One tenet of primary care is that continuity—caring for patients over time—is valuable. Traditional clerkships, however, are too short for students to experience meaningful continuity. Although medical schools have been introducing longitudinal programs,1 the considerable modifications (and costs) that are required to incorporate such programs into traditional curricula must be weighed against the value of teaching continuity, which is not well established. To add to our knowledge, we ascertained the number of longitudinal primary care ambulatory programs in North American medical schools, determined to what extent those programs incorporated continuity of care, and assessed whether faculty viewed continuity as important to their students' education.
In March 1998, we mailed postcard questionnaires to 151 medical schools (including branch campuses) in the United States, Puerto Rico, and Canada. The questionnaires asked whether the schools had longitudinal (minimum six months), primary care (family practice, general internal medicine, general pediatrics) ambulatory programs; how those programs taught continuity of care; and whether educators felt it valuable for students to experience continuity of care.
Of the schools contacted, 120 (80%) responded. Forty-four (37%) schools reported having longitudinal primary care programs as defined. Four additional schools were planning such programs; two others had shorter programs.
The respondents at 42 of the 44 (96%) schools with programs in place thought it valuable for students to experience continuity of care. Their responses fell into five themes. They most frequently cited the value of learning about a disease's natural history and the outcomes of medical care (11 respondents). The second most frequent response identified the value of forming a relationship with a patient, rather than with a complaint or disease (eight). Other responses related to learning what primary care is and what primary care physicians do (four), evaluating interest in primary care as a specialty (two), and learning responsibility for patients (one).
Thirty-two of the 44 (73%) programs were designed to expose students to continuity of care. Fourteen of those programs had students spend a half-day every week or two, for periods of six months to four years, most using the same attending physician or practice site. Other programs made specific efforts to schedule patients' follow-up appointments either when students were in the clinic (three) or directly with students rather than attendings (two). Three schools promoted the concept of students as primary doctors. Finally, four programs assigned students to follow patients for six months to two years.
The literature on the value of continuity of care addresses some of the themes we identified. Continuity provides opportunities to observe the course of disease and treatment. Another key dimension of continuity is the development of strong doctor-patient relationships, and the value of students' gaining insight into this has been articulated.2 Furthermore, experiencing continuity of care reveals the responsibilities inherent in primary care, helping students make informed decisions about specialty choice. Some evidence suggests that longitudinal experiences influence students to choose primary care3; other studies are inconclusive.4
Although 96% of the respondents with longitudinal programs believed that teaching continuity is valuable, only 73% of those programs were designed with continuity in mind. Perhaps program directors think that the logistical difficulties in accomplishing continuity outweigh its educational benefits. Once they have created a longitudinal primary care program, however, they have overcome the largest obstacle.
More studies are needed: to describe how longitudinal primary care programs teach the concept of continuity and deal with the logistics of student-patient relationships; to determine whether involvement in continuity programs improve students' education; and to measure the influence of these programs on career choice.1,3,4 These studies should also address the variations that might exist in different primary care disciplines.
1. Prislin MD, Feighny KM, Stearns JA, et al. What students say about learning and teaching in longitudinal ambulatory primary care clerkships: a multi-institutional study. Acad Med. 1998;73:680–7.
2. Hunt CE, Kallenberg GA, Whitcomb ME. Medical students' education in the ambulatory care setting: background paper 1 of the Medical School Objectives Project. Acad Med. 1999;74:289–96.
3. Stearns J, Glasser M, Miller B, et al. A longitudinal ambulatory care clerkship: graduates' reports on the effect on specialty choice and preparation for residency. Acad Med. 1993;68(10 suppl):S37–S39.
4. Grum CM, Richards PJN, Woolliscroft JO. Consequences of shifting medical-student education to the outpatient setting: effects on performance and experiences. Acad Med. 1996;71(1 suppl):S99–S101.