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Study sought answers about sites for training

Is there a "best" setting in which to teach the delivery of ambulatory care? Since 95% of medical care today takes place on an outpatient basis, assessing the quality of ambulatory-care education is increasingly important.

For third-year students just beginning their clinical rotations, a broad range of exposure to different kinds of patients and illnesses is clearly essential, explains Patricia Carney, Ph.D., assistant dean for medical education research at DMS.

Settings: In a paper published in the January issue of Academic Medicine, Carney and several colleagues evaluated the experiences of DMS students in family medicine clerkships in three different settings—academic medical centers (AMCs); other teaching hospitals, referred to as affiliated residency teaching sites (ARTs); and community-based practices (CBPs). Their goal was to determine whether the three different settings provide a comparable level of experience and education.

Over a five-year period, using a system called ClinEdDoc, students recorded such data as the ages, symptoms, procedures performed, and incidence of counseling (regarding weight loss and exercise, for example) for all patients they treated or observed. The students also recorded information about their interactions with preceptors, such as the level of student independence in taking patient histories and the amount of feedback preceptors offered. In all, more than 9,000 student-patient encounters were analyzed for the study.

"We assumed that academic medical centers would be the gold standard," Carney says. Instead, the study revealed that the kinds of patients and the nature of preceptor involvement varied according to the setting—variations suggesting not that one learning environment is superior, but that the different sites teach complementary skills.

Data: Among the variations, Carney notes, is the fact that older patients are seen more often at CBPs than at AMCs or ARTs. Consequently, students at a community clinic have signifi- cantly more experience with the symptoms and diseases of the elderly, such as angina, coronary artery disease, and type 2 diabetes. On the other hand, students at both AMCs and ARTs are more likely to encounter infants and young children and thus to have more experience with conditions such as asthma, developmental disorders, and musculoskeletal disorders.

Counseling skills—advising patients about such issues as alcohol and tobacco use, contraception, and weight control— were observed most often in AMCs, even though, as Carney points out, the need for counseling in CBPs is likely just as high. Perhaps, she observes, CBP patients get counseled by a nurse or other staff member or referred to another community agency.

In any event, students in CBPs have far fewer opportunities to observe physicians offering counseling. However, Carney adds, these students might well take it upon themselves to counsel patients when relevant opportunities arise and thus become even more valuable members of the CBP team.

While students in both ARTs and CBPs tend to function more independently than those in AMCs, those in CBPs more often get a chance to perform common procedures such as suturing, skin biopsies, and flexible sigmoidoscopies.

Cultures: This, too, may be accounted for by differences in the educational cultures of the three settings. Carney speculates that in AMCs and ARTs, where residents are also trained, medical students have to compete with residents for procedural opportunities as well as preceptor attention. Also, physicians in CBPs may be more likely to perform procedures themselves rather than referring patients to specialists.

In the end, the study concludes that all three settings offer unique opportunities for learning. The gold standard, then, is not a single setting but a combination of experiences—a finding that should shape the future of ambulatory clerkships.

Catherine Tudish

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