Learning Outcomes of an Ambulatory Care Rotation in Internal Medicine for Junior Medical Students

PAULA S. BUTTERFIELD, PhD, ANDREW G. LIBERTIN, MD

Objective: To assess the educational outcomes of training junior med- ical students in an eight-week combined ambulatory/inpatient rota- tion compared with those of training exclusively on inpatient services. Design: Participants were randomly assigned to one of three groups: those who volunteered for the ambulatory/inpatient rotation and were randomly selected; those who volunteered and were not se- lected; and those who did not volunteer. Setting: University-based internal medicine (IM) inpatient services and community-based clinics and private practices. Participants: Seventy-five third-year medical students taking the re- quired eight-week IM clerkship. Intervention: Assessment included both pre- and posttest measure- ment of students' knowledge of general internal medicine and a pro- file of the types of patient problems seen by students in ambulatory settings. Results: While students' general medicine knowledge scores in- creased significantly from pre- to posttest (p < 0.001), there was no significant difference in scores between the ambulatory/inpatient and exclusive inpatient groups. Patient log data indicated notable differences in the diagnostic compositions of students' patient loads. For instance, 38% of the ambulatory diagnoses were infectious dis- ease, neurologic, endocrine, rheumatologic, or dermatologic prob- lems, and another 15% were non-IM (e.g., obstetric/gynecologic; ear, eye, nose, and throat) problems. Only 24% of the inpatient diag- noses reflected these specialty areas. Conclusions: Ambulatory training did not significantly affect stu- dents' knowledge gain compared with that for exclusive inpatient training, but student evaluations of the rotation plus patient log data suggested that ambulatory training can provide a more complete view of general medicine practice than can exclusive inpatient training. Key words: ambulatory training; patient casemix; students. J GEN INTERN MED 1993: 8:189-192.

HOSPITAL-BASED CLERKSHIPS have b e e n the p r i m a r y c l in- ica l e x p e r i e n c e for m e d i c a l s t u d e n t s s i n c e t h e la te n ine- t e e n t h cen tu ry . S c h r o e d e r a t t r i bu t e s th is m o d e l ' s suc- cess to i ts p r a c t i c a l i t y and c o s t - e f f e c t i v e n e s s I b e c a u s e t h e hosp i t a l h i s t o r i c a l l y has p r o v i d e d s t u d e n t s a n d fac- u l t y w i t h a r e a d i l y ava i l ab le p a t i e n t p o p u l a t i o n in a s ing le l oca t i on . But as t he a c u t e n e s s o f h o s p i t a l i z e d p a t i e n t s ' i l l nes ses has i n c r e a s e d a n d the l e n g t h o f hosp i - ta l stays d e c r e a s e d , p h y s i c i a n s a re u t i l i z i n g t h e ou tpa -

Received from the Department of Medical Education, Doctors Hospi- tal (PSB), and the Department of Internal Medicine, The Ohio State University (AGL), Columbus, Ohio.

The results of this study were briefly reviewed as part of an invited roundtable discussion at the American Educational Research Association's annual meeting, April 1991, Chicago, Illinois.

Supported by a grant from the Region V Ohio Area Health Edu- cation Center.

Address correspondence and reprint requests to Dr. Butterfield: Doctors Hospital, Department of Medical Education, 1087 Dennison Avenue, Columbus, OH 43201.

t i en t s e t t i ng to e v a l u a t e and t r ea t a l l b u t t he mos t seri- o u s l y i l l pa t i en t s .

C o u p l e d w i t h c h a n g e s in t he h e a l t h ca re d e l i v e r y sys t em is a c l e a r d e m o g r a p h i c t r end : o u r p o p u l a t i o n is ag ing and the n u m b e r s o f p e o p l e l i v ing w i t h c h r o n i c i l l ne s se s a n d d i s a b i l i t i e s a re g r o w i n g . As the b a b y b o o m e r s age, t h e h e a l t h ca re n e e d s o f t he f o r e s e e a b l e f u t u r e w i l l shi f t even m o r e t o w a r d the m a n a g e m e n t o f h e a l t h p r o b l e m s o n an o u t p a t i e n t basis . To p r o v i d e ade- q u a t e t r a in ing , w e n e e d e d u c a t i o n a l p r o g r a m s tha t re- f lec t t he p r a c t i c e a r e n a in w h i c h p h y s i c i a n s w i l l b e p r o v i d i n g care .

The a m b u l a t o r y a r ena has g rea t p o t e n t i a l for th is . I t offers o p p o r t u n i t i e s to w o r k u p u n d i f f e r e n t i a t e d pa- t i en t p r o b l e m s , e x p o s e s s t u d e n t s to m y r i a d m e d i c a l p r o b l e m s n o t s een on t o d a y ' s i n p a t i e n t uni t s , and g ives t h e m o p p o r t u n i t i e s to w a t c h the na tu ra l h i s to ry o f dis- ease and to l e a r n t h e i m p o r t a n c e o f m a n a g i n g ca re lon- g i t u d i n a l l y . I t a l so ra ises t he r e l e v a n c e o f soc ia l , finan- c ia l , p s y c h o l o g i c a l , a n d i n t e r p e r s o n a l i s sues a s s o c i a t e d w i t h ca r ing for a m o r e a u t o n o m o u s p a t i e n t p o p u l a t i o n . But w e n e e d to de f ine and e v a l u a t e c a r e f u l l y t h e goa l s and o u t c o m e s o f a m b u l a t o r y - b a s e d t e a c h i n g efforts to m a x i m i z e t h e i r e d u c a t i o n a l va lue . 2

W h i l e m e d i c a l e d u c a t o r s s u p p o r t t he d e v e l o p - m e n t o f a m b u l a t o r y ca re c l e r k s h i p s , 1, 3-8 efforts to im- p l e m e n t and s y s t e m a t i c a l l y e v a l u a t e t he e d u c a t i o n a l o u t c o m e s o f w e l l - d e f i n e d p r o g r a m s for m e d i c a l stu- d e n t s t r a i n e d in th is s e t t i ng have b e e n sparse . W i t h o u t da ta f rom s u c h p r o g r a m s , w e have o n l y t h e a s s u m p t i o n tha t a m b u l a t o r y t r a i n i n g can offer an a d e q u a t e c o m p l e - m e n t to o u r c u r r e n t i n p a t i e n t p r a c t i c e s . O n e r e c e n t s t u d y f o u n d s ign i f i can t ga ins in s t u d e n t s ' k n o w l e d g e ove r a c o m b i n e d a m b u l a t o r y a n d i n p a t i e n t ro t a t ion , 2 b u t t he s t u d y was s m a l l a n d the r e su l t s w a r r a n t e d fur- t he r i nves t iga t ion . Repor t s s u c h as a r e c e n t o n e b y Harr i s e t al. 9 d e s c r i b e t he d e s i g n o f a m b u l a t o r y c le rk- sh ips a n d r e p o r t h o w t h e y have b e e n r e c e i v e d b y stu- d e n t s and facu l ty , b u t t h e y l ack da ta e v a l u a t i n g ac tua l l ea rn ing . W e s t i l l n e e d s tud ie s tha t e s t ab l i sh and ve r i fy t he p r a c t i c a l k n o w l e d g e ga ins o f s t u d e n t s t r a i n i n g in a m b u l a t o r y se t t ings a n d t h e a d e q u a c T o f a m b u l a t o r y t r a in ing as a m e c h a n i s m for p r o v i d i n g s t u d e n t s w i t h a g e n e r a l e d u c a t i o n in m e d i c i n e . Th is s t u d y offers o n e c o n t r i b u t i o n to tha t l a rge r effort .

O u r p u r p o s e was to assess the e d u c a t i o n a l out - c o m e s o f t r a i n i n g j u n i o r m e d i c a l s t u d e n t s in an e ight - w e e k c o m b i n e d a m b u l a t o r y / i n p a t i e n t r o t a t i o n com- p a r e d w i t h t h o s e o f t r a in ing e x c l u s i v e l y on i n p a t i e n t

189

190 Butterfield, Libertin, THIRD-YEAR AMBULATORY CLERKSHIP

services. Assessment inc luded both pre- and posttest measurement of students ' knowledge of general inter- nal medic ine and a profile of the types of patient prob- lems seen by students in ambulatory settings.

METHODS

All third-year medical students who were regis- tered for the eight-week Janua ry - February and March - April 1990 internal medic ine clerkships were given the opt ion of participating in the ambulatory pi lot project. For each eight-week clerkship period, eight students were randomly selected from among those expressing interest in the project. Four were randomly assigned to the first four-week rotation, and the remaining four to the second four-week rotation. They spent the other four weeks of the clerkship on an inpatient service. We were able to accommodate a total of 16 students (eight per clerkship) in the ambulatory program. All other students spent both four-week rotations on inpatient services, most of wh ich are subspecialty-based.

Twelve communi ty internists were solicited to part icipate as project preceptors . We met with them before the program started to familiarize them with our educational goals and their roles and responsibilities in training students. We maintained te lephone contact wi th them throughout the project to help ensure the quick resolut ion of any problems.

The students on the ambulatory rotations were scheduled to work in at least two different clinics per week, averaging four to five patients per half-day. When working in hospital-based clinics, they were expec ted to attend the hospitals' internal medicine conferences and to accompany their preceptors on inpatient rounds. The preceptors then made efforts to have the students fol low discharged patients in the ambulatory clinic. The students also at tended our depar tment ' s thr ice-weekly lecture conferences required of all third- year clerks.

To assess students ' knowledge of general internal medicine, one of the authors (AGL) created a 45-item examination comprising both simple questions and short case vignettes, each with mult iple-choice re- sponses. Items were a combinat ion of cases/questions wri t ten specifically for this examination plus items used at another university in a third-year ambulatory rotation (the University o f Texas at Galveston). The examinat ion addressed issues of epidemiology, diag- nostic evaluation, physical diagnosis, and management of problems representat ive of internal medicine, in- c luding inpatient as well as outpat ient problems. It was reviewed by three general internists, including the gen- eral medicine division chief and the medic ine clerk- ship director, for breadth of content and face validity.

All the students took this examination as a pretest on the first day of the internal medic ine clerkship and as a posttest eight weeks later. It took about one hour to

TABLE 1 Means and Standard Deviations, by Study Group, of General Internal

Medicine Knowledge Examination Pre- and Posttest Scores*

Pretest Posttest Mean SD Mean SD

Group 1 --students who volunteered and were selected for the ambulatory project (o = 16)

Group 2--students who volunteered but were not selected for the ambulatory project (n = 28)

Group 3--students who did not volunteer for the ambulatory project (n = 31 )

20.50 3.43 22.88 3.84

20.04 3.34 22.32 3.65

20.45 3.48 22.16 4.88

*38-item examination, Kuder-Richardson 20 (KR-20) reliability co- efficient for posttest = 0.59.

complete . Following an i tem analysis, we eliminated seven test items and used the revised 38-item examina- tion for the data analysis. The revised examination had Kuder-Richardson 20 (KR-20) lo reliability coefficients of 0.39 for the pretest and 0.59 for the posttest. The students also took a required departmental examina- tion at the end of the clerkship. The KR-20 reliability coefficients for the clerkship examinations were 0.66 and 0.39 (different examinations were used for all clerkship periods) . The students ' scores on the pre- and posttest general medicine examinations had no bearing upon students ' final clerkship grades.

The students used an outpat ient log to record the diagnoses of all the patients they saw in the ambulatory clinics. They also comple ted a writ ten evaluation of the ambulatory rotation. At the end of each clerkship, we interviewed the students in the project to discuss their percept ions of the rotation and to offer recommenda- tions regarding ambulatory training.

ANALYSES AND RESULTS

Seventy-five students comple ted their internal medicine clerkships in January-February or March - April 1990. Sixty-one percent expressed interest in the ambulatory project . Student scores were divided into three groups for data analysis: those who volunteered for the project and were selected (n ----- 16), those who volunteered and were not selected (n ---- 28), and those who were not interested in volunteering or did not express a preference (n---- 31). Students in the latter two groups spent all eight weeks on inpatient services. This design al lowed us to account for student bias re- sulting from select ion preference.

The mean pre- and posttest scores and standard deviations on the general internal medicine knowledge examination, by group, are summarized in Table 1. A

JOURNAL OF GENERAL INTERNAL MEDICINE. Volume 8 (April), 1993 191

two-way analysis of variance with repeated measures indicated a statistically significant (p < 0 .001) in- crease in pre- to posttest scores for the groups overall, but no significant difference be tween the groups and no interaction effect.

All the students in the ambulatory project passed the required clerkship examination and the medicine rotation. Because of the low reliability coefficient of the March-Apr i l clerkship examination, no analysis was done wi th those data. A one-way analysis of var- iance on the Janua ry - February scores indicated no sig- nificant difference in scores be tween the groups.

Fourteen of the 16 students turned in comple ted patient diagnostic logs. They recorded a total of 865 patient visits representing 909 primary diagnoses and / or presenting symptoms. The logs reflected nearly 250 di f ferent primary diagnoses, which we categorized into 18 medical subspecialties or o ther medical disciplines. We then computed the f requency with which the sub- specialties and other disciplines were represented in the general medicine patient popula t ion seen by our students.

Nearly 15% of the primary diagnoses were non- medicine problems [obs te t r ic-gynecologic ; ortho- ped ic - su rg ica l ; psychiatric; and ear, eye, nose, and throat (EENT)], whi le another 21% were neurologic, endocrine, rheumatologic, and dermatologic prob- lems. Infectious diseases were the most common prob- lems seen, representing about 17% of the primary diagnoses. The students saw twice as many obs t e t r i c - gynecologic problems (4%) as hematologic problems (2%). About a dozen cases of cancer or suspected cancer as a primary diagnosis were seen, or 1.3% of all patient problems. The students saw 117 cases of pri- mary hypertension, which as 12.9% of the total diag- noses seen. About 9% of all the patient visits included such things as health screens, physicals, weight changes, fatigue, and other problems not readily assign- able to another subspecialty or discipline; they were categorized under general medicine.

The students ' wri t ten evaluations of the ambula- tory project were consistently positive, and data from the interviews indicated that ambulatory care training was important for junior clerks for several reasons. It gave them an oppor tuni ty to see patients improve. As one student said,

It's important to see that peop le do get bet ter and that internal medicine doctors can make a differ- ence instead of just watching patients dwindle and die. I 've been on h e m e / o n c for a month now and I 'd really be a lot more down if I hadn ' t had that month of ambulatory.

Several argued the need to see patients with pre- viously undiagnosed problems and to focus on com- mon rather than complex or esoteric medical problems

early in their training. Most also thought the ambulatory exper ience was essential for helping junior medical students make well- informed decisions about resi- dency choice, especially regarding internal medicine as a career. One student described it this way:

As third-year students, we have to make up our minds what we want to do. And, you know, it's such an artificial setting being in a hospital and watching these patients in the last stages of life, and trying to make a decision on what you want to do with your own life. I think that was one of the most valuable things about this program. You get out in the real world and see what it's all about. My perspective is so much different after a month of ambulatory than it was after a month in the hospital.

CONCLUSIONS

The students ' general medic ine knowledge scores increased significantly over the courses of their clerk- ships, but we found no significant difference between the groups. While the increase was statistically signifi- cant, it was not necessarily a practical gain. The length of the ambulatory experience, the short (eight-week) clerkship period, and the use of a pre/post tes t examina- t ion that inc luded common inpatient as well as outpa- t ient general medicine problems are all factors that may have contr ibuted to the small gain in scores over time.

The students ' favorable evaluations of the rotation plus the outcomes data led us to conclude that combin- ing ambulatory and inpatient settings could offer an educational exper ience that is comparable to inpatient training in terms of knowledge gain and potential ly superior in terms of students' attitudes toward internal medicine.

The most notable findings of this study came from the patient log data, which suggested that ambulatory training can provide students with a more general med- ical educat ion than can exclusive inpatient training. Data from another project conduc ted at our institution during the second half of the ambulatory project (March-Apri l 1990) he lped support this conclusion. Students on the inpatient services in March-Apri l were asked to log the primary diagnoses of all patients they saw. They used a different report ing format so the data are not direct ly comparable, but the general trends are still quite clear. The ambulatory data reflected 909 pri- mary diagnoses (an average of 65 per student) and the inpatient data reflected 2,192 diagnoses (an average of 66 per student) .

Figure 1 compares the percentages of diagnoses seen in the ambulatory clinics versus the inpatient ser- vices for the major subspeciahies. Cardiology, hematol- ogy, nephrology (excluding hypertension), and pul- monary problems together accounted for only 23% of

192 Butterfield, Liberb'n, THIRD-YEAR AMBULATORY CLERKSHIP

Cardiology

Hematology/ oncology

Pulmonary

Nephrology

Endocrine/ metabolic

Gastrointes- tinal Infectious disease

Dermatology

Neurology

Rheuma- tology

Hypertension*

Non-internal medicine1"

,N\\\\\\\\\\\\\\\\\\"~

~ \ N N \ N \ N \ \ \ \ \ N \ ~ N . \ \ \ N ' I

,\\\\\',,\\\\\\\\\\\\q

~ \ ' - . \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ' q

i i i q I i I

0 4 8 12 16 20 24 28 32

[ Percent of Diagnoses I

Inpatient Ambulatory

FIGURE 1. Percentages of inpatient and ambulatory diagnoses by subspecialty. *Hypertension was recorded separately so it would not exag- gerate either the cardiology or the nephrology diagnoses, tThis includes diagnoses in ear, eye, nose, and throat; obstetrics-gynecology; ophthal- mology; orthopedics; and psychiatry.

the pa t i en t d iagnoses seen in the a m b u l a t o r y c l in ics , yet they r e p r e s e n t e d 5 6% of the i n p a t i e n t diagnoses . W h i l e 38% of the o u t p a t i e n t d iagnoses were in fec t ious dis- ease, neu ro log i c , e n d o c r i n e , r heuma to log i c , or derma-

to logic p rob l ems , o n l y 24% of the i n p a t i e n t d iagnoses ref lected these spec ia l ty areas. Ano the r 15% of the am-

bu la to ry p r o b l e m s were o b s t e t r i c - gyneco log ic , o r t h o p e d i c - s u r g i c a l , EENT, and psychia t r ic ; n o n e of these d i sc ip l ines was r epo r t ed a m o n g the p r ima ry inpa- t i en t diagnoses . O n e c o u l d a rgue that s tuden t s are ex- posed to these d i s c ip l i ne s d u r i n g the i r o b s t e t r i c s -

gynecology , surgery, or psych ia t ry c lerkships . But s ince pa t i en t s of ten are t rea ted in genera l in te rn i s t s ' offices for such p rob lems , e x p o s u r e to t h e m d u r i n g a genera l m e d i c i n e ro ta t ion serves two ends: it p rov ides s tuden t s w i t h a m o r e c o m p l e t e v i e w of gene ra l medi - c ine p rac t i ce and exposes t h e m to myr iad cross-disci- p l i na ry c o m p l a i n t s m a n a g e d exc lus ive ly o n an ou tpa- t i en t basis or by a genera l internist.11

Despi te the logis t ical cha l l enges of a m b u l a t o r y t ra in ing, the o n g o i n g d e m a n d for p r imary care physi-

cians, c o m b i n e d wi th a d e c l i n e in s t ude n t in teres t in in te rna l m e d i c i n e , 6, 12 unde r sc o r e s the prac t ica l va lue of s tudies such as this one . Schwartz et al. 6 f o u n d that an

a m b u l a t o r y care e lec t ive was one pos i t ive factor affect- ing s tuden t s ' s e l ec t ion of i n t e rna l m e d i c i n e and that 90% of the s tuden t s w h o c o n s i d e r e d in te rna l m e d i c i n e b u t la ter chose a no t he r spec ia l ty made the i r dec i s ions d u r i n g the i r j u n i o r c lerkships . These f indings are con- s i s tent w i t h o u r s t uden t s ' emphas i s o n p r o v i d i n g ambu- la tory t r a in ing in the th i rd year. In add i t ion , over 60% of the j u n i o r c lerks s c r eened for ou r s tudy were in t e re s t ed in the a m b u l a t o r y c o m p o n e n t , sugges t ing that s tuden t s are we l l aware of the i m p o r t a n c e of a m b u l a t o r y train- ing. Al though most i n t e rna l m e d i c i n e p rograms do no t r e qu i r e an a m b u l a t o r y ro ta t ion d u r i n g the j u n i o r year, 13 co l l ec t ive efforts a r o u n d the c o u n t r y toward more care- fu l ly des igned and eva lua ted a m b u l a t o r y p rograms may h e l p a l ter that t r e nd a nd serve to r e n e w med ica l s t u d e n t in teres t in p r i m a r y care m e d i c i n e .

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