Primary Care Clerkship Research Articles

Continuous Quality Improvement and Knowledge for Improvement Applied to Asthma Care

Two key ideas in the practice of continuous quality improvement (CQI) in health care are knowledge for improvement as distinguished from professional knowledge in improving the end results of patient care and the failure of the bad apple theory to explain variation in outcomes. As part of their eight-week primary care clerkship, medical students at Case Western Reserve University (Cleveland, Ohio) are assigned to more than 20 sites in the greater Cleveland area where they observe and report on the cost and outcome of care for a patient with asthma. (An earlier article presented run charts and fishbone diagrams based on these reports.) In continuing this project, as described in this article, students report on the frequency of causes of variation in costs and outcomes of care. Students are asked to cite the one factor they believe had the most important effect on the cost and clinical outcome of the asthma patient they studied. For cost variation ranked by frequency, disease severity and site of care are reported most frequently, each accounting for 18% of responses. The most frequently reported cause of outcome variation was disease severity. No correlation was found between cost and outcome; higher costs do not produce healthier patients nor are they associated with greater outcome severity. For the nine most frequently used sites of care, the one-way analysis of means for costs shows that average costs for eight of nine sites are well within the expected range. Only one site (G) falls outside the upper boundary. Bringing this one "bad apple" site into conformity would have very little effect on overall costs. The one-way analysis of standard deviations shows that there may be only one case in the site that explains the bad apple outlier. Although more than one half of the causes of asthma variation reported in this study fall outside traditional professional knowledge, most of the content of health professions education still falls within the professional realm. Real improvement will require combining traditional professional knowledge with knowledge for improvement.

A description of ambulatory teaching in a longitudinal primary care program

The need for increased ambulatory education is now widely recognized. Recently, attention has been focused on the need for more information regarding the specific nature of ambulatory teaching. The study describes the process of ambulatory teaching as it occurred in a longitudinal primary care clerkship for third‐year medical students. The results are based on in‐depth interviews with 22 faculty, students’ written assessments of the clerkship teaching, and encounter log data. A consistent teaching methodology was used. The model identified consists of progressive responsibility for students with a concurrent modification of the teaching role of faculty through three stages: modeling, supervision, and consultation. This study also indicated there may be a relation between the number of patient encounters and the teaching methods used, although the educational significance and the desirability of the methods have not been determined. Comparison of ambulatory teaching methods in other primary care specialtie...

A rural multidisciplinary clerkship in primary care

A rural multidisciplinary clerkship in primary care

Medical students' confidence and the characteristics of their clinical experiences in a primary care clerkship.

To investigate the relationship between medical students' confidence and their experiences in caring for patients within a primary care clerkship, because hands-on experience is assumed to be positively related to the development of confidence (a subjective marker of competence). The participants were 60 students from the class of 1992 who completed a required third-year ambulatory care clerkship at the University of Kentucky Medical Center. The students documented their one-on-one experiences in patient care (under the supervision of preceptors in family practice, general pediatrics, or general internal medicine) by completing data cards on each patient encounter. Also, for each encounter, the students used a Likert scale to rate their levels of confidence in dealing with the patient's primary diagnosis. The variables recorded on the cards were then used to predict the students' levels of confidence during the encounters. The statistical analysis included descriptive statistics, Pearson correlations, and a stepwise multiple-regression procedure. The mean number of patient encounters per student was 99. The regression procedure selected three variables from the data cards as significant independent predictors of the students' confidence: management responsibility for the patient's problem (R2 = .40), prior exposure to the patient's problem (R2 = .08), and performance of laboratory work during the patient encounter (R2 = .06). These variables were responsible for predicting 54% of the observed variance in the students' confidence (R2 = .54). Hands-on clinical experience was more important for building students' confidence than any other encounter variable.

Physiciansʼ productivity and teaching responsibilities

There is considerable concern about the impact of teaching responsibilities on physicians' productivity. Previous research employing independent sample designs has suggested that physicians who teach medical students are less productive then their nonteaching counterparts. This study examined the productivity of 15 family practice faculty and third-year resident physicians practicing in the Family Medical Center of the University of Kentucky College of Medicine; in addition to the care of patients, the physicians were assigned to teach third-year medical students participating in an ambulatory primary care clerkship. The productivity of each physician (i.e., number of patients seen per half day) was measured during a four-month period in the spring of 1991. The physicians' levels of productivity with and without medical students were compared through the use of a paired-sample design. No significant difference in productivity levels was observed. Ambulatory-care teaching responsibilities may not diminish physicians' productivity in academic teaching practices.

An alternative clerkship model for ambulatory training: An interdisciplinary primary care experience

The Primary Care Clerkship of George Washington University is the only required ambulatory experience in the medical school curriculum. This 6‐week clerkship for third‐year medical students blends exposure to several primary care disciplines: family practice, internal medicine, pediatrics, and geriatrics. In addition to addressing epidemiologically common conditions, the curricular goals emphasize primary care concerns such as the doctor‐patient relationship, clinical epidemiology, the natural history of disease, appropriate and cost‐effective use of resources and consultants, quality assessment, screening strategies, and critical thinking skills. Each student is assigned two primary preceptors for the entire clerkship and spends 80% of his or her time in patient care. Typically, one of each student's preceptors works in the Medical Center's faculty practice; the other is a physician in private practice or in an inner‐city clinic for the medically underserved and homeless. Students may also work with geri...

Association between clinical experiences in family practice or in primary care and the percentage of graduates entering family practice residencies.

In 1990 the authors surveyed all U.S. medical schools in order to solicit information about students' clinical experiences in family practice and in primary care. Of 126 schools, 104 (82.5%) responded. Survey data were correlated with each school's quartile ranking based on the average percentage of graduates who entered family practice residencies. A significant association (p = .0013) was found between required family practice clerkships or preceptorships and institutions ranked in the highest quartile (i.e., having more than 17% of their graduates enter family practice). A similarly significant association (p = .0056) was found for those 12 institutions that had more than 30% of their students select family practice options in required primary care clerkships or preceptorships. The authors suggest that active recruiting of students to take such options may increase the number of graduates who enter family practice.

An Assessment of the Mastery of Entry-Level Practice Competencies Using A Primary Care Clerkship Training Model

An Assessment of the Mastery of Entry-Level Practice Competencies Using A Primary Care Clerkship Training Model

Introducing Quality Improvement Thinking to Medical Students: The Cleveland Asthma Project

This article describes a medical school's effort to introduce quality improvement (QI) concepts and methods through experiential learning to students as part of a required eight-week primary care clerkship. Each student describes a patient with asthma, investigates the cost of care, and assesses the outcome through an interview with the patient. These patients are considered together as recipients of an areawide process of care. The statistical tools of QI were adapted in a workbook to help students understand care as a process and their role as physicians in improving it.

Effect of a year-long primary care clerkship on graduatesʼ selection of family practice residencies

This report compares the selection of family practice residencies from 1981 through 1989 by graduates trained at two campuses of the State University of New York (SUNY)-Health Science Center at Syracuse College of Medicine, at other New York State campuses, and at all U.S. medical schools. One of the SUNY-Syracuse cohorts comprised the students who had completed all their work at the Syracuse campus, while the other comprised those who had spent their third year at the campus in Binghamton, which has a year-long, half-day-a-week primary care clerkship that is not available at the Syracuse campus, which has no primary care clerkship. Comparison of the proportions of the graduates in the two SUNY-Syracuse cohorts who chose family practice residencies, and comparisons of the proportions of graduates from other New York state schools and from all U.S. schools who selected family practice residencies during the same nine-year period, indicate that the proportion of students trained during their third year at the Binghamton campus who selected family practice residencies was significantly greater (21%; p less than .001). Additional investigation is required to determine whether the year-long nature of the required clerkship affects graduates' choices more than does the primary care content of the clerkship.

Evaluation of an educational program in health care teams.

In July 1975, the Division of Ambulatory and Community Medicine at the University of California, San Francisco, initiated an interdisciplinary team education program as part of a required core medical clerkship in primary care. Significant emphasis was placed on evaluation of student and patient service outcomes. Overall, students rated the teaching in the program as moderately effective. The major measured gain for students was in their formal knowledge of the principles of teamwork, with secondary gains in patient problem-solving skills. The gains in knowledge were greatest for medicine and pharmacy students. During the team education program, the average number of patients seen by student providers was greater than it had been during previous clerkships. Similarly, the comprehensiveness of care provided was higher during the team education program. Although no significant differences were found between student teams and individual providers, those teams with consistent membership from all three participating disciplines (medicine, pharmacy, and nursing) delivered more comprehensive care.

Medical student instructional costs in a primary care clerkship

Using a variety of techniques, such as logs kept daily by the faculty, direct observation, and on-site interviews, the authors determined the instructional costs of a required third-year primary care clerkship based in an ambulatory care setting. Included in the analysis were labor costs of both faculty members and nonfaculty personnel, space and materials, and general university overhead. Total instructional costs were $54.20/student/day. If other third-year clinical clerkships generate equivalent costs, the direct instructional costs of clerkships for third-year medical students would be in excess of $11,500/student/year. The study results imply that ambulatory-based teaching of medical students generates considerable costs and thus requires support from student tuition, federal or state government, or other sources.