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Copyright 2001 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2001
To assess medical students' interest in a career in pediatrics following their categorical pediatric clerkship.
Satisfaction questionnaire to 704 third-year clerks in 5 university medical schools following the pediatric clerkship.
Analysis of the influence of the community office-based experience compared with the inpatient experience, and examination aspects of the office preceptorship most valued by the medical students.
Main Outcome Measure
Satisfaction questionnaire addressing office-based experiences.
Third-year pediatric clerks report that the private office setting provides a valuable learning experience, particularly when there is exposure to a wide spectrum of disease and when the preceptor had time to teach. Feelings about pediatrics as career choice rose during the clerkship from neutral to positive, and the frequency of strongly positive feelings rose from 9.2% to 28.6%. In deciding about pediatrics as a career, experiences with patients and residents in the inpatient setting still seem to count more than those experiences in the outpatient setting.
Categorical pediatric clerkships provide learning environments that influence students positively toward pediatrics as a career choice. This choice is enhanced by encouraging community practitioners with students in their office to expose them to a wide variety of issues and devote time to teaching.
CLINICAL training for medical students is increasingly occurring in ambulatory as opposed to inpatient settings, including the offices of community preceptors.1 Indeed, a survey of 70 pediatric clerkships disclosed that fully two thirds of these include outpatient education in private offices, and that students spend an average of 1.2 weeks in that setting.2 Most teaching in the office setting is accomplished through one-on-one clinical precepting between a clinical faculty member and a student, and feedback from students about these experiences throughout the years has been mixed. As is expected, students make career choices based on their clerkship experiences; however, less is known about the extent to which ambulatory-based or community-based education influences career preference, or about which aspects of these experiences are most valued. Given these considerations, we examined a set of themes on the office-based experience to probe the following questions: What is the influence of the office-based experience compared with the traditional inpatient experience on students' interest in a career in pediatrics? What aspects of the office preceptorship are most valued by the medical students?
We administered a questionnaire to third-year clerks in 5 different schools during the academic year 1997-1998. The 5 schools were the University of Rochester, Rochester, NY, the Medical College of Virginia Commonwealth University, Richmond, the University of Nebraska, Omaha, Indiana University, Indianapolis, and Jefferson Medical College, Philadelphia, Pa. This was a satisfaction questionnaire addressing office-based experiences that was completed at the end of the students' pediatric clerkship. The questionnaire began with 2 questions regarding feelings about pediatrics as a career choice before starting and after completion of the pediatric clerkship. It then proceeded with the 12 questions listed in Table 1 and concluded with a rating of the 5 items presented in Table 2. Data management and statistical analyses were completed using SAS statistical software for Windows, version 6.12 (SAS Institute Inc, Cary, NC). Descriptive data are summarized as means, for ease of presentation, as well as "percent who strongly agree" to reflect the Likert-type questions. Ordinal stepwise logistic regression analyses using the LOGISTIC procedure were used to determine associations between 2 response variables ("the preceptorship was an excellent learning experience" and "feelings about pediatrics as a career at the end of the clerkship") and several explanatory variables. The explanatory variables were left as 5 levels on an continuous ordinal scale rather than dichotomized. The procedure used a stepwise approach, specifying a .10 significance level for entry into the model and a .10 significance for staying in the model. Only those variables with an associated χ2 statistic at the .10 significance level were reported. Data from the 5 institutions were combined for all analyses even though the programs differed slightly in the duration of the private office experience.
Of 833 questionnaires distributed to students, 704 (85%) were returned and are reported below. Prior to the pediatric clerkship, students had only spent a mean of 4 days (range, 2-9 days) in a private pediatrician's office. During the clerkship, days in the private office were a mean of 13.3 days (range, 5-23 days). Our questionnaire revolved around 6 major themes that emerge from the responses to the specific questions on the Likert scale listed in Table 1. The first of these themes is the students' perception of the private office as a learning setting. Overall, students agreed that time in the private office setting provided a valuable learning experience, with opportunity for independent patient exposure and observation. With regard to the second theme, exposure to illness, students felt that there was indeed appropriate exposure to well-child care and mild disease. However, they felt less positive about their exposure to a wide spectrum of diseases. In addressing the third issue of mentoring, students agreed that their preceptor was a good role model and had time to teach, which is comforting given the time constraints of the office setting. Students also agreed that their preceptor taught them about the importance of being advocates for child health. In response to the question pertaining to their perception of the role of societal issues on child health, we learned that they agreed only somewhat that they were exposed to these issues. This was not a very strong statement, and it did not help, in retrospect, to ascertain how this exposure might or might not have taken place. The last theme refers to the practice of medicine, regarding which students agreed that they learned a lot about the functioning of a pediatric practice. However, they were less likely to feel that they had a good exposure to issues related to the cost of medical care, insurance, or managed care.
To gain some insight into what aspects of the private practice experience contributed most to making it a valuable encounter, we performed a correlation between the ratings of each of the items in our questionnaire and the score on the statement, "the preceptorship was an excellent learning experience." The results are presented in Table 3. Factors most predictive of an excellent learning experience were whether or not students felt they were exposed to a wide spectrum of disease and whether or not the preceptor had time to teach. What least mattered was whether there was exposure to the role of societal issues on child health or whether the preceptor or the office staff taught about the functioning of a pediatric practice.
Feelings about pediatrics as a career choice rose during the clerkship from neutral (mean score, 2.83 of a possible 5) to positive (mean score, 2.14) and the frequency of strongly positive feelings rose from 9.2% to 28.6%. To examine factors that may have influenced this change in students' attitudes, we present in Table 4 the results of a logistic regression analysis examining associations between student feelings toward pediatrics as a career at the end of the clerkship and the questions we posed. By far, the biggest factor was the inpatient experience: the patients and the residents with whom the students worked during their ward month, which confirms earlier results.3 It should be noted that although the ward attending received a high average rating (Table 2), there was no correlation between the ward attending rating and career choice, whereas there was a modest but significant (P = .006) correlation of the rating of the private preceptor with interest in a pediatric career (Table 4). Our earlier study indicated that interest in pediatrics as a career correlated most with the experience with ward residents and ward patients3 as noted by others4
though not all.5
The skills required to work in an office and in time constraints to perform focused histories and physical exams are most often cited as the major difficulty with learning ambulatory care.6
In the ambulatory setting, the pace of information gathering is unlike the ward experience, as information is obtained during more than 1 visit. However, the students surveyed for this study felt that they had a good to excellent learning experience, and that, despite the time constraints, their preceptors usually had time to teach. In fact, the extent to which a preceptor had time to teach was one of the main predictors of a positive office learning experience.
We were surprised to learn that the single best predictor of the preceptorship being an excellent learning experience was the perception of exposure to a wide spectrum of diseases. Many students pointed out (Table 1) that they had not felt exposed to a wide spectrum of disease in their preceptorships. This contrasts with the notion that the number of separate student encounters with individual patients is greater in a pediatrician's office than on an inpatient ward. Hence, students in the ambulatory setting may be exposed to a significant amount of well-child care or to the early presentation of mild disease. Compared with the inpatient setting, fewer tests are ordered and discussed, there is little or no interaction with other subspecialists and there is less time or need to generate a detailed differential diagnosis. Moreover, hospital faculty may perpetuate the notion that inpatient education is still the best.7 Thus, the student may acquire the impression that he or she is not learning clinical reasoning skills owing to insufficient exposure to in-depth workups and procedural skills. The take-home point for preceptors is that the student benefits from maximizing the variety of patients seen in their office by, for example, encouraging attendance in evening sick-visit clinics in addition to well-child and routine follow-up visits. Compared with a survey performed 5 years prior to this one, and done at 11 medical schools, the rating of private practice preceptors improved substantially, while the ratings of other people encountered by students in the clerkship changed little (Table 2).3 It should be noted, however, that the schools that participated in the current survey selected themselves because they had a structured community preceptorship, which was not a selection criteria for the earlier survey.3 Thus, the degree of improvement in rating of preceptors seen in this comparison may be influenced by this self-selection. Nonetheless, it is clear that at the 5 institutions participating in this survey, community preceptors seem to have a more positive influence on the students' opinions regarding pediatrics than hospital-based pediatricians.
We learned that the private office preceptor was a good role model. This makes sense since students witness their office preceptors spending much of the day examining and talking with patients and parents. Indeed, the ambulatory setting advantageously promotes exposure to what is referred to as patient-doctor interaction.8 The students can observe that patient autonomy is better enhanced in an ambulatory setting, and the physicians can demonstrate how to navigate between a chief complaint for an illness and what a patient or parent really wants from an encounter.9 We had predicted based on comments from our own students that the opportunity to see patients on their own would be highly predictive of a positive office experience, and it was indeed an important factor. However, it was less predictive than the spectrum of disease, the time the preceptor had to teach, and observing one's preceptor interact with patients.
We also learned that students also felt appropriately aware of the role of societal issues on child health. Thus, the opportunity to discuss behavior change, risk factors, or the effect of public interventions on individuals allows preceptors to demonstrate to students the importance of health promotion and disease prevention.9 Again, this makes sense, as students are exposed during clerkship to what may be closer to the morbidity of illness within society in general and, as referred to by Lawrence,10 the sociology of help-seeking behavior.
Finally, students gained some insight into how an office operates, but judging from their ratings, they learned relatively little about costs, insurance, or managed care. These responses may underscore the fact that medical education provides so little, if any, attention to the logistics of medical practice. There may neither be motivation to pay attention to these concerns, nor sensitivity to the relevance of economic and political constraints on practice, nor interest. As well, a negative prevailing attitude on the part of preceptors toward managed care or other concurrent difficulties might have dissuaded students from wanting to learn about these issues.
While ambulatory care was perceived as exterior to the central teaching mission of a medical school,11 planners of medical school curricula recognize ever more that a general pediatric focus is an appropriate component of the pediatric clerkship regardless of ultimate career choice. Indeed, curricular themes in medical education are emphasizing how to learn rather than strictly what to learn, which is a task that fits well into ambulatory education. In this study, we present data from third-year pediatric clerks reporting that the private office setting provides a good learning experience, particularly so when there is exposure to a wide spectrum of disease and when the preceptor had time to teach. These conclusions are derived from students' subjective assessments of the educational effectiveness of ambulatory experiences but not objective measurements of educational accomplishments in these settings. However, in deciding on pediatrics as a career, experiences in the inpatient setting still seem to count more than experiences in the outpatient setting. It is perhaps not surprising that ratings of ward patients correlated so strongly with career choice, as students will consider a career in pediatrics insofar as that they derive satisfaction from participating in the health care of children or adolescents who have illness serious enough to warrant hospitalization. However, we did note a trend compared with the 1992-1993 survey for the office preceptor to have a modest but increasing effect on career decisions, while the rating of the ward attending physician, though still positive, did seem to correlate with career choice in this study.
While the depth and complexity of inpatient medical care of patients may repel students from primary care specialties, exposure to office-based pediatrics seeks to offset this concern.12 Insofar as office-based pediatricians attract students to pediatrics, it follows that in order to encourage students' entry into primary care, barriers and limitations to establishing learning in primary care teaching sites need to be overcome. This is so because clinical education must occur where the majority of physician-patient contact and decision making occur, namely the ambulatory site rather than the ward.
Community faculty may fail to model the cognitive goals that can be so effectively attained in the ambulatory environment such as knowledge of the natural history of illness or clinical decision making under conditions of uncertainty.13 On the other hand, students may lack the sophistication to perceive what is being modeled, as surmised for example, by noting that students reported only fair exposure to a wide spectrum of disease. Yet, in the office students learn the relationship between medical decision making and quality of care. The provision to the students of both the important concepts and the framework in which to practice ambulatory medicine enhances student integration within the private office and promotes learning.14 What the private office setting allows is the return of a form of apprenticeship. Apprenticeships encourage modeling (observation of the teacher) followed by attempting.
Medical school curricula are evolving, with ambulatory experiences occurring early in training, which will offset the perception that ambulatory medicine is not merely inpatient skills "made simple."15 The students will thus learn that primary care skills (data gathering, problem solving, decision making, dealing with uncertainty) are no less important than the expertise in the arguably more seductive use of high-tech medicine in the inpatient setting, where each and every symptom or problem must have all possible etiologies ruled in or out to the highest order of resolution. In the office setting, the students will learn that everything is not ruled out in this manner, and they will thus seek to enhance clinical reasoning skills in other ways.16 What our study documents is that learning skills can be enhanced for the student if there is exposure to and learning about a wide range of issues. With an increase in the proportion of medical care delivered in ambulatory settings, physicians need to become better prepared to deliver that care. Congruent with this idea, planners of medical education need to remember to convince or remind their colleagues in private offices that they have a lot to offer to their students. This is not a new challenge.16-18
Accepted for publication October 4, 2000.
This work was presented in part at the Annual Meeting of the Pediatric Academic Societies, San Francisco, Calif, May 3, 1999.
Corresponding author and reprints: Nicholas Jospe, MD, Department of Pediatrics, Children's Hospital at Strong University of Rochester, 601 Elmwood Ave, Rochester, NY 14642 (e-mail: Nicholas_Jospe@urmc.Rochester.edu).
Jospe N, Kaplowitz PB, McCurdy FA, Gottlieb RP, Harris MA, Boyle R. Third-Year Medical Student Survey of Office Preceptorships During the Pediatric Clerkship. Arch Pediatr Adolesc Med. 2001;155(5):592–596. doi:10.1001/archpedi.155.5.592