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.

Impact of a preceptor education board and computer network to engage community faculty at Dartmouth Medical School.

In 1994, as part of the Generalist Physician Initiative of The Robert Wood Johnson Foundation, Dartmouth Medical School established two programs to support and engage community-based teaching. The Preceptor Education Board and Community Computer Network were established to support a network of community-based preceptors and to facilitate communication between course directors at the school and community-based teachers. The board's mission is to organize, develop, and support a network of community-based primary care faculty, and to create and review community-based curricula. Through the board, community faculty members have made substantial contributions to curriculum, evaluation, faculty development, governance, and financing in community-based teaching. The Community Computer Network provides hardware, software, network systems, and support. Course directors and students have reported improved community-based educational experiences as a direct result of the Network. These two initiatives are dynamic and effective ways to improve the quality of community-based education and preceptors' morale. These efforts have strengthened the community faculty and their connection to the academic medical center.

Focus groups: a useful tool for curriculum evaluation.

BACKGROUND AND OBJECTIVES: Focus group interviews have been used extensively in health services program planning, health education, and curriculum planning. However, with the exception of a few reports describing the use of focus groups for a basic science course evaluation and a clerkship's impact on medical students, the potential of focus groups as a tool for curriculum evaluation has not been explored. Focus groups are a valid stand-alone evaluation process, but they are most often used in combination with other quantitative and qualitative methods. Focus groups rely heavily on group interaction, combining elements of individual interviews and participant observation. This article compares the focus group interview with both quantitative and qualitative methods; discusses when to use focus group interviews; outlines a protocol for conducting focus groups, including a comparison of various styles of qualitative data analysis; and offers a case study, in which focus groups evaluated the effectiveness of a pilot preclinical curriculum.

Community preceptors' views of a required third-year family medicine clerkship.

BACKGROUND: Previous studies documented the importance of family medicine clerkships to medical student education and to the potential costs of precepting students borne by community physicians. But what are the physicians' views of their experience, their perceived needs for teaching, and sources of satisfaction from the preceptor role? OBJECTIVES: To explore preceptors' views of a required, third-year family medicine clerkship, focusing on satisfaction with the teaching experience, effect of having students in the practice, and concerns about continuing as a preceptor. METHODS: Preceptors from 38 private practices were asked to participate in a 15-minute telephone survey, using a semistructured interview format. RESULTS: Thirty-five physicians (92%) agreed to participate and 33 of the 35 primary preceptors were interviewed. Of those interviewed, 29 (88%) indicated a positive teaching experience, and 31 (94%) desired to continue precepting. Intangible rewards (eg, love of teaching or "giving back" to the specialty of family medicine) far out-weighed tangible rewards (eg, dinners or letters of appreciation) with regard to their desire to precept. Continued satisfaction with precepting seemed to be affected by loss of revenue to the practice, longer work hours, ability to effectively manage time and patient load, and need for additional educational resources and equipment. CONCLUSIONS: Intrinsic rewards seem to be a key factor in the physicians' decision to precept. Moreover, to reinforce the preceptor's continued desire to precept, faculty development, provision of educational tools and resources, and remuneration may be necessary. Preceptors should be asked routinely about their needs, and special programs of support should be offered.

Monitoring students' clinical experiences during a third-year family medicine clerkship.

PURPOSE: To demonstrate the importance of monitoring the clinical experiences and types of supervision that students receive in physicians' offices, in order to ensure quality control during a required clerkship. METHOD: In a documentation system introduced in 1991-92, third-year students in the family medicine clerkship at the University of North Carolina at Chapel Hill School of Medicine were asked to complete an optical scan card for every patient they saw. The card information consisted of demographic data, patient continuity, medical problems, types of histories and physical examinations, patient education issues, primary care procedures, and type of supervision. The data were collected from 293 students placed in 63 practices from December 1991 through November 1993. RESULTS: Hypertension, health maintenance, and upper respiratory infection were the most frequently recorded medical problems. Although the students obtained adequate experience performing focused histories and physicals, their experiences with certain physical examinations (breast, rectal, and genital) were inconsistent. Patterns of supervision by the preceptors varied among practices. CONCLUSION: Although the validity of the data has not been assessed, previous literature and other information indicate that the documentation system successfully described the students' clinical experiences. The benefits of implementing such a monitoring system include highlighting the students' lack of certain experiences and making comparisons across sites in order to encourage change among preceptors.