Direct observation of community-based ambulatory encounters involving medical students
S. H. Frank, K. C. Stange, D. Langa and M. Workings
Department of Family Medicine, Case Western Reserve University, Cleveland, OH 44106-4950, USA. shf2@po.cwru.edu
CONTEXT: The current shift of predoctoral medical education from inpatient
tertiary settings to community-based, ambulatory practice has raised
questions about the effect of the medical student on the process of patient
care. OBJECTIVE: To determine how the presence of a medical student during
the ambulatory medical encounter affects the use of clinical time and
patient satisfaction. DESIGN: Cross-sectional, multimethod study using
direct observation of ambulatory care by research-trained nurses. SETTING:
A total of 16 community-based family practice offices accepting family
practice clerkship students. PATIENTS: A total of 452 outpatient visits
with and without student involvement. MAIN OUTCOME MEASURES: Clinical time
use as measured by the Davis Observation Code; patient satisfaction was
assessed with the Medical Outcomes Study 9-item visit rating scale.
RESULTS: When students were involved, physicians spent more time discussing
visit expectations (P=.03) and less time in history taking (P=.007),
providing assessment (P=.01), and answering questions (P=.04). Despite
these differences, patients were equally satisfied with explanations
received, and there was no change in the rank order of the 5 most commonly
observed physician behaviors. There was no difference in time spent in
treatment planning, physical examination, health education, or social
chatting. The physician spent equal time with the patient with (10.3
minutes) and without (9.9 minutes, P=.6) student involvement. There was no
decrease in patient satisfaction when students were involved. Physicians
were more likely to discuss another family member's problems when a student
was present (P=.001). Students were directed to care for minority patients
at a disproportionate rate (P=.001), controlling for confounding variables.
CONCLUSIONS: Medical student involvement alters the content but not the
duration of the ambulatory medical encounter. Application of validated
measures indicate that students did not impair patient satisfaction or
hinder the physicians' ability to ensure that patient expectations for the
visit were met.
