Time-efficient preceptors in ambulatory care settings.

PURPOSE: With increasing amounts of medical education occurring in ambulatory care and managed care settings, time-efficient and educationally effective teaching methods are in high demand. To identify such methods, four exemplary preceptors who taught in a family medicine clerkship in the context of their managed care clinics were observed in two consecutive years. The purpose of this second observational case study was to look at the teaching and practice strategies of these four exemplary preceptors in more detail and to directly measure the use of strategies that have previously been identified. METHOD: Observation of 44 patient encounters by four exemplary preceptors in ambulatory managed-care settings. RESULTS: On average, these preceptors spent one minute per patient more when the student was involved. With students present, the preceptors saved 3.3 minutes per patient in charting time, while spending 2.2 minutes more listening to student presentations and 1.6 minutes more in pure teaching time. The preceptors spent half a minute less time in direct contact with each patient when a student was present. However, the patients received 12.4 additional minutes from the health-care team. CONCLUSION: Time savings from student charting may allow preceptors to teach and care for patients without losing valuable practice time.     

Primary care teaching physicians' losses of productivity and revenue at three ambulatory-care centers

This study reports two years of basic data concerning University of Illinois clerkship students, their teaching faculty, and their patients at three community health centers. Students from four classes (1985, 1986, 1987, and 1988) were studied in 1985 and 1986. The faculty were family physicians, internists, and pediatricians who provided 20% of the undergraduate medical education for the last 30 months of a four-year curriculum. The study's goal was to develop estimates of the primary care teaching physicians' productivity, to compare them with the productivity of physicians not involved in teaching, and to provide estimates of revenue shortfalls that occurred for the physicians who were teaching. The estimated productivity of the teaching physicians, working 29 hours a week in ambulatory-care settings, was lower by 30-40% when they were teaching medical students than the productivity of nonteaching physicians regionally and nationally. The average patient-care revenue loss for a full-time-equivalent faculty member per full-time-equivalent student for 1985 was estimated to be $27,531 (regional comparison) or $21,143 (national comparison). The corresponding figures for 1986 were $24,294 and $21,525, respectively. The study's results should be useful to those who are planning to establish ambulatory-care delivery systems and also to directors of existing ambulatory-care delivery systems who may be contemplating accepting medical students.     

Multi-institutional development and utilization of a computer-assisted learning program for the pediatrics clerkship: the CLIPP Project.

Computer-assisted instruction (CAI) holds significant promise for meeting the current challenges of medical education by providing consistent and quality teaching materials regardless of training site. The Computer-assisted Learning in Pediatrics Project (CLIPP) was created over three years (2000-2003) to meet this potential through multi-institutional development of interactive Internet-based patient simulations that comprehensively teach the North American core pediatrics clerkship curriculum. Project development adhered to four objectives: (1) comprehensive coverage of the core curriculum; (2) uniform approach to CAI pedagogy; (3) multi-institutional development by educators; and (4) extensive evaluation by users. Pediatrics clerkship directors from 30 institutions worked in teams to develop a series of 31 patient case simulations. An iterative process of case content and pedagogy development, case authoring, peer review, and pilot-testing ensured that the needs of clerkship directors and medical students were met. Fifty medical schools in the United States and Canada are presently using CLIPP. More than 8,000 students have completed over 98,000 case sessions, with an average of 2,000 case sessions completed per week at this time. Each CLIPP case has been completed by more than 3,000 students. The current cost of CLIPP development is approximately $70 per student user, or $6 per case session. The project's success demonstrates that multi-institutional development and implementation of a peer-reviewed comprehensive CAI learning program by medical educators is feasible and provides a useful model for other organizations to develop similar programs. Although CAI development is both time-consuming and costly, the initial investment decreases significantly with broad use over time.     

An efficient and effective teaching model for ambulatory education.

Teaching and learning in the ambulatory setting have been described as inefficient, variable, and unpredictable. A model of ambulatory teaching that was piloted in three settings (1973-1981 in a university-affiliated outpatient clinic in Portland, Oregon, 1996-2000 in a community outpatient clinic, and 2000-2001 in an outpatient clinic serving Dartmouth Medical School's teaching hospital) that combines a system of education and a system of patient care is presented. Fully integrating learners into the office practice using creative scheduling, pre-rotation learning, and learner competence certification enabled the learners to provide care in roles traditionally fulfilled by physicians and nurses. Practice redesign made learners active members of the patient care team by involving them in such tasks as patient intake, histories and physicals, patient education, and monitoring of patient progress between visits. So that learners can be active members of the patient care team on the first day of clinic, pre-training is provided by the clerkship or residency so that they are able to competently provide care in the time available. To assure effective education, teaching and learning times are explicitly scheduled by parallel booking of patients for the learner and the preceptor at the same time. In the pilot settings this teaching model maintained or improved preceptor productivity and on-time efficiency compared with these outcomes of traditional scheduling. The time spent alone with patients, in direct observation by preceptors, and for scheduled case discussion was appreciated by learners. Increased satisfaction was enjoyed by learners, teachers, clinic staff, and patients. Barriers to implementation include too few examining rooms, inability to manipulate patient appointment schedules, and learners' not being present in a teaching clinic all the time.     

Clinical genetics provider real-time workflow study

PurposeOur work is the first documentation, in real time, of workflow in a general genetics department including data on patient care, research, and other activities for both clinical geneticists and genetic counselors.MethodsAll physician geneticists and genetic counselors in the medical genetics department used an electronic tool to record their activities in 15 minute increments during clinic hours, evenings, and weekends over a 10-week period.ResultsThe average work week was 54.1 hours for physicians and 43.5 hours for genetic counselors. During clinic hours physicians spent about one-fourth of their time on direct patient care, one-fourth on other patient-related activities, one-fourth on research unrelated to individual patient care, and the remaining fourth on all other activities. However, after hours and on weekends they spent most of their time on research. Genetic counselors spent half of their time on patient-related activities, one-fourth on direct patient care, and the remainder on all other activities. The total professional time averaged 7 hours per new patient and 3.5 hours per follow-up with nearly 60% of this time devoted to patient-related activities.ConclusionsThe labor intensive nature of clinical genetics, the large amount of time devoted to patient-related activities, and continuing limitations on billing by genetic counselors all contribute to the financial challenges faced by genetics departments.     

Time allocation of students in basic clinical clerkships in a traditional curriculum.

The objective of this study was to determine the amounts of time spent in various activities by medical students enrolled in basic clinical clerkships. In the fall of 1989, 80 third-year students at the University of North Carolina at Chapel Hill School of Medicine recorded their time allocations in eight categories over 24 hours for three consecutive days. After personal time, the students spent the greatest amount of time in organized educational activities (rounds, conferences, lectures), followed in decreasing order by chartwork, patient contact, examination study, ancillary activities, procedures, and directed study. The students reported an average of 5.8 hours of sleep per night. The students reported that when they were on call, they had significant increases in patient contact, chartwork, and ancillary activities. The authors suggest that third-year students may spend too much of their time in organized educational activities, and may benefit educationally from increased amounts of patient contact and decreased amounts of ancillary activities. These data provide an opportunity for clerkship and curriculum organizers to analyze the efficacy of the basic clinical clerkships.     

How residents spend their nights on call.

PURPOSE: Night call is a significant part of residents' education, but little information about their night-call activities is available. This study recorded residents' activities during night-call rotations on internal medicine and pediatrics wards. METHOD: In June and July 1997, on-call pediatrics and internal medicine residents at an urban academic medical center were accompanied by trained observers on the general wards between the hours of 7 PM and 7 AM. The types and duration of activities were recorded. RESULTS: Residents were observed for 106 nights. Internal medicine and pediatrics residents spent their time similarly. They spent 5.3 hours and 5.7 hours per night, respectively, on "basic" activities such as eating, resting, chatting, and sleeping, and an average of 2.6 hours and 2.2 hours, respectively, on chart review and documentation. In both programs, discussing the case with team members averaged 1.5 hours per night and use of the computer averaged slightly more than half an hour. Internal medicine residents spent approximately 1.5 hours on patients' history and physical examinations while pediatrics residents spent 1.3 hours. With each new patient, internal medicine residents spent an average of 19.7 minutes and pediatrics residents spent 16.5 minutes. The only significant difference between the two groups of residents was that the pediatrics residents spent more time per night on procedures than did the internal medicine residents (37 minutes versus 14 minutes, p < 0.01). CONCLUSIONS: Residents from both programs spent a surprising amount of time each night on chart review and documentation. In fact, they spent more time with charts than with patients. Whether this activity truly contributes to residents' education or improved patients' outcomes is not clear.     

Primary care physician time utilization before and after implementation of an electronic health record: a time-motion study

Despite benefits associated with the use of electronic health records (EHRs), one major barrier to adoption is the concern that EHRs may take longer for physicians to use than paper-based systems. To address this issue, we performed a time-motion study in five primary care clinics. Twenty physicians were observed and specific activities were timed during a clinic session before and after EHR implementation. Surveys evaluated physicians' perceptions regarding the EHR. Post-implementation, the adjusted mean overall time spent per patient during clinic sessions decreased by 0.5 min (p=0.86; 95% confidence interval [-5.05, 6.04]) from a pre-intervention adjusted average of 27.55 min (SE=2.1) to a post-intervention adjusted average of 27.05 min (SE=1.6). A majority of survey respondents believed EHR use results in quality improvement, yet only 29% reported that EHR documentation takes the same amount of time or less compared to the paper-based system. While the EHR did not require more time for physicians during a clinic session, further studies should assess the EHR's potential impact on non-clinic time.     

Development of a multidisciplinary primary care program at the Drew University of Medicine and Science.

This article describes a required primary care curriculum for all third and fourth year medical students at the Drew/UCLA Medical Education Program. The curriculum is a supplement to the traditional medical school clinical requirements. Key features of the primary care core curriculum in the third year include a weekly half-day multidepartmental continuity clinic in a community health center serving underrepresented minority populations, a weekly didactic conference on primary care and society, a weekly clinical workshop on primary care skills, a weekly case review conference, and an orientation to primary care research methods. Fourth year medical students select a primary care subinternship that extends half days for 10 weeks in a community-based ambulatory care clinic. Fourth-year students also are required to select a mentor and conduct a research project on a primary care topic. Continuity of care records suggest that this program has been successful in allowing medical students to assume primary responsibility for a set of patients and to maintain significant levels of continuity of care over the course of the year. The evolution of the program, problems encountered, and anticipated changes in the curriculum are discussed.     

Participation of internal medicine department chairs in the internal medicine clerkship--results of a national survey.

PURPOSE: To characterize the involvement of internal medicine department chairs in the core third-year internal medicine clinical clerkship. METHOD: In 2003, the Clerkship Directors in Internal Medicine (CDIM) surveyed its membership. Along with demographics, clerkship directors were asked if the department's chair participated in the clerkship, the number of hours per month the clerkship director and chair discussed clerkship issues, and if published job expectations were discussed. RESULTS: The response rate was 62% (158/254): 103 responses (89 clerkship directors) represented unique medical schools, which formed the basis of the analysis. Eighty-two percent (84/103) reported the chair taught in the clerkship: 54% as teaching attending, 53% as ward attending, 13% as ambulatory attending, and 20% other (e.g., lectures, student rounds, morning report). Of them, 36% performed two activities; 14% three activities; and 2% four activities. Thirty-six percent of the clerkship directors discussed published expectations with their chair. They spent 1.7 (SD 2.2) hours per month with the chair discussing clerkship issues. However, 17% spent zero hours per month with the chair, and 29% spent zero hours per month with a dean's office representative. Chairs who taught spent more time each month with the clerkship director compared with chairs who did not teach (1.9 versus .82 hours, p = .01, Mann-Whitney). There was no association between the chairs' teaching and clerkship directors' demographics. CONCLUSIONS: Internal medicine department chairs are significantly involved in the clinical education of medical students, both administratively and through direct teaching. Chairs who teach spend more time discussing clerkship issues with the clerkship director. Chairs and clerkship directors should discuss expectations, and chairs should continue to visibly demonstrate their commitment to students' education.     

Positive impact of genetic counseling assistants on genetic counseling efficiency,patient volume,and cost in a cancer genetics clinic

PurposeCancer genetics clinics have seen increasing demand, challenging genetic counselors (GCs) to increase efficiency and prompting some clinics to implement genetic counseling assistants (GCAs). To evaluate the impact of GCAs on Geisinger’s cancer genetics clinic, we tracked GC time utilization, new patient volume, and clinic cost per patient before and after implementing a GCA program.MethodsGCs used time-tracking software while completing preappointment activities. Electronic health records were reviewed for appointment length and number of patients per week. Internal salary data for GCs and GCAs were used to calculate clinic costs per patient.ResultsTime spent by GCs completing each preappointment activity (21.8 vs. 15.1 minutes) and appointment length (51.6 vs. 44.5 minutes) significantly decreased after GCA program implementation (p values < 0.001). New patients per week per GC significantly increased (7.9 vs. 11.4, p < 0.001). Weekly clinic cost per patient significantly decreased ($233 vs. $176, p = 0.03).ConclusionImplementing a GCA program increased GC efficiency in preappointment activities and clinic appointments, increased patient volume, and decreased clinic cost per patient. Such a program can improve access to GC services and assist GCs in focusing on the direct patient care for which they are specially trained.     

A model for faculty practice teaching clinics developed at the Oregon Health Sciences University.

In 1988 the Oregon Health Sciences University established its first faculty practice teaching clinic wherein physicians in training were incorporated into a faculty private practice clinic; this pilot project proved very successful and has been subsequently adopted as the model for essentially all outpatient clinics (both medical and surgery) in the university system. The model encourages efficiency, overhead control, and appropriate staffing; it also compensates faculty members for their additional time spent teaching. The authors conclude this model may help other academic training centers adapt to the changing demands of medical education.     

An economic evaluation of asthma in the United States.

BACKGROUND. Asthma is a common chronic illness. Recently, increases in morbidity and mortality due to this disease have been reported. We studied the distribution of health care resources used for asthma in order to lay the groundwork for further policy decisions aimed at reducing the economic burden of this disorder. METHODS. Estimates of direct medical expenditures and indirect costs (in 1985 dollars) were derived from data available from the National Center for Health Statistics. These cost estimates were projected to 1990 dollars. RESULTS. The cost of illness related to asthma in 1990 was estimated to be $6.2 billion. Inpatient hospital services represented the largest single direct medical expenditure for this chronic condition, approaching $1.6 billion. The value of reduced productivity due to loss of school days represented the largest single indirect cost, approaching $1 billion in 1990. Although asthma is often considered to be a mild chronic illness treatable with ambulatory care, we found that 43 percent of its economic impact was associated with emergency room use, hospitalization, and death. Nearly two thirds of the visits for ambulatory care were to physicians in three primary care specialties--pediatrics, family medicine or general practice, and internal medicine. CONCLUSIONS. Potential reductions in the costs related to asthma in the United States may be identified through a closer examination of the effectiveness of care associated with each category of cost. Future health policy efforts to improve the effectiveness of primary care interventions for asthma in the ambulatory setting may reduce the costs of this common illness.     

Comparing students' feedback about clinical instruction with their performances

Validation of students' feedback as a measure of teaching effectiveness has been problematic for courses teaching clinical skills. This is true in part because establishing a valid and reliable method of assessing students' mastery of clinical skills has been a stumbling block. Reported here is the correlation of students' performances on an objective structured clinical examination (OSCE) with previously and independently collected feedback from students. In 1987-88, 190 second-year medical students at the University of Minnesota Medical School--Minneapolis spent one fourth of a second-year clinical skills course on neurology randomly assigned to one of four teaching sites--hospitals A, B, C, and D. Following their rotations, 180 of the students completed usable feedback forms. The students were consistently and significantly more positive about the teaching at hospital A. At the end of the year, all 190 students were tested using an OSCE having 20 stations, four of which presented neurologic problems. The students who had the neurology course at hospital A performed better on all four neurology problems, and differences were statistically significant for two of the problems. Feedback in this case accurately reflected a more effective teaching program.     

The effect of patients' race on their attitudes toward medical students' participation in ambulatory care visits.

PURPOSE: To ascertain the preconceptions of ambulatory patients seeking care in internal medicine practices toward medical students' participation in their care. METHOD: The authors developed a self-administered, seven-item survey that sought patients' demographic information and their attitudes toward medical students' participation in their ambulatory care. In 1998, this survey was given to patients seen at four distinct internal medicine ambulatory clinic settings. RESULTS: Analysis of 516 completed surveys found neutral responses to the statement: "I would benefit from having a medical student involved in my care." Respondents indicated a lack of comfort in having medical students either answer their questions or examine them in the absence of a doctor. The responses did not differ when analyzed as a function of clinic site, age, gender, education, or annual income. Non-Caucasian respondents rated the benefit of having a student present significantly lower than did Caucasian respondents. They also indicated greater concern about being examined by a student alone, that the presence of a student would make the visit last longer, and that the gender of the student was important to them. CONCLUSIONS: Patients generally have neutral feelings as to whether they would benefit from medical students' participation in their ambulatory care. Caucasian patients are significantly more favorably inclined to medical student involvement than are non-Caucasian patients.     

How do house officers spend their nights? A time study of internal medicine house staff on call

Recommendations to limit the working hours of house staff are forcing directors of training programs to reevaluate how house officers spend their time. We studied how 35 house officers in internal medicine spent their on-call time in three teaching hospitals: an urban county hospital, a university hospital, and a regional Veterans Administration medical center. Trained observers accompanied each member of different on-call teams for five nights and quantified how their time was spent. Teams consisting of residents and interns admitted three new patients per night at the Veterans Administration hospital, six at the university hospital, and eight at the county hospital. Each house officer received 16 to 25 calls per night. Up to 12 percent of their time was spent doing procedures (such as inserting intravenous catheters or drawing blood specimens) most of which could have been done by nonphysicians. From 87 to 175 minutes of on-call time was spent in direct patient evaluation, and the mean time spent on each new-patient evaluation ranged from 17 to 31 minutes. The mean time before the evaluation was interrupted ranged from 7 to 11 minutes. In contrast, 66 to 197 minutes per night was spent documenting new-patient evaluations in the hospital record. The average sleep time ranged from 122 to 273 minutes; however, the mean time before sleep was interrupted ranged from 40 to 86 minutes. We conclude that while on call, house officers spend relatively little time in direct patient contact, but they spend considerable time charting. They are frequently interrupted while working and trying to sleep. These data may be useful in finding administrative ways to improve patient care and the experience of the house staff while on call and in evaluating the effect of reforms.     

Third-year medical students' perceptions of effective teaching behaviors in a multidisciplinary ambulatory clerkship.

PURPOSE: The authors sought third-year medical students' perceptions of ambulatory preceptors' teaching effectiveness across primary care disciplines. METHODS: Third-year students at the University of Pittsburgh School of Medicine spent three-week rotations each in ambulatory internal medicine, pediatrics, family medicine, and an elective. After the 12-week clerkship, students anonymously evaluated the full-time and volunteer preceptors using a five-point Likert-type evaluation (1 = hardly at all; 5 = to a great degree) that had eight items addressing preceptor teaching behaviors, six items on attaining clerkship goals and an assessment of overall teaching effectiveness, the outcome variable of interest. RESULTS: The authors analyzed 276 evaluation forms (58% response rate) collected from July 2001 to June 2002. They found a mean effectiveness rating of 4.4 (SD.9) and no differences between genders, specialties, and faculty appointment types (p >.2 for each). The 14 items were associated with teaching effectiveness in univariate analysis (p <.01 for each). In multivariate analyses, effectiveness was associated with four preceptor behaviors: inspired confidence in medical skills, explained decisions, treated students with respect, and provided a role model (R(2) =.33). Effectiveness was associated with three items about attaining clerkship goals: allowed opportunity for improving clinical skills, practiced ethical medicine, and encouraged evidence-based medicine (R(2) =.20). CONCLUSIONS: Several teaching behaviors and measures of attaining clerkship goals influenced students' perceptions of teaching effectiveness. Involving students in a humanistic but rigorous approach to medicine and being a physician students wanted to emulate seem particularly important. These aspects appear potentially amenable to faculty development efforts.     

Development of a handheld computer documentation system to enhance an integrated primary care clerkship.

Documentation systems are used by medical schools and residency programs to record the clinical experiences of their learners. The authors developed a system for their school's (Dartmouth's) multidisciplinary primary care clerkship (family medicine, internal medicine, pediatrics) that documents students' clinical and educational experiences and provides feedback designed to enhance clinical training utilizing a timely data-reporting system. The five critical components of the system are (1) a valid, reliable and feasible data-collection instrument; (2) orientation of and ongoing support for student and faculty users; (3) generation and distribution of timely feedback reports to students, preceptors, and clerkship directors; (4) adequate financial and technical support; and (5) a database design that allows for overall evaluation of educational outcomes. The system, whose development began in 1997, generated and distributed approximately 150 peer-comparison reports of clinical teaching experiences to students, preceptors, and course directors during 2001, in formats that are easy to interpret and use to individualize learning. The authors present report formats and annual cost estimate comparisons of paper- and computer-based system development and maintenance, which range from $35,935 to $53,780 for the paper-based system and from $46,820 to $109,308 for the computer-based system. They mention ongoing challenges in components of the system. They conclude that a comprehensive documentation and feedback system provides an essential infrastructure for the evaluation and enhancement of community-based teaching and learning in primary care ambulatory clerkships, whether separate or integrated.