Ogrinc, Gregory MD, MS; Mutha, Sunita MD; Irby, David M. PhD
Dr. Ogrinc is a fellow, Veterans Affairs National Health Quality Scholars Program, White River Junction Veterans Hospital, and instructor of medicine and community and family medicine, Dartmouth Medical School, White River Junction, Vermont. Dr. Mutha is assistant professor of medicine, Division of General Internal Medicine, Dr. Irby is vice dean for education and professor of medicine, both at the University of California, San Francisco, School of Medicine.
Correspondence and requests for reprints should be addressed to Dr. Ogrinc, White River Junction VA Hospital, 11Q, 215 North Main Street, White River Junction, VT 05009; e-mail: 〈firstname.lastname@example.org〉.
This effort was supported in part by HRSA contract #97-0449(P)-BHPR, “Exploring the Value Added by Educational Activities to Clinical Care.”
Purpose: Block ambulatory rotations and longitudinal ambulatory care experiences are now common in U.S. medical schools, but little is known about their efficacy. Through a structured review of the medical literature from 1966 through March 2000, the authors summarize the characteristics of, the evidence for, and the evaluation of longitudinal ambulatory care rotations.
Method: The authors searched Medline using the terms “outpatients,” “continuity of patient care,” “ambulatory care,” “mentors,” “preceptorship,” “graduate medical education,” “curriculum,” and “clinical clerkship” cross-matched to “medical students” and “internship and residency” for literature published from 1966 through March 2000. They narrowed the list to only articles containing empirical outcome data focusing on medical students' experiences in longitudinal ambulatory care rotations. Each study was scored to assess its strengths and weaknesses.
Results: Seven articles met the search criteria. The articles identified the benefits of longitudinal ambulatory care experiences, including developing effective patient interactions and understanding chronic diseases. There were little or no differences in the students' overall knowledge acquisition when those with longitudinal experiences were compared with those in block rotations.
Discussion: Although longitudinal ambulatory care experiences are now common in medical schools, evidence supporting their widespread implementation is sparse. Few studies employ rigorous methods to evaluate educational outcomes. Research to identify benefits and costs, improve the quality and consistency of the students' experiences, and develop other innovative ways of teaching and learning ambulatory care is needed.
One of the most dramatic changes in health care in the past decade has been the shift of care from inpatient to ambulatory care settings. As care has shifted to outpatient settings, the training of medical students and residents in ambulatory care has followed. In 1992, medical schools provided an average of 11 weeks of ambulatory care training, and this had increased to 15 weeks by 1996.1 Much of the increase in ambulatory care training occurred in family practice and internal medicine clerkships. Education in the ambulatory care setting is already well established in residency training because of accreditation requirements.2
In U.S. medical schools, the ambulatory care rotation has traditionally been a four- to six-week block rotation of five to seven half-days per week, but variations in the rotations' structures abound. A longitudinal ambulatory care rotation is defined as eight weeks or more (as much as 60 months) of at least one half-day per week of ambulatory care experience in the same location, with either a single or multiple preceptors. The rationale for longitudinal ambulatory care rotations has included allowing medical students to experience continuity in patient care and to have more contact time with attending physicians. While these programs have grown in number and are intuitively attractive, little is known about their efficacy. To synthesize the current knowledge in this field, we reviewed literature published from 1966 through March 2000 and addressed the following questions:
▪ What methods have been used to evaluate longitudinal ambulatory care experiences for medical students?
▪ What is known about learning outcomes, perceptions, and satisfaction of students in longitudinal ambulatory care rotations?
▪ What unique learning opportunities exist for medical students in longitudinal ambulatory care rotations?
We began the literature search with Medline using the individual terms: (1) “outpatients,” “continuity of patient care,” and “ambulatory care”; (2) “mentors” and “preceptorship”; (3) “graduate medical education” and “curriculum”; and (4) “clinical clerkship.” Each of these terms was then cross-matched with “medical students” and “internship and residency” (see Figure 1). The search was restricted to studies involving human participants, written in English, and available in the Abridged Index Medicus list of journal titles. We identified over 1,500 articles published between 1966 and March 2000. The terms “longitudinal” and “block rotation,” when cross-matched with “medical students” and “internship and residency,” failed to match any articles.
Two of the authors (GO and SM) evaluated each citation for its relevance to longitudinal ambulatory care education, and one or both of these authors selected 89 articles for further examination. Because most residency training programs require continuity experiences and resident—physicians are capable of greater autonomy than medical students, the authors chose to focus on studies of medical students.
We studied the abstracts of the 89 articles for information about outcomes in longitudinal ambulatory care rotations. Using an adapted thematic-synthesis model of literature review, 25 articles were read in their entirety for empirical data on medical students and longitudinal ambulatory care experiences using quantitative or qualitative research methods.3 This enabled us to categorize and summarize articles of varying quality and content and frame them according to the questions posed above. Seven articles met these criteria.
Finally, based on suggestions from Handley and Stuart,4 the seven articles were reviewed for their relative strengths in three areas of interest: study design, sample size, and outcome measures. A study's design was rated from “low” (one point) for single cohort studies to “high” (three points) for randomized control trials. Cohort studies with controls received an intermediate rating of two points. Studies with sample sizes of fewer than 20 received a low rating (one point), while those with sample sizes of more than 50 received the highest rating (three points). The outcome measures used in the study were rated on a two-point scale: one point for use of subjective outcome measures only, such as participants' selfperceptions, or two points for use of objective measures, such as an objective structured clinical examination (OSCE) or United States Medical Licensing Examination (USMLE) scores.
The seven articles are summarized in Table 1. The studies involved students from all four years of medical school, but they focused on those in their clinical years of training in primary care rotations in family medicine, internal medicine, and pediatrics. The numbers of students in the studies ranged from ten to over 400 in a multi-institutional study.5,6 The methods consisted of single cohort studies,5–8 cohort studies with control groups,9,10 and a randomized controlled trial.11 The settings were academic medical centers,6,9,10,11 private practices,7,8 community health centers,5 and one multi-institutional study that involved all three settings.6 The longitudinal experiences ranged from one half day every week lasting from a minimum of eight weeks11 to a maximum of 44 months.6 One study involved rotations of up to three half days per week that lasted up to one year.9
Three studies followed single cohorts of self-selected students through longitudinal experiences.5,7,8 Using self-evaluations5,8 and student logs,7,8 students, preceptors, and patients each reported high satisfaction with their longitudinal ambulatory care experiences. Students reported that the benefits of the experience included improved understanding of the doctor—patient relationship, family dynamics, and community resources,8 as well as recognition of the importance of continuity, the psychosocial approach to patient care, and chronic disease management.5,7,8 Patients reported that care was generally better than they had received previously.5 None of these studies compared students on the longitudinal ambulatory care rotations with students on a traditional-track rotation, nor did any of these studies report educational outcomes.
Prislin et al. evaluated students' self-reported perceptions at five institutions where all the students were required to participate in a longitudinal ambulatory care experience.6 The students perceived that the medical knowledge they had acquired was similar to that acquired on traditional rotations, but that they had no apparent advantage in disease-pattern recognition or in differential diagnosis. These students described improved learning of chronic problems, hidden patient agendas, psychosocial aspects of care, and skills. No data on clerkship, USMLE Steps 1 or 2, or OSCE scores were reported.
Lewin's group followed a prospective cohort of primary-care-track students, measured objective educational outcomes, and compared the primary-care-track students with traditional-track students.9 The primary-care-track students had a longitudinal ambulatory experience as part of their curriculum, and they achieved lower USMLE Step 1 scores compared with traditional-track students. The two groups had similar scores on clerkship exams and USMLE Step 2. On a generalist OSCE, the primary-care-track students scored higher than did the traditional-track students.
Wisdom et al. followed 150 self-selected students through one of three ambulatory experiences (five half days for four weeks, seven half days for four weeks, one half day for ten to 12 weeks).10 On self-evaluations, the students rated the longitudinal experience (one half day for ten to 12 weeks) better for following patients serially and seeing acute problems. They also perceived the teaching to be better compared with the block ambulatory rotations, but no objective educational outcomes (e.g., clerkship or OSCE scores) were reported.
The only randomized controlled trial our search identified was one that randomized third-year students in their internal medicine clerkship either to the usual curriculum or to one that involved a continuity clinic with a resident (n = 20).11 No difference was found in the students' self-evaluations, OSCE scores, or clerkship examination scores in this small pilot study.
In five of the studies, students identified unique learning opportunities in longitudinal ambulatory experiences, including improved understanding of doctor—patient relationships,8 psychosocial aspects of care,6,7,9 the management of chronic illnesses,6,7,10 and the value of continuity of care.7,10 While the students perceived teaching to be better in the longitudinal ambulatory care rotations,10 no advantage was demonstrated in their developing disease-specific knowledge or in their generation of differential diagnoses when they were compared with traditional-track students.9
At a time of increased emphasis on evidence-based decision making in medicine, this literature review underscores the paucity of knowledge about progress being made in longitudinal ambulatory care education. The studies we reviewed suggest that students benefit from longitudinal ambulatory care experiences in the areas of understanding chronic illnesses and developing effective patient relationships, without apparent differences in the medical knowledge they acquire or in their performances.
We selected the seven for their empirical evidence of the longitudinal ambulatory care experiences, but the studies varied considerably. One randomized controlled trial found no difference in objective outcomes, but was limited by a sample size of 20 subjects11; one study compared three groups of 50 self-selected students in three different ambulatory rotations6; and another surveyed 429 students at five institutions.10 Of these, the latter two studies examined only subjective outcomes.6,10 Perhaps the most compelling study was a prospective cohort study with 105 participants (24 subjects and 81 controls) that examined objective outcomes and found lower USMLE scores (Steps 1 and 2) and higher generalist OSCE scores among students in the longitudinal experience.9 The studies we found provide little guidance for choosing between longitudinal and block ambulatory care rotations. While support for superior learning outcomes in longitudinal rotations is sparse, the logic of educating students in the context of their future practice setting is unassailable.
Longitudinal ambulatory care experiences for medical students are formative compared with the well-developed (and required) experiences provided in many residencies. The benefits of longitudinal ambulatory care for patients are increased patients' satisfaction and decreased use of physicians' and emergency departments' services.12–16 Physicians' satisfaction is also higher with greater patient continuity.17 At the same time, training programs have wrestled with the logistics and costs of providing adequate continuity experiences and demonstrating their impact. (One study recently demonstrated that having students or residents in an outpatient practice can increase costs by 24–36%.18) These practical concerns arise as educational initiatives are developed.
While we were disappointed to find so few strong studies of longitudinal ambulatory rotations after we excluded case reports of educational initiatives at single institutions, we believe ours is a valid assessment of the state of the literature today. We and others have called for new resources, structures, and instruments to guide the research on and improvement of ambulatory care training for medical students.19,20 The time has come to begin these efforts in earnest. Just as there are many valid methods of educating students about longitudinal ambulatory care, so too there are many strong methods of conducting research on ambulatory education. Fruitful areas for future research include the potential benefits of longitudinal ambulatory clinical experiences on patient care outcomes, mentoring and career advising, productivity in patient care, and the personal and emotional support of students.
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