The Journal of Continuing Education in the Healrh Professions, Volume 11. pp. 277-282. Printed in the U.S.A. Copyright 0 1991 The Alliance for Continuing Education and the Society of Medical College Directors of Continuing Medical Education. All rights reserved

Medicine

Physicians Learning Continuing Medical Education from Third-Year Medical Students

JOHN E. VERBY, M.D. Professor Department of Family Practice and Community Health University of Minnesota Medical School Minneapolis, MN

Between student queries and University faculty dis- courses, the Rural Physician Associate Program (RPAP) offers, and prods, the rural physician into an extended pro- gram of continuing medical education.

James Heid, M.D. RPAP Mentor - 7 years Little Falls, Minnesota, 1979

A recent editorial by Dennis K. Wentz encouraged practicing physicians and all medical educators and students of medicine to develop and promote those kinds of continuing medical education (CME) events that are more personal to the physician and are based on the clinical needs of individual patients, re- gardless of whether such needs are quantifiable. The information systems and technology to-do this are available.2 Neatly documentable and sponsor- verifiable CME seminars with lectures may become less acceptable in the fu- ture for busy primary care physicians who must take time away from their practices and patient care, pay handsome fees for a few days and may or may not leave family at home. The cost for five working days may run into $5,000 or more if one includes service lost.

Since 197 1, the Rural Physician Associate Program (RPAP) at the Uni- versity of Minnesota Medical School has placed 61 1 third-year undergrad- uate medical students with over 500 practicing rural primary care physicians in 93 rural Minnesota hospitals over a period of nine to twelve months. This experience allows the RPAP student to learn and work with numerous “I don’t know” answers from the practicing physician mentor. For that reason, a half-time librarian is supported by RPAP at the University Biomedical Library to answer and meet the physician-medical student duos’ requests for up-to-date knowledge and provide literature support for their numerous daily clinical problems. Abstracts and photocopies of up to date relevant articles

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John E . Verby

Table 1 Frequency and Percent of Participants’ Descriptions of Beneficial Program Outcome

Beneficial Outcomes 1 . Updated an area of knowledge. 2. Provided an opportunity to

meet UofM medical faculty. 3. Learned new skills or new in-

formation. 4. Provided validation concern-

ing the general quality of med- ical practice within the community.

5. Provided an opportunity to confirm or revise my medical practice related to the pre- sented topics.

6. Helped to meet my continuing education requirements.

7. Provided an opportunity to “check out” a resource person for future consultation or refer- ral.*

medical practice within the lo- cal community.

9. Stimulated subsequent discus- sions of program content among local colleagues.

10. Provided an opportunity to contact local colleagues.

1 1. Other: Provides focus of medical education. Total N: 93

8. Contributed to revisions of

Number Percent PhysiciandAllied Health** Physicians/Allied Health*’

79 5 89.8 100 64 5 72.7 100

60 5 68.2 100

61 2 69.3 40

60 1 68.2 20

56 2 63.6 40

42 47.7

35 39.8

25 3 28.4 60

8 9.1

* One physician commented, “Not when residents-in-training are sent out.” ** Other helping professionals.

come back to them by mail usually in 48 to 72 hours. In addition, all RPAP students were provided in 1984 with personal microcomputers, modems, AMA/Net Linkage (now PaperChase and Medline Access), monitors, and printers to access current knowledge at will in the most remote portions of Minnesota on the Canadian border. RPAP has an electronic mail system that can bring messages to each student and mentor on teachingearning sug- gestions, an article to read or administrative information essential to their learning environment. Thus the student helps in developing knowledge that may be applied to the patient in the community almost immediately.

The immediate application of new knowledge to the clinic-hospital pa-

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Physicians Learning CME from Third-Year Medical Students

Table 2 Participants’ Identification of Major Benefits Resulting from Specialty Faculty Visits

Number of Respondents PhysiciadOther Helping Professionals

Provision of new knowledge, updated pre- 53 3

Increased communications, consulations, 17 1

Validated present areas of practice and

sent knowledge and skills, and con- tributed to CME requirements.

and referrals with specific U of M med- ical staff and departments.

stimulated review and change in medi- cal practice.

7

Beneficial for student learning. 6 2 Increased understanding of UofM fac-

ulty’s knowledge concerning small, community practice.

Total N: 93

tients helps both student and mentor retain knowledge. It also seasons the medical students over nine to twelve months and allows the mentors and helping professionals to update the care to the people they serve.

Further research to verify improvement in patient outcomes is essential, but, in Minnesota, the medical association’s malpractice insurance company returned over two million dollars to their members in 1990. Premiums have not risen in the past two years.

One of the RPAP mentors, James K. Heid, M.D., of Little Falls, Minne- sota, commented on the impact for his personal CME in Minnesota Medicine: “The RPAP student brings a certain freshness and intellectual spark that is subtly contagious. The University faculty visits afford excellent opportunities to local medical and other helping professionals. These visits often bring super specialists into areas that have seldom known this exper- tise. Between student queries and faculty discourses, RPAP offers and prods the rural physician into an extended program of continuing education.”l

Once a month University faculty members visit the student and mentor for consultant rounds; they also review outpatient problems and assist in for- mal teaching presentations conducted by the RPAP student. Hospital and community medical and helping professional staff are welcome to attend these teaching programs for free CME credit.

Three times a year, RPAP staff come to videotape students as they in- terview patients. They review the tape with the students to strengthen their communication skills and allow them to see themselves as the patient sees them.3

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John E . Verby

Table 3 Physicians’ Identification of Impacts of Specialty Faculty Visits

Program Impacts 1. The specialty faculty visits have increased your

willingness to consult with U of M medical fac- ulty or staff. Comments: >already use U of M a fair amount > occasionally

2. Consultation with a visiting faculty member or his department has resulted from the visit.

3. Consultation has occurred with any U of M medical faculty or staff. Comments: > I usually refer to specialists in my group and they in turn do the referral to the U. > At times

ring patients to the U of M, you received the as- sistance you sought. Comments: > Very hard to contact staff of U of M hospital. > Not always. I have referred two patients to the F.P. department in the past three years, have sent all the data I had and a list of problems I wanted checked out and they didn’t do the ma- jor ones. The problem may have been with inter-agency referrals, but when one patient got lost entirely I quit, and only refer for one prob- lem and to a specific physician.

referred patients. Comments: > Absolutely, generally. > Ten physicians stated that the results were de- layed unbelievably long. Two added that it de- pended on the department. > Prior to three years ago I did refer to the U from the State Hospital. Never got letters back or information unless I called and complained. > This is much better than in the past but could still be improved.

cialty faculty visits. Comments: > Definitely. > They’re nice, but seem awfully expensive.

4. When consulting with U of M faculty or refer-

5 . You have received timely feedback regarding

6. Your opinion concerning continuation of spe-

Agree Disagree No Response 64 14 10

34 50

77 8

72 3

55 21

83 1

4

3

13

12

4

Total N: 88

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Physicians Learning CME from Third-Year Medical Students

RPAP-sponsored seminars on substance dependency, family dysfunction, and counseling are provided for both mentor and ~ tuden t .~

One probable outcome is that the RPAP student learns that in the class- room of real life sound medical practice is born of sound medical training and theory. The RPAP experience encourages personalized learning and fits the goals of adult education. As Wentz said, it is learner-driven, problem- centered, and incorporates new knowledge in a meaningful context befitting the style of physicians’ practices.*

The free formal continuing medical education for rural Minnesota pri- mary care physicians and other helping professionals provided by RPAP is a real benefit. This medical educational outreach eliminates the cost and time away from the office, hospital, nursing home, and house calls that would otherwise be necessary to obtain this information and experience. Professional and personal isolation disappear as consultative and referral re- lationships with the University are established.

Hopefully, such relevant on-site CME will allow the practicing physi- cians to spend their vacation time with their families, instead of attempting to obtain some CME while the family is swimming, relaxing on a sandy beach, or skiing from the mountain tops. It also provides them with an op- portunity to personally honor their professional commitments in equity and balance with their personal and academic commitments. The ultimate re- sponsibility for maintaining competence is dependent on the physician and not the sponsor of the CME program.

A critical appraisal of the efficacy of continuing medical education was done by Haynes, et al. in 1984. Their conclusion was that of the.248 orig- inal articles describing studies of CME interventions, only seven provided convincing evidence that CME can improve physician behaviors. Only three articles assessed patient outcomes, and one demonstrated improvement in outcomes.5 An update of this review is now under preparation.

The RPAP study revealed beneficial outcomes, benefits, and program impacts on the physician mentor of the third-year RPAP undergraduate med- ical student as shown in Tables 1, 2, and 3 and in the report published in 1983.6 The mentors learned new skills or new information to confirm or re- vise their medical practice, updated areas of knowledge, validated the gen- eral quality of medical practice within the local community, and helped to meet their continuing medical education requirements. Discontent and oc- casional hostility to medical school contacts dramatically declined when fac- ulty from the major clinical departments spent five or more hours in the rural community with the mentor, medical student, and helping professionals. At

28 1

John E . Verby

this writing, more than 3,500 faculty visits have been made to 93 rural com- munity hospitals and physicians’ offices, involving more than 500 practic- ing physicians in all of the various medical and surgical specialties.

As Dr. Heid said, “The transition from practitioner to teacher terrifies and humbles (me). It frustrates and positively defies endurance - except that it is so wonderfully stimulating. It stimulates and revives scholastic interests long lulled into dormancy. Yes, teaching is an awesome art! To teach is to learn, and in the end the teacher always learns more than the student. RPAP builds bridges of good will between the University and rural doctors.”

It is recommended that the 126 medical schools in the United States con- sider the RPAP concept as a way of enhancing the quality of learning by the medical student, physician/mentor, and other community helping profes- sionals, in a cost-effective and beneficial manner. The teaching hospitals and the people are also benefactors of this effort. References 1. Heid JK, Rural physician associate program: A boon to rural Minnesota, Minnesota

2. Wentz DK, Continuing medical education at a crossroads, JAMA 1990; 264:18 3. Verby J, The audiovisual interview (A new tool in medical education), JAMA 1976;

4. Verby J., The Minnesota rural physician associate program for medical students, J

5. Haynes RB, et al., A critical appraisal of the efficacy of continuing medical educa-

6. Verby JE, Feldman B, The rural physician associate program - A righton program for

Medicine 1979; 62: 11926-828.

236: 21: 2413-4.

Med Educ 1988; 63: 427-437.

tion, JAMA, 1984; 25 1 : 1.

all participants, Minnesota Medicine 1983; 181-185.

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