Impact of a first-year primary care experience on residency choice.

We designed a retrospective cohort study of first-year medical students to assess the impact of a community-based primary care course, Introduction to Primary Care (IPC), on residency choice. In the group that took IPC (n=282), 48.2% entered generalist residencies (internal medicine, pediatrics, family medicine, or medicine/pediatrics), compared to 38.2% in the group that wanted IPC (n=398) and 39.6% in the group that did not want IPC (n=245). Controlling for gender, students who took IPC had a 40% higher odds of selecting a generalist residency than those who wanted to take IPC (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.04 to 1.95). There was no difference between those who wanted IPC and those who did not (OR, 1.08; CI, 0.78 to 1.52). The community-based primary care experience was positively associated with students' selection of generalist residencies.

Promoting institutional change to encourage primary care: experiences at New York Medical College and East Carolina University School of Medicine.

New York Medical College and East Carolina University School of Medicine significantly changed their curricula and organizational structures in response to The Robert Wood Johnson Foundation's Generalist Physician Initiative (GPI). Seven common elements essential to successful institutional change were retrospectively identified at these two markedly different schools. They are (1) using national priorities to promote need for change, (2) establishing internal and external financial support, (3) developing a planning process and organizational structure to effect change, (4) devising an ongoing evaluation strategy, (5) sustaining positive attitudes toward primary care, (6) integrating community-based physicians, and (7) sustaining interest in the GPI. Within this framework, the authors present the GPI objectives at both schools, discuss examples of methods for institutional change and describe successes, failures, and lessons learned. The authors conclude that both schools have significantly increased the number of students choosing primary care careers and note the general perception of improvement in the quality of primary care educational programs, student recruitment, departmental collaboration, and faculty development opportunities. Although these changes have not yet been fully institutionalized, the similarities of the processes described may be of value to others addressing similar issues.

The impact of early clinical training in medical education: a multi-institutional assessment.

With funding from The Robert Wood Johnson Foundation's Generalist Physician Initiative, Dartmouth Medical School (DMS), New York Medical College (NYMC), and Virginia Commonwealth University School of Medicine (VCU-SOM) adopted early community-based training models for longitudinal clinical experiences. These schools developed different evaluation strategies to assess these models. This paper describes each program, the method used to evaluate an aspect of the program, lessons learned about early clinical teaching and learning, and challenges encountered. Each program used cross-sectional evaluation, and the analysis methods included descriptive statistics, chi-square, t-tests, analysis of variance, and generalized linear models. Dartmouth determined that the type of preceptor does not greatly influence the development of clinical skills, although case-specific differences were discovered. NYMC learned that students taught clinical skills in community-based settings performed as well as or better than their peers who received early patient experience on hospital wards. Virginia Commonwealth discovered that community experiences contributed positively to students' education, critical thinking, and problem-solving skills. Students value early clinical experiences and make important achievements in clinical skills and knowledge development, although logistic challenges exist in conducting these courses. Evaluations are critical to ensure competency, and faculty development must be linked to the evaluation process.

Benefits and costs to community-based physicians teaching primary care to medical students.

The purpose of this study was to determine the benefits and costs to community-based primary care physicians teaching medical students in their offices. Survey data were collected from 185 preceptors between 1990 and 1996. Respondents reported increases in their enjoyment of the practice of medicine (82%), time spent reviewing clinical medicine (66%), desire to keep up with recent developments in medicine (49%), and patients' perception of their stature (44%). However, 61% reported a decrease in the number of patients seen when a student was present. We conclude that despite the costs associated with teaching medical students in their offices, preceptors derived many benefits.

Influence of medical school on medical students' opinions about primary care practice.

PURPOSE: To compare first- and fourth-year medical students' opinions about primary care practice. METHOD: A cross-sectional survey was made of medical students at New York Medical College (NYMC) and East Carolina University School of Medicine (ECUSOM) over three years (1993-94, 1994-95, and 1995-96). Three consecutive classes of first-year students from both schools (n = 807), two consecutive classes of fourth-year NYMC students (n = 373), and three consecutive classes of fourth-year ECUSOM students (n = 221) were given a self-administered questionnaire about professional aspects of primary care practice. Responses to ten items about primary care practice were the independent variables in a logistic regression analysis. Career choice, categorized as primary care or non-primary care, was the dependent variable. Independent, two-tailed t-tests were employed to compare the responses of the first-year students interested in primary care careers with those of the fourth-year students interested in primary care careers. RESULTS: In all, 639 (79%) of the first-year students and 396 (67%) of the fourth-year students returned completed questionnaires. The first-year students interested in primary care careers were significantly more likely to believe that primary care practice has more prestige, has more intellectual stimulation, needs a large knowledge base, and involves work that is more important than that of non-primary care physicians, and were significantly more likely to disagree with the assertion that in primary care practice, physicians have more control over their working hours. With one exception (prestige of primary care practice), all these independent variables were significant for the fourth-year students as well. The comparison of the first- and fourth-year students indicated that the fourth-year students were significantly more likely to believe that primary care practice has more intellectual stimulation, needs a large knowledge base, and requires knowledge that non-primary care practice may not; they were also significantly more likely to disagree with the assertions that primary care practice is adequately compensated, has more prestige, and allows more control over working hours. CONCLUSION: It appears that students' positive perceptions about primary care practice may change as realistic perceptions about the professional demands on primary care physicians develop during medical school.

What predicts medical student career choice?

The literature on medical student career choice has identified several influences that can be categorized as student demographics, medical school characteristics, students' perceptions of specialty characteristics, and student-held values. A logistic regression model that included demographics, medical school, and student-rated influences as a proxy for perceptions and values was used to determine their relative contribution to student career choice for three consecutive cohorts of senior medical students attending two schools (n = 649). This model identified a positive relation between choice of primary care career and both student-rated influences and one student demographic characteristic, but not between career choice and school attended. Variables positively correlated with primary care career choice were related to working with people and marital status. Negatively correlated variables were related to income and prestige.

First-year medical students' knowledge of and attitudes toward primary care careers.

BACKGROUND AND OBJECTIVES: This study compared the knowledge of and attitudes toward primary care in relation to anticipated career choices of first-year medical students at two medical schools that differ significantly in production of primary care physicians. METHODS: A cross-sectional survey was conducted at a private, urban school in the Northeast where only a small percentage of students enter family practice residencies and a public, rural school in the Southeast where entry into family practice is among the highest in the country. The survey was conducted during the first semester of medical school. RESULTS: Ninety-six percent of students correctly identified general internal medicine, general pediatrics, and family practice as primary care fields; 51.8% identified these fields as "specialties." Statistically significant differences were seen between the percentages of students at the two schools who planned careers in primary care, suggesting that selection processes may differ between the two schools. There were no significant differences between students at the two schools in correctly identifying the characteristics of primary care practice. Only minor differences between the schools were found in assessments of the need for or importance of primary care. CONCLUSIONS: Although a significant difference in student interest in becoming primary care physicians was detected at the two schools, a surprising similarity was shown in their knowledge and attitudes about primary care. New attitudinal markers will need to be developed to help admissions committees select students most likely to enter primary care careers.