An encounter-based analysis of the nature of teaching and learning in a 3rd-year medical school clerkship

Background: Much of medical education has shifted from the hospital to ambu latory settings where each student works with a preceptor. Purpose: Our objectives were to describe the nature of community-based lear ning and to explore how learning experiences vary by type of health care vi sit. Methods: This prospective study used both paper- and computer-based documen tation systems to collect information on student-patient-preceptor encounte rs. A consecutive sample of 3rd-year medical students contributed data on 1 full clinical day each week as they rotated through a required 8-week fami ly medicine clerkship. The main measures of interest included patient age, gender, health care visit type (acute, acute exacerbation of chronic, chron ic, and health maintenance), method of learning in history taking and physi cal examinations (observing preceptor, being observed by preceptor, perform ing unobserved, or working jointly with preceptor), content of physical exa minations, amount of preceptor feedback, and preceptor teaching content. Results: Sixty-three students contributed data on 4,083 patient encounters. The majority of visits concerned acute complaints (37.7%) or health mainte nance (26.4%). Many encounters involved students conducting the cardiovascu lar and pulmonary exams (33.2% each); fewer encounters involved neurologic (6.9%), gynecological (4. 5%), and genitourinary (2.2%) exams. Students rep orted being observed performing histories and physical exams in 4% and 6% o f encounters respectively. The most common student experiences were perform ing histories and performing physical exams unobserved during acute visits, which accounted for 65.8% and 52.4% of encounters overall. Conclusions: This system is useful for determining educational content and processes that occur in ambulatory settings. Important differences were fou nd in teaching and learning by type of health care visit. This factor can a nd should be used when considering how students meet educational objectives in community-based ambulatory settings.