DOES TRAINING LOCATION INFLUENCE THE CLINICAL SKILLS OF MEDICAL-STUDENTS

Purpose. To examine the benefits of the shift of medical education int o ambulatory primary care settings by investigating whether medical st udents exposed to a common primary care problem (low back pain) in amb ulatory care settings develop better clinical skills. Method. In 1995, the authors categorized 420 students from all four North Carolina med ical schools into groups that had previously encountered patients with low back pain in ambulatory primary care settings, tertiary care sett ings, both, or neither. The clinical skills of the groups were determi ned using data collected during standardized-patient examination in wh ich students took the history of, physically examined, and chose a dia gnostic strategy for patients with acute, uncomplicated low back pain. Results. In general, there was no difference between the performances of the student groups associated with the settings of their previous encounters with low back pain. On average, the students failed to ask 35% of the history items and failed to perform 35% of the physical exa mination items. Many students chose inappropriate diagnostic strategie s. Conclusion. The lack of difference between the groups' clinical per formances indicates a need to more rigorously def;ne and evaluate outc omes of education in ambulatory care settings. The generally poor clin ical performance of all groups suggests that the current curriculum in adequately teaches clinical skills needed to assess and manage common problems. Clearer expectations of competencies and assurances that pre ceptors in ambulatory care settings will help students meet those lear ning objectives might lead to better outcomes.