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Third-Year Medical Student Survey of Office Preceptorships During the Pediatric Clerkship
Nicholas Jospe, MD;
Paul B. Kaplowitz, MD;
Fred A. McCurdy, MD;
Ruth P. Gottlieb, MD;
Mitch A. Harris, MD;
Russell Boyle
Arch Pediatr Adolesc Med. 2001;155:592-596.
ABSTRACT
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Objective To assess medical students' interest in a career in pediatrics following
their categorical pediatric clerkship.
Design Satisfaction questionnaire to 704 third-year clerks in 5 university
medical schools following the pediatric clerkship.
Methods Analysis of the influence of the community office-based experience compared
with the inpatient experience, and examination aspects of the office preceptorship
most valued by the medical students.
Main Outcome Measure Satisfaction questionnaire addressing office-based experiences.
Results Third-year pediatric clerks report that the private office setting provides
a valuable learning experience, particularly when there is exposure to a wide
spectrum of disease and when the preceptor had time to teach. Feelings about
pediatrics as career choice rose during the clerkship from neutral to positive,
and the frequency of strongly positive feelings rose from 9.2% to 28.6%. In
deciding about pediatrics as a career, experiences with patients and residents
in the inpatient setting still seem to count more than those experiences in
the outpatient setting.
Conclusion Categorical pediatric clerkships provide learning environments that
influence students positively toward pediatrics as a career choice. This choice
is enhanced by encouraging community practitioners with students in their
office to expose them to a wide variety of issues and devote time to teaching.
INTRODUCTION
CLINICAL training for medical students is increasingly occurring in
ambulatory as opposed to inpatient settings, including the offices of community
preceptors.1 Indeed, a survey of 70 pediatric
clerkships disclosed that fully two thirds of these include outpatient education
in private offices, and that students spend an average of 1.2 weeks in that
setting.2 Most teaching in the office setting
is accomplished through one-on-one clinical precepting between a clinical
faculty member and a student, and feedback from students about these experiences
throughout the years has been mixed. As is expected, students make career
choices based on their clerkship experiences; however, less is known about
the extent to which ambulatory-based or community-based education influences
career preference, or about which aspects of these experiences are most valued.
Given these considerations, we examined a set of themes on the office-based
experience to probe the following questions: What is the influence of the
office-based experience compared with the traditional inpatient experience
on students' interest in a career in pediatrics? What aspects of the office
preceptorship are most valued by the medical students?
METHODS
We administered a questionnaire to third-year clerks in 5 different
schools during the academic year 1997-1998. The 5 schools were the University
of Rochester, Rochester, NY, the Medical College of Virginia Commonwealth
University, Richmond, the University of Nebraska, Omaha, Indiana University,
Indianapolis, and Jefferson Medical College, Philadelphia, Pa. This was a
satisfaction questionnaire addressing office-based experiences that was completed
at the end of the students' pediatric clerkship. The questionnaire began with
2 questions regarding feelings about pediatrics as a career choice before
starting and after completion of the pediatric clerkship. It then proceeded
with the 12 questions listed in Table 1 and concluded with a rating of the 5 items presented in Table 2. Data management and statistical
analyses were completed using SAS statistical software for Windows, version
6.12 (SAS Institute Inc, Cary, NC). Descriptive data are summarized as means,
for ease of presentation, as well as "percent who strongly agree" to reflect
the Likert-type questions. Ordinal stepwise logistic regression analyses using
the LOGISTIC procedure were used to determine associations between 2 response
variables ("the preceptorship was an excellent learning experience" and "feelings
about pediatrics as a career at the end of the clerkship") and several explanatory
variables. The explanatory variables were left as 5 levels on an continuous
ordinal scale rather than dichotomized. The procedure used a stepwise approach,
specifying a .10 significance level for entry into the model and a .10 significance
for staying in the model. Only those variables with an associated  2 statistic at the .10 significance level were reported. Data from the
5 institutions were combined for all analyses even though the programs differed
slightly in the duration of the private office experience.
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Table 1. Student Attitudes Regarding the Private Office Experience*
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Table 2. Student Ratings of How Different Preceptors Encountered During
the Clerkship Affected Opinion of the Field of Pediatrics: Comparison With
1992-1993 Survey*
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RESULTS
Of 833 questionnaires distributed to students, 704 (85%) were returned
and are reported below. Prior to the pediatric clerkship, students had only
spent a mean of 4 days (range, 2-9 days) in a private pediatrician's office.
During the clerkship, days in the private office were a mean of 13.3 days
(range, 5-23 days). Our questionnaire revolved around 6 major themes that
emerge from the responses to the specific questions on the Likert scale listed
in Table 1. The first of these
themes is the students' perception of the private office as a learning setting.
Overall, students agreed that time in the private office setting provided
a valuable learning experience, with opportunity for independent patient exposure
and observation. With regard to the second theme, exposure to illness, students
felt that there was indeed appropriate exposure to well-child care and mild
disease. However, they felt less positive about their exposure to a wide spectrum
of diseases. In addressing the third issue of mentoring, students agreed that
their preceptor was a good role model and had time to teach, which is comforting
given the time constraints of the office setting. Students also agreed that
their preceptor taught them about the importance of being advocates for child
health. In response to the question pertaining to their perception of the
role of societal issues on child health, we learned that they agreed only
somewhat that they were exposed to these issues. This was not a very strong
statement, and it did not help, in retrospect, to ascertain how this exposure
might or might not have taken place. The last theme refers to the practice
of medicine, regarding which students agreed that they learned a lot about
the functioning of a pediatric practice. However, they were less likely to
feel that they had a good exposure to issues related to the cost of medical
care, insurance, or managed care.
To gain some insight into what aspects of the private practice experience
contributed most to making it a valuable encounter, we performed a correlation
between the ratings of each of the items in our questionnaire and the score
on the statement, "the preceptorship was an excellent learning experience."
The results are presented in Table 3.
Factors most predictive of an excellent learning experience were whether or
not students felt they were exposed to a wide spectrum of disease and whether
or not the preceptor had time to teach. What least mattered was whether there
was exposure to the role of societal issues on child health or whether the
preceptor or the office staff taught about the functioning of a pediatric
practice.
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Table 3. Logistic Analysis Associating Responses to the Statement,
"The Private Office Preceptorship Was an Excellent Learning Experience" With
Individual Statements on the Private Office Preceptorship
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Feelings about pediatrics as a career choice rose during the clerkship
from neutral (mean score, 2.83 of a possible 5) to positive (mean score, 2.14)
and the frequency of strongly positive feelings rose from 9.2% to 28.6%. To
examine factors that may have influenced this change in students' attitudes,
we present in Table 4 the results
of a logistic regression analysis examining associations between student feelings
toward pediatrics as a career at the end of the clerkship and the questions
we posed. By far, the biggest factor was the inpatient experience: the patients
and the residents with whom the students worked during their ward month, which
confirms earlier results.3 It should be noted
that although the ward attending received a high average rating (Table 2), there was no correlation between
the ward attending rating and career choice, whereas there was a modest but
significant (P = .006) correlation of the rating
of the private preceptor with interest in a pediatric career (Table 4). Our earlier study indicated that interest in pediatrics
as a career correlated most with the experience with ward residents and ward
patients3 as noted by others4
though not all.5
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Table 4. Logistic Analysis Associating Responses to the Statement,
"By the End of the Clerkship, I Had Feelings in Favor of Pediatrics as a Career"
With Other Statements on the Private Office Preceptorship
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COMMENT
The skills required to work in an office and in time constraints to
perform focused histories and physical exams are most often cited as the major
difficulty with learning ambulatory care.6
In the ambulatory setting, the pace of information gathering is unlike the
ward experience, as information is obtained during more than 1 visit. However,
the students surveyed for this study felt that they had a good to excellent
learning experience, and that, despite the time constraints, their preceptors
usually had time to teach. In fact, the extent to which a preceptor had time
to teach was one of the main predictors of a positive office learning experience.
We were surprised to learn that the single best predictor of the preceptorship
being an excellent learning experience was the perception of exposure to a
wide spectrum of diseases. Many students pointed out (Table 1) that they had not felt exposed to a wide spectrum of disease
in their preceptorships. This contrasts with the notion that the number of
separate student encounters with individual patients is greater in a pediatrician's
office than on an inpatient ward. Hence, students in the ambulatory setting
may be exposed to a significant amount of well-child care or to the early
presentation of mild disease. Compared with the inpatient setting, fewer tests
are ordered and discussed, there is little or no interaction with other subspecialists
and there is less time or need to generate a detailed differential diagnosis.
Moreover, hospital faculty may perpetuate the notion that inpatient education
is still the best.7 Thus, the student may acquire
the impression that he or she is not learning clinical reasoning skills owing
to insufficient exposure to in-depth workups and procedural skills. The take-home
point for preceptors is that the student benefits from maximizing the variety
of patients seen in their office by, for example, encouraging attendance in
evening sick-visit clinics in addition to well-child and routine follow-up
visits. Compared with a survey performed 5 years prior to this one, and done
at 11 medical schools, the rating of private practice preceptors improved
substantially, while the ratings of other people encountered by students in
the clerkship changed little (Table 2).3 It should be noted, however, that the schools that
participated in the current survey selected themselves because they had a
structured community preceptorship, which was not a selection criteria for
the earlier survey.3 Thus, the degree of improvement
in rating of preceptors seen in this comparison may be influenced by this
self-selection. Nonetheless, it is clear that at the 5 institutions participating
in this survey, community preceptors seem to have a more positive influence
on the students' opinions regarding pediatrics than hospital-based pediatricians.
We learned that the private office preceptor was a good role model.
This makes sense since students witness their office preceptors spending much
of the day examining and talking with patients and parents. Indeed, the ambulatory
setting advantageously promotes exposure to what is referred to as patient-doctor
interaction.8 The students can observe that
patient autonomy is better enhanced in an ambulatory setting, and the physicians
can demonstrate how to navigate between a chief complaint for an illness and
what a patient or parent really wants from an encounter.9
We had predicted based on comments from our own students that the opportunity
to see patients on their own would be highly predictive of a positive office
experience, and it was indeed an important factor. However, it was less predictive
than the spectrum of disease, the time the preceptor had to teach, and observing
one's preceptor interact with patients.
We also learned that students also felt appropriately aware of the role
of societal issues on child health. Thus, the opportunity to discuss behavior
change, risk factors, or the effect of public interventions on individuals
allows preceptors to demonstrate to students the importance of health promotion
and disease prevention.9 Again, this makes
sense, as students are exposed during clerkship to what may be closer to the
morbidity of illness within society in general and, as referred to by Lawrence,10 the sociology of help-seeking behavior.
Finally, students gained some insight into how an office operates, but
judging from their ratings, they learned relatively little about costs, insurance,
or managed care. These responses may underscore the fact that medical education
provides so little, if any, attention to the logistics of medical practice.
There may neither be motivation to pay attention to these concerns, nor sensitivity
to the relevance of economic and political constraints on practice, nor interest.
As well, a negative prevailing attitude on the part of preceptors toward managed
care or other concurrent difficulties might have dissuaded students from wanting
to learn about these issues.
While ambulatory care was perceived as exterior to the central teaching
mission of a medical school,11 planners of
medical school curricula recognize ever more that a general pediatric focus
is an appropriate component of the pediatric clerkship regardless of ultimate
career choice. Indeed, curricular themes in medical education are emphasizing
how to learn rather than strictly what to learn, which is a task that fits
well into ambulatory education. In this study, we present data from third-year
pediatric clerks reporting that the private office setting provides a good
learning experience, particularly so when there is exposure to a wide spectrum
of disease and when the preceptor had time to teach. These conclusions are
derived from students' subjective assessments of the educational effectiveness
of ambulatory experiences but not objective measurements of educational accomplishments
in these settings. However, in deciding on pediatrics as a career, experiences
in the inpatient setting still seem to count more than experiences in the
outpatient setting. It is perhaps not surprising that ratings of ward patients
correlated so strongly with career choice, as students will consider a career
in pediatrics insofar as that they derive satisfaction from participating
in the health care of children or adolescents who have illness serious enough
to warrant hospitalization. However, we did note a trend compared with the
1992-1993 survey for the office preceptor to have a modest but increasing
effect on career decisions, while the rating of the ward attending physician,
though still positive, did seem to correlate with career choice in this study.
While the depth and complexity of inpatient medical care of patients
may repel students from primary care specialties, exposure to office-based
pediatrics seeks to offset this concern.12
Insofar as office-based pediatricians attract students to pediatrics, it follows
that in order to encourage students' entry into primary care, barriers and
limitations to establishing learning in primary care teaching sites need to
be overcome. This is so because clinical education must occur where the majority
of physician-patient contact and decision making occur, namely the ambulatory
site rather than the ward.
Community faculty may fail to model the cognitive goals that can be
so effectively attained in the ambulatory environment such as knowledge of
the natural history of illness or clinical decision making under conditions
of uncertainty.13 On the other hand, students
may lack the sophistication to perceive what is being modeled, as surmised
for example, by noting that students reported only fair exposure to a wide
spectrum of disease. Yet, in the office students learn the relationship between
medical decision making and quality of care. The provision to the students
of both the important concepts and the framework in which to practice ambulatory
medicine enhances student integration within the private office and promotes
learning.14 What the private office setting
allows is the return of a form of apprenticeship. Apprenticeships encourage
modeling (observation of the teacher) followed by attempting.
Medical school curricula are evolving, with ambulatory experiences occurring
early in training, which will offset the perception that ambulatory medicine
is not merely inpatient skills "made simple."15
The students will thus learn that primary care skills (data gathering, problem
solving, decision making, dealing with uncertainty) are no less important
than the expertise in the arguably more seductive use of high-tech medicine
in the inpatient setting, where each and every symptom or problem must have
all possible etiologies ruled in or out to the highest order of resolution.
In the office setting, the students will learn that everything is not ruled
out in this manner, and they will thus seek to enhance clinical reasoning
skills in other ways.16 What our study documents
is that learning skills can be enhanced for the student if there is exposure
to and learning about a wide range of issues. With an increase in the proportion
of medical care delivered in ambulatory settings, physicians need to become
better prepared to deliver that care. Congruent with this idea, planners of
medical education need to remember to convince or remind their colleagues
in private offices that they have a lot to offer to their students. This is
not a new challenge.16, 17, 18
AUTHOR INFORMATION
Accepted for publication October 4, 2000.
This work was presented in part at the Annual Meeting of the Pediatric
Academic Societies, San Francisco, Calif, May 3, 1999.
From the Department of Pediatrics, University of Rochester School of
Medicine, Rochester, NY (Dr Jospe); the Departments of Pediatrics (Dr Kaplowitz)
and Biostatistics (Mr Boyle), Medical College of Virginia Commonwealth University,
Richmond; the Department of Pediatrics, University of Nebraska, Omaha (Dr
McCurdy); the Department of Pediatrics, Jefferson Medical College, Philadelphia,
Pa (Dr Gottlieb); the Department of Pediatrics, Indiana University, Indianapolis
(Dr Harris).
Corresponding author and reprints: Nicholas Jospe, MD, Department
of Pediatrics, Children's Hospital at Strong University of Rochester, 601
Elmwood Ave, Rochester, NY 14642 (e-mail: Nicholas_Jospe{at}urmc.Rochester.edu).
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