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PURPOSE: We needed specific strategies for students in diverse outpatient settings to more uniformly learn focused history and physical exam skills. METHODS: We conducted a randomized control trial to test the use of focused history and physical exam scripts in enhancing 3rd-year medical students' clinical skills at two medical schools. The article based scripts outlined focused outpatient encounters. The outcome measure was blinded analysis of progress notes using a standardized scale. Descriptive statistics were used to assess differences among student in each school, and study groups were compared using a t test. RESULTS: Five of 11 variables were statistically higher in the scripts group. These included history taking, physical examination, and overall score. CONCLUSION: Focus Scripts facilitated a specific task of learning to document focused evaluations in acute and chronic office visits.

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PURPOSE: In July 2003, resident duty hours regulations were implemented. The impact of these regulations on medical student education has received minimal attention. The objective of this study was to evaluate the perceptions of internal medicine clerkship directors about the impact of resident physician duty hours reform on medical student teaching, assessment, and clerkship structure. METHOD: A survey was sent to 114 institutional members of Clerkship Directors in Internal Medicine in May 2004. The survey included 17 attitude items rated on a 5-point Likert scale, five items related to clerkship structure, and four open-ended questions. Descriptive statistics were performed on the responses. RESULTS: Ninety-six surveys were returned (84%). The majority of respondents did not believe duty hours reform had a positive impact on clerkship students' educational experiences, whereas 48.3% agreed or strongly agreed that residents had more difficulty evaluating students' clinical skills. There was not a significant change in inpatient clerkship structure after duty hours implementation. Time for teaching students, concerns about a shift-work mentality, and student continuity with their teams were major challenges. Impact on ambulatory internal medicine rotations was minimal. CONCLUSIONS: Internal medicine clerkship directors are concerned about the impact of resident duty hours reform on student education. Additional studies of this educational impact are needed.

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BACKGROUND AND OBJECTIVES: Traditional medical school department-based clerkship structures can lead to redundancy and/or gaps in curriculum, inefficient administrative systems, and academic isolation for clerkship directors. This paper describes the approaches, successes, and challenges three institutions experienced when implementing an interdepartmental collaboration to create an integrated primary care clerkship experience. METHODS: Each school combined family medicine, ambulatory pediatrics, and ambulatory medicine into contiguous clerkship blocks. In all institutions, each clerkship maintained certain distinct features while the integrated aspects contained longitudinal curriculum of certain primary care topics. RESULTS: Evaluations by students demonstrated favorable responses to the new content and integrated methods of teaching, as did results of the Association of American Medical Colleges graduation survey. Faculty at each institution reported that their multidisciplinary approach has stimulated important educational collaborations, many of which require an economy of scale not often achievable within a single clerkship. These included innovative evaluation/documentation efforts; centralization of administrative tasks; enhanced recruitment, retention, and development of community-based faculty; an increase in the active core group of local and national primary care leaders; and an increase in scholarly activities. The collaborations have not occurred without challenges, primarily in the need for identifying sustainable resources for these and future collaborative educational endeavors. CONCLUSIONS: The benefits involved in developing an integrated primary care experience include expansion of curriculum content and methods, as well as enhancement of collegial support and resources to community-based and academic faculty. These integrations do, however, bring added challenges, time, and costs to traditional independent clerkships.

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Documentation systems are used by medical schools and residency programs to record the clinical experiences of their learners. The authors developed a system for their school's (Dartmouth's) multidisciplinary primary care clerkship (family medicine, internal medicine, pediatrics) that documents students' clinical and educational experiences and provides feedback designed to enhance clinical training utilizing a timely data-reporting system. The five critical components of the system are (1) a valid, reliable and feasible data-collection instrument; (2) orientation of and ongoing support for student and faculty users; (3) generation and distribution of timely feedback reports to students, preceptors, and clerkship directors; (4) adequate financial and technical support; and (5) a database design that allows for overall evaluation of educational outcomes. The system, whose development began in 1997, generated and distributed approximately 150 peer-comparison reports of clinical teaching experiences to students, preceptors, and course directors during 2001, in formats that are easy to interpret and use to individualize learning. The authors present report formats and annual cost estimate comparisons of paper- and computer-based system development and maintenance, which range from $35,935 to $53,780 for the paper-based system and from $46,820 to $109,308 for the computer-based system. They mention ongoing challenges in components of the system. They conclude that a comprehensive documentation and feedback system provides an essential infrastructure for the evaluation and enhancement of community-based teaching and learning in primary care ambulatory clerkships, whether separate or integrated.

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Development and support of community-based, interdisciplinary ambulatory medical education has achieved high priority due to on-site capacity and the unique educational experiences community sites contribute to the educational program. The authors describe the collaborative model their school developed and implemented in 2000 to integrate institution- and community-based interdisciplinary education through a centralized office, the strengths and challenges faced in applying it, the educational outcomes that are being tracked to evaluate its effectiveness, and estimates of funds needed to ensure its success. Core funding of $180,000 is available annually for a centralized office, the keystone of the model described here. With this funding, the office has (1) addressed recruitment, retention, and quality of educators for UME; (2) promoted innovation in education, evaluation, and research; (3) supported development of a comprehensive curriculum for medical school education; and (4) monitored the effectiveness of community-based education programs by tracking product yield and cost estimates needed to generate these programs. The model's Teaching and Learning Database contains information about more than 1,500 educational placements at 165 ambulatory teaching sites (80% in northern New England) involving 320 active preceptors. The centralized office facilitated 36 site visits, 22% of which were interdisciplinary, involving 122 preceptors. A total of 98 follow-up requests by community-based preceptors were fulfilled in 2000. The current submission-to-funding ratio for educational grants is 56%. Costs per educational activity have ranged from $811.50 to $1,938, with costs per preceptor ranging from $101.40 to $217.82. Cost per product (grants, manuscripts, presentations) in research and academic scholarship activities was $2,492. The model allows the medical school to balance institutional and departmental support for its educational programs, and to better position itself for the ongoing changes in the health care system.

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PURPOSE: Combining complementary clinical content into an integrated clerkship curriculum should enhance students' abilities to develop skills relevant to multiple disciplines, but how educational opportunities in primary care ambulatory settings complement each other is unknown. The authors conducted an observational analytic study to explore where opportunities exist to apply clinical skills during a 16-week integrated primary care clerkship (eight weeks of family medicine, four weeks of ambulatory pediatrics, and four weeks of ambulatory internal medicine). METHOD: Using handheld computers, students recorded common problems, symptoms, and diagnoses they saw. The students also recorded information about the educational process of the clerkship. Two data files were created from the database. Descriptive statistics were used to characterize the students' clerkship experiences, and ANOVA was used to evaluate differences among these blocks within the clerkship. RESULTS: Students encountered different frequencies of presenting symptoms, the majority of which occurred in pediatrics (23.2 per student per week versus 16.3 in medicine and 16.8 in family medicine; p =.01). Students provided more behavioral change counseling in family medicine (5.2 episodes per student per week versus 4.2 and 2.0 in internal medicine and pediatrics, respectively; p =.01), and they performed more clinical procedures in family medicine (1.9 per student per week versus 0.6 and 1.1 in pediatrics and internal medicine, respectively; p =.001). Students were more likely to encounter specific conditions in internal medicine (35.3 per student per week versus 30.0 and 21.4 in family medicine and pediatrics, respectively; p =.01). Elements of the teaching and learning processes also differed by clerkship. CONCLUSIONS: Very little overlap was found in symptoms, conditions, procedures, and other educational opportunities in the ambulatory pediatrics, internal medicine, and family medicine blocks that constitute the integrated primary care clerkship. The blocks provided different and complementary learning opportunities for students. These findings will assist in clerkship planning and in guiding students to seek opportunities that will ensure educational excellence.

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Six patients who failed to respond to what would ordinarily be considered therapeutically effective courses of sequential unilateral nondominant (mean number 10) and bilateral brief-pulse electroconvulsive therapy (ECT) (mean number 10) with electroencephalographic (EEG) monitoring of seizure duration (all seizures >30 s) subsequently received courses of bilateral sinusoidal ECT (mean number 6) and responded well. Some theoretical implications and clinical considerations raised by these cases are discussed.