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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© 2002 Association of American Medical Colleges
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