A study of primary care teaching comparing academic and community-based settings.

OBJECTIVE: To compare teaching activity and content between academic and community-based practices used in third year medical student primary care training. SETTING: Academic and community-based primary care practices participating in third-year internal medicine, family medicine, and primary care core clerkships. PARTICIPANTS: Five-hundred thirteen preceptor-student encounters involving 32 preceptors and 26 third-year medical students were evaluated. DESIGN: Student-preceptor pairs collected a convenience sample of data from shared patient encounters. Preceptors recorded the content of teaching interventions, and students independently documented learning points received for each clinical encounter. MEASUREMENTS AND MAIN RESULTS: Comparison of problem exposure, frequency and content of teaching interventions, and the effect of patient complexity and patient care workload on teaching frequency was made between the academic and community-based practices. Several small differences were found in the frequency of clinical problem exposure between the 2 settings. The frequency and focus of teaching interventions did not differ by practice type. Teaching by community-based preceptors tended to decrease with increased patient care workload, but increased in academically based practices. CONCLUSIONS: Although several differences exist between educational experiences in community- and academically based primary care practices, they appear to be minor and of minimal educational significance.

Evaluating students on an interdisciplinary primary care clerkship at the Pennsylvania State University College of Medicine.

With funding from The Robert Wood Johnson Foundation's Generalist Physician Initiative, the Pennsylvania State University College of Medicine created a community-based primary care clerkship in general pediatrics, general internal medicine, and family and community medicine, in which third-year students spend a month in a small town, rural area, or urban underserved medical community. In addition to linking students with preceptors who would teach the clinical skills essential to primary care practice, the medical school set out to teach and to evaluate knowledge, attitudes, and behaviors unique to primary care. This paper describes the three-part teaching tool/evaluation developed to address (1) a student's recognition of the characteristics of primary care (learning objectives assignment), (2) a student's ability to appreciate the multiple nonmedical factors influencing a patient's health and experience of illness (family project), and (3) a student's ability to solve clinical problems (clinical reasoning examination). The authors describe how these evaluation methods are linked with the clerkship's goals and objectives and how they yield a richer portrait of the student's performance than the traditional preceptor's evaluation alone can provide. They also discuss the relationship between students' performances on the primary care clerkship and their performances in other clinical clerkships. Similar clinical experiences in primary care should focus on features unique to primary care medicine in both teaching and evaluation.

Clinical use of sensitive assays for thyroid-stimulating hormone.

OBJECTIVE: To review the optimal use of sensitive assays for thyroid-stimulating hormone (TSH) by clinicians. METHODS: The available literature pertinent to the clinical application of sensitive TSH testing was identified through a systematic MEDLINE search and reviewed. Selection of materials for inclusion was based on clinical validity of the data and relevance to the study question. SYNOPSIS: Sensitive TSH assays have contributed greatly to our basic knowledge of thyroid physiology and are a powerful clinical tool in the diagnosis and treatment of thyroid disease. The clinical applicability of these assays, as is our understanding of their appropriate use, is rapidly expanding. Based upon the best evidence and current understanding of thyroid physiology, strategies are presented for appropriate use of sensitive TSH assays in healthy outpatients, in patients who are likely to have a disturbed hypothalmic-pituitary-thyroid axis, and in patients on levothyroxane therapy. CONCLUSIONS: Although many clinical questions regarding the use of sensitive TSH assays remain to be studied, it has emerged as a powerful tool for the diagnosis and management of thyroid disease. Optimal use of sensitive TSH assays requires an understanding of TSH physiology and measurement, coupled with appropriate application and interpretation in specific clinical settings.