An encounter-based analysis of the nature of teaching and learning in a 3rd-year medical school clerkship

Medical students' preparedness for professional activities in early clerkships

BACKGROUND

Sufficient preparedness is important for transitions to workplace participation and learning in clinical settings. This study aims to analyse medical students' preparedness for early clerkships using a three-dimensional, socio-cognitive, theory-based model of preparedness anchored in specific professional activities and their supervision level.

METHODS

Medical students from a competency-based undergraduate curriculum were surveyed about preparedness for 21 professional activities and level of perceived supervision during their early clerkships via an online questionnaire. Preparedness was operationalized by the three dimensions of confidence to carry out clerkship activities, being prepared through university teaching and coping with failure by seeking support. Factors influencing preparedness and perceived stress as outcomes were analysed through step-wise regression.

RESULTS

Professional activities carried out by the students (n = 147; 19.0%) and their supervision levels varied. While most students reported high confidence to perform the tasks, the activity-specific analysis revealed important gaps in preparation through university teaching. Students regularly searched for support in case of difficulty. One quarter of the variance of each preparedness dimension was explained by self-efficacy, supervision quality, amount of prior clerkship experience and nature of professional activities. Preparedness contributed to predicting perceived stress.

CONCLUSIONS

The applied three-dimensional concept of preparedness and the task-specific approach provided a detailed and meaningful view on medical students' workplace participation and experiences in early clerkships.

Medical student changes in self-regulated learning during the transition to the clinical environment

BACKGROUND

Self-regulated learning (SRL), which is learners' ability to proactively select and use different strategies to reach learning goals, is associated with academic and clinical success and life-long learning. SRL does not develop automatically in the clinical environment and its development during the preclinical to clinical learning transition has not been quantitatively studied. Our study aims to fill this gap by measuring SRL in medical students during the transitional period and examining its contributing factors.

METHODS

Medical students were invited to complete a questionnaire at the commencement of their first clinical year (T0), and 10 weeks later (T1). The questionnaire included the Motivated Strategies for Learning Questionnaire (MSLQ) and asked about previous clinical experience. Information about the student's background, demographic characteristics and first clinical rotation were also gathered.

RESULTS

Of 118 students invited to participate, complete paired responses were obtained from 72 medical students (response rate 61%). At T1, extrinsic goal orientation increased and was associated with gender (males were more likely to increase extrinsic goal orientation) and type of first attachment (critical care and community based attachments, compared to hospital ward based attachments). Metacognitive self-regulation decreased at T1 and was negatively associated with previous clinical experience.

CONCLUSIONS

Measurable changes in self-regulated learning occur during the transition from preclinical learning to clinical immersion, particularly in the domains of extrinsic goal orientation and metacognitive self-regulation. Self-determination theory offers possible explanations for this finding which have practical implications and point the way to future research. In addition, interventions to promote metacognition before the clinical immersion may assist in preserving SRL during the transition and thus promote life-long learning skills in preparation for real-world practice.

Impact of family medicine clerkships in undergraduate medical education: a systematic review

OBJECTIVE

Synthesise evidence about the impact of family medicine/general practice (FM) clerkships on undergraduate medical students, teaching general/family practitioners (FPs) and/or their patients.

DATA SOURCES

Medline, ERIC, PsycINFO, EMBASE and Web of Knowledge searched from 21 November to 17 December 2013. Primary, empirical, quantitative or qualitative studies, since 1990, with abstracts included. No country restrictions. Full text languages: English, French, Spanish, German, Dutch or Italian.

REVIEW METHODS

Independent selection and data extraction by two authors using predefined data extraction fields, including Kirkpatrick's levels for educational intervention outcomes, study quality indicators and Best Evidence Medical Education (BEME) strength of findings' grades. Descriptive narrative synthesis applied.

RESULTS

Sixty-four included articles: impact on students (48), teaching FPs (12) and patients (8). Sample sizes: 16-1095 students, 3-146 FPs and 94-2550 patients. Twenty-six studies evaluated at Kirkpatrick level 1, 26 at level 2 and 6 at level 3. Only one study achieved BEME's grade 5. The majority was assessed as grade 4 (27) and 3 (33). Students reported satisfaction with content and process of teaching as well as learning in FM clerkships. They enhanced previous learning, and provided unique learning on dealing with common acute and chronic conditions, health maintenance, disease prevention, communication and problem-solving skills. Students' attitudes towards FM were improved, but new or enhanced interest in FM careers did not persist without change after graduation. Teaching FPs reported increased job satisfaction and stimulation for professional development, but also increased workload and less productivity, depending on the setting. Overall, student's presence and participation did not have a negative impact on patients.

CONCLUSIONS

Research quality on the impact of FM clerkships is still limited, yet across different settings and countries, positive impact is reported on students, FPs and patients. Future studies should involve different stakeholders, medical schools and countries, and use standardised and validated evaluation tools.

How we use patient encounter data for reflective learning in family medicine training

INTRODUCTION

Consulting with patients is the core learning activity of Australian family medicine (general practice/GP) training, providing a rich source of reflective learning for trainees. We have developed a reflective learning program for postgraduate vocational trainees based on clinical encounters.

METHODS

The Registrar Clinical Encounters in Training (ReCEnT) program is an educational program documenting GP trainees' consultations in five Australian GP training providers. Trainees record patient demographics, consultation details, problems managed, management practices and educational factors from sixty consecutive consultations per six-month training term. Trainees receive a detailed feedback report comparing individual data to aggregated trainee data and national GP data.

RESULTS

The patient encounter system provides multiple opportunities for reflective learning across a number of domains of exposure and practice. Reflection can occur during completion of the encounter form; as self-reflection on the feedback report; as facilitated reflection with the GP trainer and medical educator; and as part of integration of data into teaching. We have identified areas for further development, including enhancing the reflective skills of trainees and trainers.

CONCLUSION

The ReCEnT patient encounter program provides a rich platform for reflective learning for vocational trainees and supports development of skills in lifelong learning.

Study protocol: the Registrar Clinical Encounters in Training (ReCEnT) study

BACKGROUND

Patient encounters are the core learning activity of Australian general practice (family practice) training. Exposure to patient demographics and presentations may vary from one general practice registrar (vocational trainee) to another. This can affect comprehensiveness of training. Currently, there is no mechanism to systematically capture the content of GP registrar consultations. The aim of the Registrar Clinical Encounters in Training (ReCEnT) study is to document longitudinally the nature and associations of consultation-based clinical and educational experiences of general practice registrars.

METHODS/DESIGN

This is an ongoing prospective multi-site cohort study of general practice registrars' consultations, entailing paper-based recording of consultation data. The study setting is general practices affiliated with three geographically-based Australian general practice regional training providers. Registrars record details of 60 consecutive consultations. Data collected includes registrar demographics, details of the consultation, patient demographics, reasons for encounter and problems managed. Problems managed are coded with the International Classification of Primary Care (second edition) classification system. Additionally, registrars record educational factors related to the encounter. The study will follow the clinical exposure of each registrar six-monthly over the 18 months to two years (full-time equivalent) of their general practice training program.

CONCLUSIONS

The study will provide data on a range of factors (patient, registrar and consultation factors). This data will be used to inform a range of educational decisions as well as being used to answer educational research questions. We plan to use ReCEnT as a formative assessment tool for registrars and help identify and address educational needs. The study will facilitate program evaluation by the participating training providers and thus improve articulation of educational programs with practice experience. From the research point of view it will address an evidence gap - the in-practice clinical and educational experience of general practice trainees, determinants of these experiences, and the determinants of registrars' patterns of practice (for example, prescribing practice) over the course of their training.

Students' workplace learning in two clerkship models: a multi-site observational study

CONTEXT

Longitudinal integrated clerkships (LICs) are established, rapidly growing models of education designed to improve the core clinical year of medical school using guiding principles about workplace learning and continuity. This study is the first to report data from direct observations of workplace learning experiences of students on LICs and traditional block clerkships (BCs), respectively.

METHODS

This multi-institution study used an observational, work-sampling methodology to compare LIC and BC students early and late in the core clinical year. Trained research assistants documented students' activities, participation (observing, with assistance, alone), and interactions every 10 minutes over 4-hour periods. Each student was observed one to three times early and/or late in the year. Data were aggregated at the student level and by in-patient or out-patient setting for BC students. One-way analysis of variance (anova) was used to compare two groups early in the year (LIC and BC students) and three groups late in the year (LIC, out-patient BC and in-patient BC students).

RESULTS

Early-year observations included 26 students (16 LIC and 10 BC students); late-year observations included 44 students (28 LIC, eight out-patient BC and eight in-patient BC students). Out-patient activities and interactions of LIC and BC students were similar early in the year, but in the later period LIC students spent significantly more time performing direct patient care activities alone (25%) compared with out-patient (12%) and in-patient (7%) BC students. Students on LICs were significantly more likely to experience continuity with patients as 34% of their patients returned to them, whereas only 5% of patients did so for out-patient BC students late in the year.

CONCLUSIONS

By late year, LIC students engage in patient care more independently and have more opportunities to see clinic patients on multiple occasions than BC students. Consistent with the principles of workplace learning, these findings suggest that yearlong longitudinal integrated education models, that rely mostly on ambulatory settings, afford students greater opportunities to participate more fully in the provision of patient care.

Implementing feedback cards in core clerkships

CONTEXT

Historically, medical students report receiving little formative feedback. Reports of feedback processes are generally limited to a single course or specialty. There is a paucity of research detailing feedback across the core clerkship year.

OBJECTIVES

We aimed to determine the feasibility of a cross-clerkship feedback encounter card system, describe the content of feedback requested and received during the core clerkships, and examine student satisfaction with the feedback card system.

METHODS

Students (n = 127) enrolled in six mandatory clerkships were required to complete feedback cards, twice weekly during inpatient rotations and once weekly during outpatient rotations. Students checked-off areas in which they wanted to receive feedback and gave the card to a supervisor, who indicated areas in which feedback was provided. Descriptive statistics summarised completeness and feedback content. A two-factor anova estimated differences between students' perceptions of feedback usefulness pre- and post-feedback card implementation.

RESULTS

A total of 5369 feedback cards were completed in 2006 (78% of the target). Feedback about presentation skills (57% of cards) and fund of knowledge (48% of cards) were most frequently requested. On approximately 80% of the cards, students received feedback in the area(s) they had requested. During each clerkship, students requested feedback in most areas at least once. The mean rating of feedback usefulness was significantly lower after feedback card implementation (mean 3.6, standard deviation [SD] 1.1) than before implementation (mean 3.7, SD 1.0) (F = 11.022, P < 0.001, effect size = - 17).

CONCLUSIONS

Despite evidence that students received feedback multiple times, satisfaction was low. Research identifying factors that improve satisfaction with feedback during clinical training is needed.

Tracking reflective practice-based learning by medical students during an ambulatory clerkship

OBJECTIVE

To explore the use of web and palm digital assistant (PDA)-based patient logs to facilitate reflective learning in an ambulatory medicine clerkship.

DESIGN

Thematic analysis of convenience sample of three successive rotations of medical students' patient log entries.

SETTING

Johns Hopkins University School of Medicine.

PARTICIPANTS

MS3 and MS4 students rotating through a required block ambulatory medicine clerkship.

INTERVENTIONS

Students are required to enter patient encounters into a web-based log system during the clerkship. Patient-linked entries included an open text field entitled, "Learning Need." Students were encouraged to use this field to enter goals for future study or teaching points related to the encounter.

MEASUREMENT AND MAIN RESULTS

The logs of 59 students were examined. These students entered 3,051 patient encounters, and 51 students entered 1,347 learning need entries (44.1% of encounters). The use of the "Learning Need" field was not correlated with MS year, gender or end-of-clerkship knowledge test performance. There were strong correlations between the use of diagnostic thinking comments and observations of therapeutic relationships (Pearson's r=.42, p<0.001), and between diagnostic thinking and primary interpretation skills (Pearson's r=.60, p<0.001), but not between diagnostic thinking and factual knowledge (Pearson's r =.10, p=.46).

CONCLUSIONS

We found that when clerkship students were cued to reflect on each patient encounter with the electronic log system, student entries grouped into categories that suggested different levels of reflective thinking. Future efforts should explore the use of such entries to encourage and track habits of reflective practice in the clinical curriculum.

Perceptions and attributions of third-year student struggles in clerkships: do students and clerkship directors agree?

PURPOSE

To explore the congruence between students' and clerkship directors' perceptions and attributions of students' struggles during the transition to clerkships.

METHOD

Focus groups and interviews were conducted with third- and fourth-year medical students and clerkship directors at 10 U.S. medical schools in 2005 and 2006. Schools were selected to represent diverse locations, sizes, and missions. Interviews and focus groups were recorded, transcribed, and analyzed thematically.

RESULTS

Students' struggles included understanding roles and responsibilities, adjusting to clinical cultures, performing clinical skills, learning the logistics of clinical settings, and encountering frequent changes in staff, settings, and content. Clerkship directors recognized students' struggles with roles and responsibilities, performing clinical skills, and adjusting to clinical cultures, but they also focused on students' difficulties applying knowledge to clinical reasoning and engaging in self-directed learning.

CONCLUSIONS

Clerkship directors and students recognize many challenges associated with learning and performing in the clerkships. Students' perspectives suggest that these challenges may be more complex than clerkship directors and clinical teachers realize and/or are capable of addressing. The areas in which clerkship directors' and students' perspectives are not congruent point to directions for future research that can guide curricula and teaching strategies.

Tracking clerkship experience: just what do clinical clerks see on an Elder Care rotation?

The Schulich School of Medicine, University of Western Ontario, Canada, has created a mandatory clerkship in Elder Care that consists of small group seminars, clinical experiences, and an Elder Care manual. This article describes the use of a paper-based log to track students' clinical encounters to determine whether the Elder Care clerkship offers students the opportunity for a broad range of clinical experiences to address curriculum objectives. Using a paper-based log that was completed after each clinical encounter, students recorded information including the reason for assessment, tests completed, care recommendations, and personal reflections. Each of 70 students completed an average of 5.5 logs. Cognitive/psychiatric, medical, functional, and social problems were reported in more than 83% of the logs. Almost all students saw at least one patient with cognitive decline and one with depressive symptoms. Only six students reported seeing a patient with delirium. Students were able to think reflectively on their experiences. In matching the clerkship objectives to the learning modality(ies) in which they were addressed, it was found that knowledge-related objectives were supported primarily by seminars and manual content. Skills-related objectives were supported primarily by clinical experiences. The clinical experience logs used in this study provided evidence that, in the Elder Care clerkship, for the most part, students are seeing what we think they should be seeing. Study results have informed the revision of the logs, which will be an ongoing method of tracking objectives and students' reflections and ensuring continuous quality improvement.

Reliability and Usefulness of Clinical Encounter Cards for a Third-Year Surgical Clerkship

BACKGROUND

Third-year medical students (MS3) were given clinical encounter cards (CECs) to stimulate feedback during their surgery clerkship. This study analyzes the feedback given on their clinical performance using CECs.

METHODS

Two hundred one students enrolled in the 12-week surgery clerkship were given CECs. Each card contained the chief focus of the encounter, which was rated on a six-point Likert scale. The CECs were analyzed to determine if they provided reliable formative information, identified marginal performances, and identified differences between raters, settings, rotations, and aspects of clinical performance evaluated.

RESULTS

Seven thousand three hundred eight CECs were submitted from 201 students. The CECs were completed most often (65%) in the inpatient setting. Technical skills were evaluated on 49% of CECs, history/physical examinations on 40%, and case presentations on 30%. There were comments written on half of the CECs and 89% of these were strictly positive. Women (52.8%) and faculty (63.3%) were more likely to provide written comments. The students were most likely to seek feedback from the interns and faculty who gave significantly higher ratings. The Cronbach-alpha reliability coefficient was 0.69, based on 12 raters per student. There was a significant positive correlation (P < 0.05) between the CEC composite rating and the clinical performance rating (r = 0.356), NBME score (r = 0.258), and the final grade (r = 0.250).

CONCLUSIONS

The implementation of CECs in a surgery clerkship provided a large quantity of positive feedback. The quality was limited because there were minimal recommendations for improvement and they were a poor predictor of overall clinical performance.

A web-based system for students to document their experiences within six core competency domains during all clinical clerkships

The authors describe the design and implementation of a new Web-based system that allows students to record important features of their clinical encounters during all 10 required clinical clerkships, document their learning experiences in six major competency domains, and generate detailed real-time reports for themselves and their clerkship directors. A new Web-based system, DMEDS (Dartmouth Medical Encounter Documentation System), accepts input from computers and PDAs. Its design permits students to describe their patients, learning sites, interactions with preceptors, and important aspects of their clinical encounters in all of our medical school's competency domains. Using a common format for all required clerkships, clerkship directors select specific items most relevant to their clerkships from a common menu and set learning targets for specific diagnoses and clinical skills. This new system was designed in the fall of 2003, tested in the spring of 2004, and implemented in all clerkships for the 2004 to 2005 academic year. During the first full academic year that DMEDS was used, students documented nearly 32,000 discrete student-patient-preceptor encounters, an average of between 21 and 120 clinical encounters per Year 3 clerkship. Highlights of the analysis of these initial data include the following: (1) insights into how educational targets are set, (2) the extent of site-to-site variation in clerkship experiences, (3) the epidemiology of patients' declining student involvement, and (4) student experiences in and understanding of the newer competency domains.DMEDS can be used in all clinical clerkships and can address student experiences in all competency domains. It provides substantial value to students, clerkship directors, preceptors, and medical school administrators. As secondary benefits, the authors found that DMEDS facilitates educational research and is readily adapted for use in residency and fellowship programs as well. Student feedback highlights the need to pay close attention to the time invested by students documenting their clinical encounters. Course directors must ensure that the benefits to students (such as knowledge of meeting learning targets and preceptors providing direct feedback to students) are transparent. Finally, for other schools contemplating the change to a competency-based curriculum with the use of a clinical encounter documentation system, the time required for both students and faculty to adopt and fully engage these major educational culture shifts seems to be at least several years.

Narrative review: use of student-generated logbooks in undergraduate medical education

BACKGROUND

Logbooks are used by clinical clerkships in undergraduate medical education as tools for individual student guidance, programmatic evaluation, and Liaison Committee on Medical Education (LCME) accreditation. The purpose of this narrative review was to summarize the published literature on the form and function of logbooks and to review logbook validity and reliability. We performed a literature search from 1980 through 2004 and reviewed 50 articles on logbook use during clinical clerkships.

SUMMARY

Articles were categorized into 5 themes: description and feasibility of logbooks (27 articles), accuracy and completeness of logbook entries (14 articles), utility to student education (11 articles), utility to program evaluation (26 articles), and connecting logbook process measures to clerkship outcomes (2 articles).

CONCLUSIONS

A feasible and acceptable logbook system is an attainable goal, although students usually did not complete logbooks unless required. The available literature does not establish that logbooks currently in use have sufficient reliability or validity to allow for the routine use of the information for program change or accreditation purposes. The ideal logbook should be inexpensive, feasible, and acceptable to students and should allow rapid collation of accurate, relevant data for timely analysis and feedback to the student and clerkship director.

Preclinical preceptorships in medical school: can curricular objectives be met in diverse teaching settings?

BACKGROUND

Although preclinical preceptorships for medical students during the first 2 years are now common, little is known about how well the curricular objectives can be met in clinical training sites.

PURPOSE

To evaluate whether a clinical encounter system can help align preclinical preceptorship experiences with the core curriculum.

METHODS

Using a PDA documentation system, 27 students collected student-preceptor-patient encounter information on all patients (N = 2,953) during a 2-year clinical training course. We compared Years 1 and 2 teaching and learning processes, common symptoms seen, and counseling skills performed and examined how well these clinical experiences aligned with the curricular goals.

RESULTS

The majority of encounters in Year 1 involved the student observing the preceptor perform a history (47%) or physical exam (40%). In Year 2, there was a shift to student and preceptor both participating in the history (Year 1, 12%; Year 2, 24%; p = .004) and physical exam (Year 1, 34%; Year 2, 47%; p = .002). Cardiovascular; pulmonary; and head, eyes, ears, nose, and throat examinations were most common in Year 1 and increased in Year 2. Genitourinary, gynecologic, and neurological examinations occurred least often, and only the neurological examinations increased significantly in Year 2. Overall, at least 75% of students could find opportunities in Years 1 and 2 to achieve the majority of curricular goals.

CONCLUSIONS

Knowing what students experience at their preceptor sites is vital for clinical skills course evaluation. Student-preceptor-patient encounter data should be used to complement other course evaluations to aid curriculum planning and decrease variability in student experiences.

Nurturing educational research at Dartmouth Medical School: the synergy among innovative ideas, support faculty, and administrative structures

In recent years, Dartmouth Medical School has increased its commitment to educational research within the school, and in collaboration with other schools across the country. Passionate faculty members with ideas and expertise in particular curricular areas are one critical component needed for a successful educational research program. Other components include an atmosphere that fosters research collaborations and mentoring, and various types of institutional support structures. This same model has effectively supported basic science and clinical research for decades. Because of the complexities involved in studying medical education, Dartmouth Medical School has invested in support structures for educational grant and manuscript development, financial support for pilot projects and partial salary support for investigators and key staff members, and other support targeted toward specific research projects. Ultimately, the goal is to use the results of the school's educational research projects to improve the curriculum through cycles of hypothesis development and testing, providing evidence for subsequent curricular change. When some research findings are relevant and applicable for use in other medical schools, that is an additional benefit of the educational research process. In this report, the authors describe the development of Dartmouth Medical School's infrastructure for supporting educational research, which has helped to accelerate the educational research productivity teaching faculty now enjoy. The authors also address some of the challenges that they anticipate in the near future.

Ambulatory care education: how do academic medical centers, affiliated residency teaching sites, and community-based practices compare?

PURPOSE

Little is known about how different ambulatory sites compare as clinical educational settings. The authors used students' log data to compare the educational content and processes in academic medical center-based clinics (AMCs), affiliated residency teaching sites (ARTs), and local community-based practices (CBPs) at one medical school.

METHOD

Students recorded their experiences with symptoms, counseling, procedures, and common medical conditions as well as characteristics of the learning process during a required eight-week third-year ambulatory clerkship in family medicine. Descriptive statistics, chi-square for differences in categorical variables, and analysis of variance and multivariate analysis of variance for differences in continuous variables were used to compare the educational settings.

RESULTS

Over 9,000 encounters were analyzed; 29.7% occurred in AMCs, 14.8% in ARTs, and 55.5% in CBPs. The proportion of continuity visits was lowest in the AMCs and highest in CBPs (13% versus 22%, respectively; p <.01). Students saw almost 57,000 symptoms and conditions. Of 19 symptoms compared, seven differed significantly among the three settings: back pain, cough, dyspnea, ENT (ears, nose, throat problems), fatigue, knee pain, and vomiting. All but one of these were least likely to occur in ARTs. Procedures were performed more frequently, whereas counseling skills were called upon less frequently in CBPs. Students reported being more likely to work unobserved while conducting physical examinations in ARTs and CBPs. Amount of feedback provided on clinical skills did not differ, but students reported receiving more teaching about patient management in ARTs and AMCs versus CBPs (74%, 72%, and 66% of encounters, respectively; p <.01).

CONCLUSIONS

Academic and community settings can complement each other as learning sites for an ambulatory clerkship in family medicine, and common curricular expectations can be achieved. Settings' differences and similarities should be taken into account when developing, implementing, or revising clerkship programs and should be considered with students' interests and previous clinical experiences before assigning students to a teaching site.

An analysis of students' clinical experiences in an integrated primary care clerkship

PURPOSE

Combining complementary clinical content into an integrated clerkship curriculum should enhance students' abilities to develop skills relevant to multiple disciplines, but how educational opportunities in primary care ambulatory settings complement each other is unknown. The authors conducted an observational analytic study to explore where opportunities exist to apply clinical skills during a 16-week integrated primary care clerkship (eight weeks of family medicine, four weeks of ambulatory pediatrics, and four weeks of ambulatory internal medicine).

METHOD

Using handheld computers, students recorded common problems, symptoms, and diagnoses they saw. The students also recorded information about the educational process of the clerkship. Two data files were created from the database. Descriptive statistics were used to characterize the students' clerkship experiences, and ANOVA was used to evaluate differences among these blocks within the clerkship.

RESULTS

Students encountered different frequencies of presenting symptoms, the majority of which occurred in pediatrics (23.2 per student per week versus 16.3 in medicine and 16.8 in family medicine; p =.01). Students provided more behavioral change counseling in family medicine (5.2 episodes per student per week versus 4.2 and 2.0 in internal medicine and pediatrics, respectively; p =.01), and they performed more clinical procedures in family medicine (1.9 per student per week versus 0.6 and 1.1 in pediatrics and internal medicine, respectively; p =.001). Students were more likely to encounter specific conditions in internal medicine (35.3 per student per week versus 30.0 and 21.4 in family medicine and pediatrics, respectively; p =.01). Elements of the teaching and learning processes also differed by clerkship.

CONCLUSIONS

Very little overlap was found in symptoms, conditions, procedures, and other educational opportunities in the ambulatory pediatrics, internal medicine, and family medicine blocks that constitute the integrated primary care clerkship. The blocks provided different and complementary learning opportunities for students. These findings will assist in clerkship planning and in guiding students to seek opportunities that will ensure educational excellence.

Development of a handheld computer documentation system to enhance an integrated primary care clerkship

Documentation systems are used by medical schools and residency programs to record the clinical experiences of their learners. The authors developed a system for their school's (Dartmouth's) multidisciplinary primary care clerkship (family medicine, internal medicine, pediatrics) that documents students' clinical and educational experiences and provides feedback designed to enhance clinical training utilizing a timely data-reporting system. The five critical components of the system are (1) a valid, reliable and feasible data-collection instrument; (2) orientation of and ongoing support for student and faculty users; (3) generation and distribution of timely feedback reports to students, preceptors, and clerkship directors; (4) adequate financial and technical support; and (5) a database design that allows for overall evaluation of educational outcomes. The system, whose development began in 1997, generated and distributed approximately 150 peer-comparison reports of clinical teaching experiences to students, preceptors, and course directors during 2001, in formats that are easy to interpret and use to individualize learning. The authors present report formats and annual cost estimate comparisons of paper- and computer-based system development and maintenance, which range from $35,935 to $53,780 for the paper-based system and from $46,820 to $109,308 for the computer-based system. They mention ongoing challenges in components of the system. They conclude that a comprehensive documentation and feedback system provides an essential infrastructure for the evaluation and enhancement of community-based teaching and learning in primary care ambulatory clerkships, whether separate or integrated.

A collaborative model for supporting community-based interdisciplinary education

Development and support of community-based, interdisciplinary ambulatory medical education has achieved high priority due to on-site capacity and the unique educational experiences community sites contribute to the educational program. The authors describe the collaborative model their school developed and implemented in 2000 to integrate institution- and community-based interdisciplinary education through a centralized office, the strengths and challenges faced in applying it, the educational outcomes that are being tracked to evaluate its effectiveness, and estimates of funds needed to ensure its success. Core funding of $180,000 is available annually for a centralized office, the keystone of the model described here. With this funding, the office has (1) addressed recruitment, retention, and quality of educators for UME; (2) promoted innovation in education, evaluation, and research; (3) supported development of a comprehensive curriculum for medical school education; and (4) monitored the effectiveness of community-based education programs by tracking product yield and cost estimates needed to generate these programs. The model's Teaching and Learning Database contains information about more than 1,500 educational placements at 165 ambulatory teaching sites (80% in northern New England) involving 320 active preceptors. The centralized office facilitated 36 site visits, 22% of which were interdisciplinary, involving 122 preceptors. A total of 98 follow-up requests by community-based preceptors were fulfilled in 2000. The current submission-to-funding ratio for educational grants is 56%. Costs per educational activity have ranged from $811.50 to $1,938, with costs per preceptor ranging from $101.40 to $217.82. Cost per product (grants, manuscripts, presentations) in research and academic scholarship activities was $2,492. The model allows the medical school to balance institutional and departmental support for its educational programs, and to better position itself for the ongoing changes in the health care system.