Article

Consequences of shifting medical-student education to the outpatient setting: Effects on performance and experiences

Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0368, USA.
Academic Medicine (Impact Factor: 3.47). 02/1996; 71(1 Suppl):S99-101. DOI: 10.1097/00001888-199601000-00056
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    ABSTRACT: Context The decentralization of clinical teaching networks over the past decade calls for a systematic way to record the case-mix of patients, the severity of diseases, and the diagnostic procedures that medical students encounter in clinical clerkships.Objective To demonstrate a system that documents medical students' clinical experiences across clerkships.Design and Settings Evaluation of a method for recording student-patient clinical encounters using a pocket-sized computer-read patient encounter card at a US university hospital and its 16 teaching affiliates during academic years 1997-1998 through 1999-2000.Participants A total of 647 third-year medical students who completed patient encounter cards in 3 clerkships: family medicine, pediatrics, and internal medicine.Main Outcome Measures Number of patient encounters, principal and secondary diagnoses, severity of diseases, and diagnostic procedures as recorded on patient encounter cards; concordance of patient encounter card data with medical records.Results Students completed 86 011 patient encounter cards: 48 367 cards by 582 students in family medicine, 22 604 cards by 469 students in pediatrics, and 15 040 cards by 531 students in internal medicine. Significant differences were found in students' case-mix of patients, the level of disease severity, and the number of diagnostic procedures performed across the 3 clerkships. Stability of the findings within each clerkship across 3 academic years and the 77% concordance of students' reports of principal diagnosis with faculty's confirmation of diagnosis support the reliability and validity of the findings.Conclusions An instrument that facilitates students' documentation of clinical experiences can provide data on important differences among students' clerkship experiences. Data from this instrument can be used to assess the nature of students' clinical education. Figures in this Article Medical students are exposed to an array of clinical experiences in hospital and ambulatory settings during their clinical clerkships. Monitoring these experiences is essential to ensure that students acquire an appropriate mix of clinical experiences. Attempts made over the last 25 years1 to document the clinical experiences of students have used such recording devices as casebooks,2 logbooks,3- 8 optical scan forms,9- 10 handheld or palmtop computers,9,11 and pocket-sized encounter cards.12 These studies have been limited to small samples in isolated clerkships over brief time periods3,8- 9,13- 24 and they have largely ignored the severity of illness. Dramatic changes in the financing and delivery of health care during the past decade have altered the clinical environments in which medical education occurs.25- 28 As medical education becomes increasingly decentralized, clinical education has partially shifted from a tertiary inpatient setting to community-based and ambulatory sites.3,29- 31 In this kind of educational environment, it is still essential that medical students encounter a variety of disease entities and are given the opportunity to perform basic diagnostic and therapeutic maneuvers. Effective curriculum management requires a valid and reliable system to document the range and type of students' clinical experiences. Only by monitoring students' opportunities for clinical encounters with a diverse mix of patients can informed decisions be made regarding the appropriateness of a teaching network, training sites, and the balance between inpatient and ambulatory activities. As medical schools review their learning objectives to better define the competencies needed by future physicians,32 it will become even more important to document the clinical educational opportunities offered to medical students. We investigated the applications of a new system to document key aspects of the clinical experiences of third-year medical students in 3 clerkships (family medicine, pediatrics, and internal medicine) at Jefferson Medical College, Philadelphia, Pa. We provide evidence of validity and reliability, as well as representative examples of the information produced by the system.
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