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.

Health, Society, and the Physician: problem-based learning of the social sciences and humanities. Eight years of experience.

We describe a required course for fourth-year medical students focusing on the application of the social sciences and the humanities to critical decisions in the practice of medicine. During 160 hours (70 with faculty contact) in a 7-week period, active, patient-centered, problem-based learning takes place in small collaborating groups, is facilitated by trained tutors, and uses computerized access to library materials plus reference files and resource persons. Major issues identified in the cases are clarified in complementary lectures and symposia. Formative evaluation is ongoing within tutorial groups. Summative evaluation is determined by the individual student's performance in a final complex management problem using a simulated patient. Evaluation of the course, and the basis for its ongoing revision, are provided by participating students and faculty, whose evaluations of the course have been favorable in 80% to 90% of cases.

Functional health status levels of primary care patients.

A cross-sectional study was conducted on functional status of adults visiting primary care practices. Limitations in physical and mental function were assessed independently in 28 practices by patients (N = 1,227) and physicians (N = 47) using a simple global index of disability. Results indicated 12% of patients rated their physical limitations as major and 8% rated major emotional limitations during the past month. Comparable assessments by physicians were 5% and 4%, respectively. Differences between patients and physicians were statistically significant and are demonstrated to be clinically relevant. Patients' functional limitations were associated with increased utilization of ambulatory care, older age, lower level of education, unemployment, and a primary diagnosis of a chronic condition. We conclude that functional status can be routinely recorded in medical practice to help describe severity, predict utilization, and improve the physician-patient relationship.

Use of an interpractice medical information system to develop a data-based clinical cost-consciousness curriculum in Primary Care settings.

A data-based cost-consciousness curriculum was developed that stresses teaching by community physician preceptors in their own practice settings, using an educational packet that incorporates the teaching practice's own data. The cost awareness program represents an educational application of an interpractice medical information system developed by the Primary Care Cooperative Information Project (COOP Project). This system allows patients to be tracked longitudinally within a practice and enables cross-practice comparisons of process, outcomes, and costs for similar cohorts of patients. Initial experiences during the pilot year suggest that the use of practice-based data by physician preceptors is a sound strategy, giving the preceptors flexibility in tailoring their approach to specific teaching/learning situations. Student and preceptor reaction was generally positive. Cost issues are threatening to physicians and it is appropriate to design educational strategies which allow physician preceptors to articulate their perspectives. As role models for medical students, preceptors are in an excellent position to influence physicians in training to be more cost conscious as physicians.