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: 2.93). 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.
    JAMA The Journal of the American Medical Association 286(9):1035-1040. DOI:10.1001/jama.286.9.1035 · 35.29 Impact Factor
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    ABSTRACT: To compare the performance of third-year medical students who completed the ambulatory component of their pediatric rotation in a community setting with the performance of third-year medical students who had their ambulatory experience on campus. As part of a pilot project to implement a third-year Multidisciplinary Ambulatory Clerkship, 61 third-year medical students spent 12 weeks rotating through the primary care disciplines of family medicine, internal medicine, and pediatric practitioners' offices at sites distant from the university campus while 127 students remained on campus for their ambulatory experiences in these disciplines. The components of the overall pediatric grade consisted of a clinical performance evaluation in the ambulatory setting (4 weeks), a clinical performance evaluation on a 4-week inpatient rotation, and a grade from a multiple-choice final examination. The overall mean+/-SD final pediatric grade of students receiving their ambulatory pediatrics experience in the Multidisciplinary Ambulatory Clerkship was 86.5+/-3.4 compared with 88.0+/-3.4 for students receiving their ambulatory experience on campus (P<.007). This difference was accounted for by performance on the written final examination. Multidisciplinary Ambulatory Clerkship students had a mean+/-SD score of 78.9+/-8.3 and a failure rate of 18% compared with a mean score of 83.7+/-8.1 and failure rate of 3.9% for students who remained on campus for their ambulatory experience (P<.001 for both comparisons). No differences were noted between the 2 groups on their clinical performance evaluations for their ambulatory or inpatient experiences. These data suggest a difference in the learning experience between students receiving their pediatric ambulatory experience in the community vs on campus. Differences in exposure to structured learning experiences that occurred more frequently on campus might account for some of the difference in final examination results. Development of a standardized, structured learning experience across community sites would seem to be an appropriate means of enhancing learning in the community setting.
    Archives of Pediatrics and Adolescent Medicine 05/1998; 152(4):397-401. DOI:10.1001/archpedi.152.4.397 · 5.73 Impact Factor
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