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September 3, 1997

Direct Observation of Community-Based Ambulatory Encounters Involving Medical Students

Author Affiliations

From the Department of Family Medicine (Drs Frank and Stange and Ms Langa), Department of Sociology (Dr Stange and Ms Langa), Department of Epidemiology and Biostatistics (Dr Stange), Cancer Research Center (Dr Stange), Case Western Reserve University, Cleveland, Ohio; and the Department of Family Medicine, Henry Ford Health System (Dr Workings), Detroit, Mich.

JAMA. 1997;278(9):712-716. doi:10.1001/jama.1997.03550090036029

Context.  —The current shift of predoctoral medical education from inpatient tertiary settings to community-based, ambulatory practice has raised questions about the effect of the medical student on the process of patient care.

Objective.  —To determine how the presence of a medical student during the ambulatory medical encounter affects the use of clinical time and patient satisfaction.

Design.  —Cross-sectional, multimethod study using direct observation of ambulatory care by research-trained nurses.

Setting.  —A total of 16 community-based family practice offices accepting family practice clerkship students.

Patients.  —A total of 452 outpatient visits with and without student involvement.

Main Outcome Measures.  —Clinical time use as measured by the Davis Observation Code; patient satisfaction was assessed with the Medical Outcomes Study 9-item visit rating scale.

Results.  —When students were involved, physicians spent more time discussing visit expectations (P=.03) and less time in history taking (P=.007), providing assessment (P=.01 ), and answering questions (P=.04). Despite these differences, patients were equally satisfied with explanations received, and there was no change in the rank order of the 5 most commonly observed physician behaviors. There was no difference in time spent in treatment planning, physical examination, health education, or social chatting. The physician spent equal time with the patient with (10.3 minutes) and without (9.9 minutes, P=.6) student involvement. There was no decrease in patient satisfaction when students were involved. Physicians were more likely to discuss another family member's problems when a student was present (P=.001). Students were directed to care for minority patients at a disproportionate rate (P=.001), controlling for confounding variables.

Conclusions.  —Medical student involvement alters the content but not the duration of the ambulatory medical encounter. Application of validated measures indicate that students did not impair patient satisfaction or hinder the physicians' ability to ensure that patient expectations for the visit were met.