January 1997

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor's Note: Gregory A. Doyle, MD, is the predoctoral director in the Department of Family Medicine at West Virginia University School of Medicine (WVUSM). Chris T. Patricoski, MD, is curriculum coordinator of rural medicine for the Department of Family Medicine at WVUSM. This article reflects on an original research project and a review of the current cost-of-teaching literature. In the second part of this column, Laura-Mae Baldwin, MD, MPH, addresses strategies to decrease the costs of teaching. Dr Baldwin is an associate professor of family medicine at the University of Washington. I welcome your comments (e-mail: ppaulman@mail.unmc.edu). I also encourage all predoctoral directors to make copies of this column and distribute it to their preceptors.

Costs of Teaching for Community Teachers of Family Medicine
Little is known about the time and cost for family physicians teaching medical students in ambulatory settings, despite the renewed interest in medical student education in ambulatory care settings. Most patients are seen and treated in community physicians' offices, and those admitted are generally sent to community hospitals. Family physicians have the greatest accessibility to the patient population and are in a position to have the greatest impact on treatment and prevention. This implies that a portion of medical education can and should occur in communities under the direction of motivated and skilled family physicians.

Physicians' offices have successfully been used as teaching sites for many years. It is important for medical students to work with family physicians because family medicine uses a predominantly ambulatory care approach as a teaching model.

The following information focuses on what rural physicians, who teach in their offices, perceive to be their cost in time and decreased patient volume when they are teaching medical students.

During the period of July 1991­June 1994, we surveyed our community family physician preceptors with written questionnaires regarding time spent with medical students and the number of patients seen. These community physicians were asked to record "additional time spent with the medical student to fulfill your teaching role," "average patient load," and "actual patients seen for each day of the week, Monday through Friday."

On average, third-year medical students added 73.33 minutes to the time our physicians spent in their practice each day. Patient productivity was decreased an average 2.2 patients per day. Physicians reported that they delay administrative tasks and work additional time to complete their patient load when they are teaching students.

Garg et al(1) noted that academic physicians were 30%­40% less productive than comparable nonacademic physicians. Kearl and Marinous(2) found no change in the productivity of family physicians in an academic program when they were teaching medical students. However, in private office settings, the decreased patient visits average 1.2 a day. Kirz and Larsen(3) noted a similar decrease of .65 patient visits per day and an additional 43.8 minutes spent per half day in teaching by primary care physicians. The subjective benefits of student involvement include improved patient satisfaction, enhanced provider education, and the joy of practice.

Several studies have confirmed that it costs community physicians time and revenue to teach medical students. Despite the cost, community family physicians have donated their time and expertise to training medical students in their communities for years. By using community physician teachers, departments of family medicine have enhanced the quality of family medicine education without a large increase in university faculty. This degree of volunteerism is unique to family medicine. There are multiple financial barriers to maintaining a private practice, especially in rural areas. As decentralization of medical education continues, it is increasingly important to note the cost in time and productivity for a community family physician when she or he teaches medical students and consider methods of compensation.
Gregory A. Doyle, MD
Chris T. Patricoski, MD

Acknowledgment: This program was made possible by DHHS/PHS/HRSA grant #1D15PE80017-01, Grants for Predoctoral Training in Family Medicine--Training Third-year Medical Students in Rural Health Care Delivery Settings.

References
1. Garg ML, Boero JF, Christiansen RG, Booher CG. Primary care teaching physicians' losses of productivity and revenue at three ambulatory care centers. Acad Med 1991;66(6):348-53.
2. Kearl GW, Mainous AG III. Physicians' productivity and teaching responsibilities. Acad Med 1993;68(2):166-7.
3. Kirz HL, Larsen C. Costs and benefits of medical student training to a health maintenance organization. JAMA 1986;256(6):734-9.

Managing Clinic Time While Precepting Medical Students
One of the greatest challenges of teaching medical students in the clinic setting is maintaining patient flow while securing adequate teaching time. We have all had the experience of reaching the midpoint of a busy clinic and feeling frustrated because other patients are waiting and we don't have the time we'd like to make the important teaching points.

A wide variety of strategies can be used before, during, and after the clinical encounter to successfully combine effective teaching with patient care. When you know you will be working with a medical student, it is helpful to approach the day's activities with your dual role as teacher and physician in mind.

1. Assess each student's clinical skills before he or she begins working with you. Students with little clinical experience may need to spend time observing you before being asked to evaluate patients independently.

2. Make sure your clinic will run as smoothly as possible on a teaching day by arriving a bit early to review the clinic schedule and by making sure all charts, lab and X-ray reports, consultation notes, etc, are available. Prepare your nursing staff by reviewing any special tasks they'll be involved in during the course of the day.

3. Recognize that working with a student will slow you down. Consider setting aside two 15-minute periods during each half day that you are teaching in clinic.

4. Make sure the student is well oriented to your clinic and its procedures, so he or she will not spend excessive time finding equipment, ordering tests, etc. If you have forms and flow sheets used for annual physicals, well-child care, or prenatal care, make sure that the student is aware of and uses these forms. Use other clinic personnel to orient the student and answer student questions about your clinic.

5. Remember that the student does not need to see every patient. Meet with the student at the beginning of the clinic to review the schedule and identify the patients who will offer the best learning experiences. Make sure to strike a balance between patients with greater and lesser degrees of complexity.

6. Before the student enters a room to see a patient, review the differential diagnosis for the patient's chief complaint and the questions the student might ask. Many students are accustomed to doing comprehensive inpatient evaluations and have no experience with the focused history and physical exam. Therefore, review what history and physical examination items are not indicated for each patient. Let the student know how long you expect him or her to spend with the patient.

7. See other patients while the student is evaluating his or her patient.

8. Observe the student doing the history and physical exam on some of the patients. This can eliminate the need for a lengthy presentation, while allowing you to give direct feedback to the student on his or her interviewing and physical exam skills. Giving specific feedback and instruction early will allow the student to progress more rapidly.

9. Discuss only those issues important to the diagnosis and treatment of the patient at the time of the visit. Let the student know that you can go into more detail about some of the other teaching points at the end of your clinic.

10. Delegate part of your usual role to the student so that you can spend that time teaching. For example, the student can look up lab and X-ray results, research information from a text about a patient problem, call a consultant, organize the patient's disposition, etc.

11. Last but not least, be easy on yourself as a teacher. You can't make all the available teaching points during each clinical session. If you do, the student may be overwhelmed anyway! Make one important teaching point per patient so that the student can fully absorb the information.

Best wishes for a career of time-effective student teaching!
Laura-Mae Baldwin, MD, MPH

Acknowledgments: My thanks to the following teachers whose collective wisdom is shared in this column: Lili Church, MD; Peter DeNeef, MD; Sharon Dobie, MD; Tom Greer, MD, MPH; Bill Neighbor, MD; Roger Rosenblatt, MD, MPH; and Ron Schneeweiss, MD. Additional thanks go to Drs Greer and Neighbor for reviewing this column and providing helpful comments and suggestions.