Academic Medicine highlights strong DMS education in patient care

July 11, 2002

Hanover, NH -- Dartmouth Medical School physicians and researchers have collaborated on projects that address how to meet the challenges of teaching aspiring doctors in the outpatient setting. They are featured in a series of five special-themed articles reported in the July Academic Medicine, the journal of the American Association of Medical Colleges.

About 90 percent of medical care takes place in an ambulatory setting, and the average physician appointment is about 15 minutes, according to Patricia Carney, PhD, author of three of the studies. Teaching and learning in the ambulatory care setting have been described as inefficient, variable and unpredictable. Inserting medical student teaching into that environment is different than having a captive audience at the patient's bedside and medical educators are continually evaluating ways to assure that doctors-to-be have the kind of experiences they need.

"DMS has significant and long experience with the challenges of teaching in the ambulatory setting," notes Martha Regan-Smith, MD, lead author of one of the articles. "It was the first (in 1989) medical school to implement a clinical curriculum in which more than 40% of its required clerkship curriculum [when students gain experience with patients in medical settings] was in the ambulatory setting. Prior to 1989, the clerkship curriculum was like others in that most all of the required clerkships were taught in hospital using inpatients--only community and family medicine was taught in an outpatient setting. After 1989, all clerkships had at least a portion of their clerkship taught in the outpatient setting."

Several studies have revealed teaching in outpatient clinics has a negative impact on preceptor productivity, and a teaching model that fully integrates the learner into the practice and the process of care has not yet been developed. In one article, however, DMS authors present a promising model of ambulatory teaching that was piloted in three settings (including one in 2000-2001 in the outpatient clinic serving the DMS teaching hospital at Dartmouth-Hitchcock Medical Center). It combines the systems of education and patient care and maintains or improves preceptor productivity compared to when the preceptor is not teaching. By fully integrating the learner into the office practice using creative scheduling, pre-rotation learning and learner competence certification, learners were able to fill roles traditionally fulfilled by physicians and nurses. The major implication for ambulatory medical education is that learning needs to be front-loaded to provide a teaching preceptor's patient care team with clinically competent learners able to efficiently contribute to patient care.

A second article describes an innovative educational support system that uses handheld computer documentation systems to enhance teaching and learning. Nationally, medical schools and residency programs have used documentation systems to record the clinical experiences of their students. The authors developed a system for the multidisciplinary primary care clerkship that documents students' clinical and educational experiences and provides peer-comparison feedback reports utilizing a timely data reporting system. They present cost comparisons of paper- and personal digital assistant (PDA)-based system development and maintenance, outlining the five critical components necessary for development and implementation of such a system and discuss the benefits and challenges involved with each component and plans for its maintenance and future use. They conclude that a comprehensive documentation and feedback system provides an essential infrastructure for the evaluation and enhancement of community-based teaching, learning and research in primary care ambulatory clerkships.

A related study reports that integrated primary care clerkship curriculum enhances students' abilities to develop skills relevant to multiple disciplines. Using data based on up to 15,000 student/patient/preceptor encounters, the authors explore where opportunities to apply clinical skills exist in a 16-week integrated primary care clerkship.

Another article discusses the trend in longitudinal ambulatory care experiences that are now common in medical schools, despite the fact that evidence supporting this widespread implementation is sparse. Reviewing the medical literature from 1966 through March 2000, the researchers studied the efficacy of longitudinal ambulatory care rotations focusing on medical student's experiences in these rotations. The articles identified the published benefits of longitudinal ambulatory care experiences, including developing effective patient interactions and understanding chronic diseases.

A fifth article outlines a collaborative model to integrate institutional and community-based interdisciplinary education through a centralized office, and reviews the strengths and challenges in applying it, the educational outcomes tracked to evaluate its effectiveness, and estimates of funds needed to ensure its success.

DMS has developed a centralized office, the office of community based education and research, to foster interdisciplinary community-based education. As part of this centralized approach, DMS has succeeded in developing a uniform system of rewarding community-based faculty, and identifying and recruiting sites using an interdisciplinary approach. DMS also uses interdisciplinary leadership and input to guide community-based educational support and research activities that will ultimately span the entire medical education continuum. Indicators of success in this approach include the ability to monitor the balance between achieving educational and research project outcomes and attaining sufficient funds to pay the direct costs of the central infrastructure.
DMS news is on the web at

Academic Medicine Articles (

"An Efficient and Effective Teaching Model for Ambulatory Education," Martha Regan-Smith, MD, EdD, William W. Young, MD, and Adam M. Keller, MPH.

"An Analysis of Students' Clinical Experiences in an Integrated Primary Care Clerkship," Patricia A. Carney, PhD, Catherine F. Pipas, MD, M. Scottie Eliassen, MS, Sarah C. Mengshol, MD, Leslie H. Fall, MD, Karen E. Schifferdecker, PhD, Ardis L. Olson, MD, Deborah A. Peltier, MD, and David W. Nierenberg, MD.

"Development of a Handheld Computer Documentation System to Enhance an Integrated Primary Care Clerkship," Catherine F. Pipas, MD, Patricia A. Carney, PhD, M. Scottie Eliassen, MS, Sarah C. Mengshol, MD, Leslie H. Fall, MD, Ardis L. Olson, MD, Karen E. Schifferdecker, PhD, Margaret T. Russell, MS, Deborah A. Peltier, MD, and David W. Nierenberg, MD.

"A Collaborative Model for Supporting Community-based, Interdisciplinary Education," Patricia A. Carney, PhD, Karen E. Schifferdecker, PhD, Catherine F. Pipas, MD, Leslie Fall, MD, Daniel A. Poor, MEd, Debbie Peltier, MD, David W. Nierenberg, MD, and W. Blair Brooks, MD.

"Evidence for Longitudinal Ambulatory Care Rotations: A Review of the Literature," Gregory Ogrinc, MD, MS, Sunita Mutha, MD, (University of California, San Francisco, School of Medicine), and David M. Irby, PhD (University of California, San Francisco, School of Medicine).

The Geisel School of Medicine at Dartmouth

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