preceptor. Purpose: Our objectives were to describe the nature of community-based learning and to explore how learning experiences vary by type of health care visit. Methods: This prospective study used both paper- and computer-based documentation systems to collect information on student-patient-preceptor encounters. A consecutive sample of 3rd-year medical students contributed data on 1 full clinical day each week as they rotated through a required 8-week family medicine clerkship. The main measures of interest included patient age, gender, health care visit type (acute, acute exacerbation of chronic, chronic, and health maintenance), method of learning in history taking and physical examinations (observing preceptor, being observed by preceptor, performing unobserved, or working jointly with preceptor), content of physical examinations, amount of preceptor feedback, and preceptor teaching content. Results: Sixty-three students contributed data on 4,083 patient encounters. The majority of visits concerned acute complaints (37.7%) or health maintenance (26.4%). Many encounters involved students conducting the cardiovascular and pulmonary exams (33.2% each); fewer encounters involved neurologic (6.9%), gynecological (4.5%), and genitourinary (2.2%) exams. Students reported being observed performing histories and physical exams in 4% and 6% of encounters respectively. The most common student experiences were performing histories and performing physical exams unobserved during acute visits, which accounted for 65.8% and 52.4% of encounters overall. Conclusions: This system is useful for determining educational content and processes that occur in ambulatory settings. Important differences were found in teaching and learning by type of health care visit. This factor can and should be used when considering how students meet educational objectives in community-based ambulatory settings.

Economic impact of a primary care career: a harsh reality for medical students and the nation.

Purpose The ranks of U.S. medical students choosing careers in primary care (PC) are declining even as the demand for new PC physicians is increasing. Although the decision to choose a career in PC is multifactorial, financial security in the setting of rising medical student debt is often cited as a reason to pursue other medical specialties. The authors sought to quantify the financial factors associated with a career in PC. Method The authors used economic modeling, which employs a variety of factors, to develop a net income and expense model. They attempted to account for the variability of factors by looking at best, worst, and average expense scenarios. They used published retrospective data from the Bureau of Labor Statistics, the 2007 Physician Compensation Survey, the National Association of Realtors, the College Board, and U.S. News and World Report regarding medical student debt, physician reimbursement, retirement planning, college savings, and cost-of-living expenses to develop their models. Results PC salaries, in contrast to other subspecialties, result in an initial budgetary deficit and decreased discretionary spending. This gap closes as PC physician income rises in the first few years of practice. Only under scenarios of optimal low cost assumptions or no debt do a PC physicians initial earnings exceed predicted expenses. Conclusions PC physicians, in the first three to five years following residency, will have expenses that exceed earnings. This reality greatly increases the financial disincentive for pursuing a career in PC compared with other fields of medicine.

A collaborative model for supporting community-based interdisciplinary education.

Development and support of community-based, interdisciplinary ambulatory medical education has achieved high priority due to on-site capacity and the unique educational experiences community sites contribute to the educational program. The authors describe the collaborative model their school developed and implemented in 2000 to integrate institution- and community-based interdisciplinary education through a centralized office, the strengths and challenges faced in applying it, the educational outcomes that are being tracked to evaluate its effectiveness, and estimates of funds needed to ensure its success. Core funding of

Preclinical Preceptorships in Medical School: Can Curricular Objectives Be Met in Diverse Teaching Settings?

180,000 is available annually for a centralized office, the keystone of the model described here. With this funding, the office has (1) addressed recruitment, retention, and quality of educators for UME; (2) promoted innovation in education, evaluation, and research; (3) supported development of a comprehensive curriculum for medical school education; and (4) monitored the effectiveness of community-based education programs by tracking product yield and cost estimates needed to generate these programs. The models Teaching and Learning Database contains information about more than 1,500 educational placements at 165 ambulatory teaching sites (80% in northern New England) involving 320 active preceptors. The centralized office facilitated 36 site visits, 22% of which were interdisciplinary, involving 122 preceptors. A total of 98 follow-up requests by community-based preceptors were fulfilled in 2000. The current submission-to-funding ratio for educational grants is 56%. Costs per educational activity have ranged from

Educational Epidemiology: Applying Population-Based Design and Analytic Approaches to Study Medical Education

811.50 to

An analysis of students' clinical experiences in an integrated primary care clerkship

1,938, with costs per preceptor ranging from

Development of a handheld computer documentation system to enhance an integrated primary care clerkship.

101.40 to

Differences in ambulatory teaching and learning by gender match of preceptors and students.

217.82. Cost per product (grants, manuscripts, presentations) in research and academic scholarship activities was

A web-based system for students to document their experiences within six core competency domains during all clinical clerkships.

2,492. The model allows the medical school to balance institutional and departmental support for its educational programs, and to better position itself for the ongoing changes in the health care system.