Help! There's a medical student in my office
By Deborah Gesensway
After volunteering his VA clinic office for medical student education, Craig S. Roth, FACP, was surprised to find himself dreading something he had always loved--teaching.
"I thought I was a reasonably good teacher in the hospital, that I had expertise in medical education," Dr. Roth said, "but when the first student came into my office, it just felt bad. I had to keep asking myself why it was so different." One day a week a University of Minnesota fourth-year medical student came to the office. On those days, Dr. Roth said he felt as though he was shortchanging everyone--his patients, the student, and even his family, since he ended up working longer hours.
As a result, Dr. Roth decided to diagnose the problems faced by office-based preceptors. At the May meeting of the Society of General Internal Medicine (SGIM) in San Diego, he pulled together a group of internists to talk about the challenges of teaching medical students in outpatient practices. The group came up with a long list of tips to help office-based preceptors balance the pressures of teaching and service without going broke or burning out.
The internists concluded that a whole new breed of teachers must be recruited and nurtured if more medical training is going to be moved into the outpatient setting. "We can't just transfer a lot of the teaching methods that we've used in the hospital to the clinic and expect them to work," Dr. Roth said.
But so far, in most areas of the country, there are many more medical students and residents who need outpatient placements than there are community-based internists lining up for clinical faculty appointments.
"Right now," said Donald R. Bordley, FACP, associate professor of medicine and director of medical student programs for the division of medicine at the University of Rochester, "I can't place [all students in their third-year medicine clerkship] in practices because I don't have enough preceptors ... It's a very intense and demanding experience."
And not just for the teacher. Office-based teaching also can strain the resources, staff and operations of an office. Teaching hospitals are set up to accommodate students, with conference rooms, libraries, staff who expect to see students wandering the halls, and patients with time on their hands. In a doctor's office, Dr. Roth said, "Students can be a big obstacle for everyone."
Students as well can find the experience unnerving. In the doctor's office, as opposed to in the hospital setting, medical students are usually on their own, expected to pull their own weight and contribute to the functioning of the practice.
For Dr. Roth, the job of being a preceptor has gotten easier since he accepted the fact that having a student around generally adds an hour to his workday. He has also learned that the way he teaches in the hospital--giving mini-lectures, for example--doesn't work under the time constraints of the office. Instead, he has created a worksheet that students use to take notes when they interview or examine a patient. The worksheet guides students through the encounter with the patient and helps them focus on what is important. Dr. Roth said that reviewing the students' notes in this format also helps him stay focused on a limited number of teaching points.
"My biggest tip," Dr. Roth said, "would be [to] ... try to recognize the amount of time [outpatient teaching] is going to take and reduce your schedule accordingly. Make longer appointments for individual patients, even if you have to take an extra bit of call for a colleague in exchange. ... If you're serious about working on a patient's problem, there is rarely a substitute for taking a little extra time." The same is true for teaching, he said.
Time is less of a problem for Rebecca Wadsworth, ACP Member, who teaches medical students in her rural upstate New York internal medicine practice. Her students are in their third year at the University of Rochester, and they come to her all day, every day, for six weeks straight. In Dr. Wadsworth's case, letting the medical student take up extra time is not a possibility. Not only does she have a young son at home, she also believes it is important to be a role model--to show the students that a rural internist does not necessarily work all the time.
Dr. Wadsworth said she has found that much of the teaching can be done "in the normal ebb and flow of conversation" and by sending the student to the library in the evenings to read pertinent articles about issues that come up during the day.
Community-based teaching can work well, Dr. Wadsworth said, when the internist realizes students "are thrilled to be able to do the simple stuff"--the earaches, the sinus infections and other bread-and-butter complaints of a doctor's office. This is the kind of medicine they rarely get a chance to see when they are working with hospitalized patients, she said.
In addition, Dr. Wadsworth said, students truly contribute to her practice by spending time with difficult patients whose depressions, anxieties or other psycho-social problems require more time than the doctor can give them herself. Dr. Wadsworth said one of her recent students focused on counseling patients about how to stop smoking. "I think it made a huge difference," she said. "Patients have been asking me ever since, 'Where did she go?'"
Only three of Dr. Wadsworth's patients have ever refused to see a medical student. In two of those cases, she said she thinks the patients were reluctant because the students were minorities. "I'm not going to force [people] on each other," she said.
Dr. Bordley said patient refusal rates in general are very low, running somewhere between 5 and 10%. To avoid any surprises, he suggests that preceptors send a letter to scheduled patients, describing the teaching program and advising them to let the office staff know if they would rather not be seen by a student during their visit.
In addition, all outpatient teachers are given a plaque to hang on their walls, which sends a "message to the patient that their doctor is somebody special, and that participating is an honor, not a burden," Dr. Bordley said. Beginning with the coming academic year, he said, photos of the students will be sent to the offices with the suggestion that they be posted so patients will be less startled by an unfamiliar face.
The photograph idea, Dr. Bordley said, came from Dr. Roth's SGIM conference session on tips for office-based teaching. The following are some of the other tips shared at that meeting:
- Make a year-round commitment. If you are serious about office-based teaching, figure out a way to do it all year, even if only for one day a week. That way, you can modify your practice fundamentally so a student has a place in it. This might include setting aside an office for a student or acquiring teaching materials, including books or videotapes.
- Get your staff's buy-in. For example, by making the nurses and front office staff part of the orientation team, you will not only empower your secretaries and medical assistants, but also save yourself the time it takes to orient each student to the office's policies and procedures.
- Follow up with patients. The next time you see them, thank patients for helping out in the education of a student. Ask them what it was like having a medical student present. You can ask an open-ended question such as, "I was worried that I might have shortchanged you."
- Limit your teaching points. Restrict yourself to one teaching point per patient or a few per afternoon. And you may want to save them for the end of the afternoon.
- Think about variety. Consider the wide range of topics students need to learn about, and then give yourself a break by having them work occasionally with nurses or help with billing.
- Ask for a little seasoning. Do not let the medical school send you students who are green.
"My own opinion is that if we are ... [to avoid] inefficiencies in practice, the students need to be very well grounded in taking histories and doing physical exams and recording the data before they go into anybody's office," Dr. Bordley said. "The practitioner has the right to expect that students are good at these things, and that the students relate well to people. I think this sense of urgency about getting students into the office nationally has to be tempered by some of these practical realities, or we are going to get into trouble."
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