Screening applicants for a rural medical education program.

The goal of the Rural Medical Education (RMED) Program of the University of Illinois College of Medicine at Rockford is to train rural family physicians. This article describes the screening instrument developed by RMED to identify appropriate candidates.

Defining and evaluating quality for ambulatory care educational programs.

As the training of medical students and residents increasingly moves to ambulatory care settings, clerkship and program directors must find a way to use their limited resources to guide the development and evaluation of the quality of these ambulatory-based learning experiences. To evaluate quality, directors must first define, in operational and measurable terms, what is meant by the term "quality" as it is applied to ambulatory-based education. Using educational theories and the definition of quality used by health care systems, the authors propose an operational definition of quality for guiding the planning, implementation, and evaluation of ambulatory care educational programs. They assert that quality is achieved through the interaction of an optimal learning environment, defined educational goals and positive outcomes, participant satisfaction, and cost-effectiveness. By describing the components of quality along with examples of measurable indicators, the authors provide a foundation for the evaluation and improvement of instructional innovations in ambulatory care education for the benefit of teachers, learners, and patients.

The use and compensation of community preceptors in U.S. medical schools.

PURPOSE: To better understand how U.S. medical schools are using and compensating community preceptors. METHOD: In 1995, the authors sent questionnaires to associate deans for education at all 125 U.S. medical schools. Each questionnaire asked whether that school used community preceptors to teach students and, if so, from what disciplines community preceptors came, at what sites community preceptors taught students, how community preceptors were compensated, and how these factors varied for each year of medical school. RESULTS: One hundred schools (80%) completed the questionnaire. Ninety-six reported using community preceptors. Primary care physicians were used most often, and private practices were the dominant teaching location. A clinical academic appointment was the most common compensation. Few schools compensated community preceptors monetarily. Community preceptors' involvement was substantial in all four years, but greatest in year three. CONCLUSION: Community preceptors are widely used in educating medical students, especially in year three. More recognition and better compensation of these important educators is necessary.

What students say about learning and teaching in longitudinal ambulatory primary care clerkships: a multi-institutional study.

PURPOSE: Ambulatory primary care clerkships have become crucial elements in medical education. Although most such clerkships employ a block-rotation format, an alternative longitudinal approach has been developed. This study examines students' perceptions of learning and instruction occurring during longitudinal ambulatory clerkships. METHOD: Characteristics of longitudinal ambulatory primary care clerkships at five medical schools are described. Responses of 429 medical students to a standardized survey administered at these institutions are analyzed to ascertain perceptions of learning and teaching occurring during longitudinal ambulatory clerkship experiences. RESULTS: Enhancements of interpersonal communication and clinical skills were perceived to be the most positive learning attributes of the longitudinal ambulatory clerkships. No advantage was discerned with respect to disease-pattern recognition or generation of differential diagnoses. While significant inter-institutional variation was present, particularly with respect to instructional format, there was notable agreement regarding several aspects of clerkship-related learning and the adequacy of faculty supervision. CONCLUSION: Students perceived that learning during longitudinal ambulatory clerkships had greater impact on skill enhancement than on attainment of knowledge-related objectives. Sources of variation in student opinion, perceptions of learning as a function of career preference, and correlation of students' perceptions of learning to demonstrable changes in their competence require further investigation.

Graduate medical education for rural physicians: curriculum and retention.

The chronic shortage of rural physicians prompts further consideration of the educational interventions that have been developed to address this issue. Despite rural admission strategies and a variety of undergraduate, graduate and postgraduate curricular innovations, the recruitment and retention of family physicians into many rural areas has not kept pace with the retirement of older general practice physicians. This paper reviews the 1994 American Academy of Family Physicians' rural training recommendations in the light of several recent educational needs assessments. These studies affirm the need for rural residency rotations and the need to maintain and better implement the established rural clinical training guidelines. However, although preparation for rural medical practice has been addressed and is being adequately accomplished in the clinical knowledge and procedural skills areas, instruction and experiences relating to the "realities of rural living" need to be enhanced to increase the retention duration of rural physicians. This can be accomplished with more curricular emphasis on developing community health competencies, including community-oriented primary care (COPC). Physicians who know how to collaborate with community members on health improvement projects have skills that can also facilitate integration and, hence, retention.

Medical students' understanding of ethical issues in the ambulatory setting.

BACKGROUND: The education of medical students concerning ethical issues focuses mainly on critically ill hospitalized patients. However, in the outpatient setting physicians encounter many problems that require ethical decision making. The present study is an assessment of medical students' awareness and understanding of ethical issues commonly encountered in the ambulatory setting. METHODS: A questionnaire was designed to evaluate general knowledge of medical ethics using 12 clinical vignettes. These vignettes depict situations in the ambulatory setting which involve ethical problems. The questionnaire was distributed to medical students who were asked to state whether an ethical issue was present, its significance, and what the specific issue was. RESULTS: Students' abilities to identify that an ethical issue was involved in each vignette ranged from 34.2% to 96.4%. A majority of students identified the presence of an ethical dilemma in seven out of 12 vignettes. The significance rating varied from 2.8 to 4.4 on a scale of 1 to 5. The results indicate that traditional education in medical ethics does not necessarily prepare students to recognize these problems in the clinical setting. CONCLUSIONS: The medical students surveyed for this study seem to be variably prepared to recognize obvious ethical dilemmas in the ambulatory setting. Medical education must prepare students to recognize and appropriately manage these commonly encountered situations.

Illinois RMED: a comprehensive program to improve the supply of rural family physicians.

BACKGROUND: Rural areas of the United States are perennially medically underserved, and the state of Illinois is no exception. A recent survey showed that 75 of Illinois' 84 rural counties are primary care physician shortage areas. In response to this chronic physician shortage, the Illinois Rural Medical Education (RMED) Program was developed by the University of Illinois College of Medicine at Rockford. The RMED program is a comprehensive, multifaceted program that combines recruitment, admissions, curriculum, support, and evaluation components and is longitudinal across all 4 years of the medical school experience. The admissions process seeks to select students who possess traits indicative of success in eventual rural family practice. These traits are fostered and developed by the 4-year rural curriculum, which emphasizes family medicine, community-oriented primary care, the physician functioning in the context of community, relevant aspects of the "hidden" curriculum, and service learning. After 6 years, RMED has graduated 39 physicians; 69% have gone into family practice, and a total of 82% have selected primary care residencies.

How ambulatory care is different: a paradigm for teaching and practice.

This paper reviews the issues regarding an increased emphasis on medical education and practice in the ambulatory care setting. A paradigm for ambulatory medicine is offered which combines the elements of 'traditional' medical care and teaching with the more 'distinctive' elements representative of the ambulatory setting. The former includes aetiology, history, physical examination, laboratory tests and therapy; while the latter includes continuity, context, health education, economics and responsibility. The paradigm is illustrated in relation to the problem of hypertension. The ambulatory medicine paradigm is further discussed with respect to potential barriers to its acceptance. These include: (1) the assumption that 'traditional' medical education does teach all 10 elements of the paradigm; (2) the axiom that if one learns to care for the sickest patients, the less ill ones should be manageable; (3) the intuitive aspects of the 'art' of practising ambulatory medicine; (4) the recognition that this teaching will require a longitudinal experience; and (5) perception that the five distinctive elements are not 'hard' science and objectively measurable. Nevertheless, the changing face of medical practice requires the adoption of an ambulatory medicine paradigm in medical education.

Dementia and depression symptomatology as assessed through screening tests of older patients in an outpatient clinic.

OBJECTIVE: This study examined the prevalence of dementia and depression symptoms as assessed through screening instruments in older patients visiting a family practice clinic, compared screening results with indications of either a dementia or depression-related diagnosis as reported on patients' medical records and billing statements, and examined the relationship between screening instrument results and patients' demographics. METHODS: A total of 214 patients were interviewed and completed a written survey relating to dementia (Mini-Mental State Exam), depression (Beck Depression Inventory), medical conditions, and demographics. Patients were 60 years of age and older visiting a family practice clinic serving an outpatient population in northwest Illinois and southern Wisconsin. The clinic is an undergraduate teaching site of the University of Illinois College of Medicine at Rockford. Patients were interviewed at the time of their visits for routine medical care as they appeared on study recruitment days. RESULTS: The response rate was greater than 90%. About 20% of the patients scored in the range of possible cognitive impairment and over 22% scored in the range of possible mild to moderate depression. Overall, about 38% of the patients showed symptoms of either dementia or depression, or both. Based on chart review, there was significant under-reporting of dementia or cognitive difficulties and low correlation between screening results and chart and billing information related to depression. CONCLUSIONS: The results reaffirm a significant rate of mental health problems in older patients in outpatient settings. This situation warrants examination of the reasons for under-reporting of mental health problems and the potential relationship between mental health problems and the general health status of elderly patients.