DIRECT OBSERVATION OF COMMUNITY-BASED AMBULATORY ENCOUNTERS INVOLVINGMEDICAL-STUDENTS

Context.-The current shift of predoctoral medical education from inpat ient tertiary settings to community-based, ambulatory practice has rai sed questions about the effect of the medical student on the process o f patient care. Objective.-To determine how the presence of a medical student during the ambulatory medical encounter affects the use of cli nical time and patient satisfaction. Design.-Cross-sectional, multimet hod study using direct observation of ambulatory care by research-trai ned nurses. Setting.-A total of 16 community-based family practice off ices accepting family practice clerkship students. Patients.-A total o f 452 outpatient visits with and without student involvement. Main Out come Measures.-Clinical time use as measured by the Davis Observation Code; patient satisfaction was assessed with the Medical Outcomes Stud y 9-item visit rating scale. Results.-When students were involved, phy sicians spent more time discussing visit expectations (P=.03) and less time in history taking (P=.007), providing assessment (P=.01), and an swering questions (P=.04), Despite these differences, patients were eq ually satisfied with explanations received, and there was no change in the rank order of the 5 most commonly observed physician behaviors. T here was no difference in time spent in treatment planning, physical e xamination, health education, or social chatting. The physician spent equal time with the patient with (10.3 minutes) and without (9.9 minut es, P=.6) student involvement, There was no decrease in patient satisf action when students were involved. Physicians were more likely to dis cuss another family member's problems when a student was present (P=.0 01). Students were directed to care for minority patients at a disprop ortionate rate (P=.001), controlling for confounding variables. Conclu sions.-Medical student involvement alters the content but not the dura tion of the ambulatory medical encounter. Application of validated mea sures indicate that students did not impair patient satisfaction or hi nder the physicians' ability to ensure that patient expectations for t he visit were met.