American College of Physicians: Internal Medicine — Doctors for Adults ®

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How teaching students affected me—and my patients

From the November 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Kenneth M. Granet, FACP

Six months after a program that allowed medical students into my practice as part of an ambulatory care clinical rotation had ended, I noticed a resounding sign of success: Every student came back and asked if they could watch me again in their "spare" time. They had gotten the message that to truly understand what they read in books, they needed to see it in action.

In my three years of teaching medical students in my office, I have seen students go from figuring out what a lymph node is to teaching me things. The transformation is wonderful.

Like other physicians who choose to participate in ambulatory teaching, I volunteer. Most physicians are discouraged by that aspect—who has the time? In truth, it does slow you down a little, but you manage to make up the time. And I have found no overall negative economic impact on my practice. The patients love it, the students love it and I love it.

ACP's New Jersey Chapter designed its mentor program to expose first-year medical students at an early stage of their careers to internal medicine in the outpatient setting. This program reflects internal medicine's shift in focus from the inpatient to outpatient ambulatory setting.

During my own training—the early 1980s—I had to obtain special permission from my program director to take an ambulatory elective. Today, medical schools are routinely integrating ambulatory courses as part of clinical rotations, and graduate medical education requires that residents spend at least 25% of their time in an ambulatory setting.

What we didn't know when we first started participating in the New Jersey Chapter's program was how patients were going to react. There were few studies that evaluated patient attitudes towards medical students in a clinic situation, and there were no studies regarding students at any level in a private practice setting. Nor were there any studies designed to assess the impact on a practitioner. Did it detract from patient care? Did it disrupt the office?

To get those answers, my office studied patient attitudes toward medical student participation in the summer of 1996. As part of the chapter's mentoring program, the setting involved a private internal medicine office staffed by one physician and a student with one year of medical school under her belt.

We asked 105 consecutive patients, regardless of their health status, to complete a two-part questionnaire before and after seeing the physician and medical student. One hundred of those patients completed the questionnaire; nearly 60% were females, about 40% males. Nineteen percent were new patients, and the average age was 45.4. All of the female patients and 95% of the male patients reported a positive experience, and nearly all were willing to have students present at future appointments.

I believe the overwhelmingly positive response was due in large part to the fact that I took the time to introduce patients to the student before taking the history and examining the patient—all with the student present. Therefore, it was relatively easy to integrate the student into the office without sacrificing the patient-physician relationship.

Not only did patients enjoy seeing their doctor in a teaching role, at times they even felt like educators themselves. One patient sent me information about his disease, orthostatic hypertension, and wanted to make sure the student received that information.

The medical students benefited by having an experience that allowed them to integrate their basic science work with clinical science. One first-year student even had the opportunity to orally present a research paper on her experience training in the outpatient setting at a New Jersey scientific meeting. She was the first student ever to do so.

These study results can be used to promote educating students in the outpatient setting. They show that, if done correctly, these programs are a win-win situation for students, patients and physicians alike.

Dr. Granet is a general internist in solo practice in Eatontown, N.J.

References:
Kassirer JP. Redesigning graduate medical education—location and content. NEJM.1996; 335: 507-509.

Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. NEJM.1996; 335: 514-518.

Simons BJ, Imboden BA, Martel JK. Patient attitudes toward medical student participation in a general internal medicine clinic. J. General Internal Medicine. 1995; 10: 251-254.

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