October 1998

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor's Note: This column begins a series of columns on teaching students in community settings prior to the traditional junior and/or senior year clinical rotations. Francis Kohrs, MD, MSPH, serves as the predoctoral director for the Department of Family Practice at the University of Kentucky.

I welcome your comments about this feature, and I also encourage all predoctoral directors to make copies of this feature in its entirety and distribute it to their preceptors. Send your submissions to Paul Paulman, MD, University of Nebraska, Department of Family Medicine, 600 South 42nd Street, Box 983075, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501. E-mail: ppaulman@mail.unmc.edu. Submissions should be no longer than 3-4 double-spaced pages. References can be used but are not required. Count each table or figure as one page of text.

For the last 2 years, the Department of Family Practice at the University of Kentucky has partnered with the Good Samaritan Foundation, a regional charitable foundation, to provide students with an experience in family practice prior to entering their first year of medical school. Students are selected based on several factors, including the students’ interest in family practice and personal ties to a medically underserved community in rural Kentucky. This program aims to foster students’ interest in family practice, pair students with physician mentors, and nurture ties between the students and the students’ community. The experience consists of a 1-day orientation, a 4-week experience with a family physician preceptor, and a 1-day debriefing session at the end of the experience.

Precepting the Prematriculation Student
Safety Issues and the Prematriculation Learner
Safety issues are a major concern for those administering prematriculation preceptorship programs. In most settings, experiences that involve potential contact with blood and body fluids should be anticipated, and learners should be briefed on universal precautions. At the University of Kentucky, we provide all students with a seminar on universal precautions prior to their experience. In addition, students are advised of the potential risks and benefits of starting their hepatitis B vaccination series at this time.

Diagnosing the Level of the Learner
Prematriculation students come from a wide variety of backgrounds. Some learners have had significant experiences in health care. Debriefing the learner in relation to these experiences may help the preceptor orient the student to the practice and tailor the experience to the learner’s needs. For example, some learners may have experience in nursing or allied health settings, including the emergency medical system, military, or laboratory prior to applying to medical school.

In addition, personal and family experiences may have a profound impact on a student’s career choice. In many cases, the prematriculation experience can provide the first venue for the learner to explore and discuss these experiences and related issues.

Basic History Taking, Vital Signs, and the Physician’s Practice
Most prematriculation students observe the family physician preceptor interacting with patients, an activity often called shadowing. This gives the learner an opportunity to observe how a history is taken, the value of continuity in patient care, and how sensitive matters such as sexual relationships, domestic discord, substance abuse, and sudden loss are handled by the physician.

It is often these experiences surrounding sensitive psychological matters that are remembered and valued by the learner. These experiences are often appreciated as pivotally important in the physician-patient relationship. At the same time, these skills are more difficult to acquire than the basic review of systems and not often discussed in introductory texts to the history and physical exam.

A useful exercise after a patient interview is to ask the student to present the patient. Invariably the student will use hand gestures to communicate the patient’s complaint. In our experience, simply by asking the student not to use his or her hands during these presentations, significant learning will occur. This will also provide an opportunity for the preceptor to orient the student to the fundamentals of anatomic description. Over the course of several weeks, significant progress and important skills are learned and observed.

In addition to time spent shadowing the physician, students should spend time with the nursing staff learning to take vital signs and initial complaints. Also, some time in the laboratory, medical records, and front office can give students a broad overview of the practice of medicine and scope of activities in the family practice office.

The Role of the Physician in the Community
Beyond the office-based practice, the rural experience we offer at the University of Kentucky also provides students with an opportunity to observe the role of physicians in the community. Involving students in community activities can highlight the importance of physicians as community leaders.

Onward Into the First Year
Exploring students’ backgrounds and their expectations and anxieties surrounding their entry into the first year of medical school is also an important part of the prematriculation experience. Recounting the first experience in the anatomy laboratory with cadaver dissection can provide a chance to explore the anxieties that students will more than likely have. In addition, workload issues often weigh heavily on students’ minds. A frank discussion of the stresses accompanying the first year of training and strategies for dealing with those stresses is valued by most students.

Corresponding Author: Address correspondence to Dr Kohrs, University of Kentucky, Department of Family Practice, Kentucky Clinic Bldg. K-302, Lexington, KY 40536-0284. 606-257-4860. Fax: 606-323-6661. E-mail: fpkohr1@pop.uky.edu.

Editor's Note: This column is a follow-up to a previous column by Kent Sheets, PhD, about working with students not interested in family practice. Dr Sheets serves as director of educational development for the Department of Family Medicine at the University of Michigan.

Part of the reality of serving as a preceptor is acknowledging that not every student who will be assigned to your office will be interested in family practice to the same extent. A previous “For the Office-based Teacher of Family Medicine” column1 dealt with the likelihood that as more and more medical schools require family medicine clerkships and preceptorships, all department faculty and staff and community preceptors will inevitably encounter students who are not receptive to family practice and/or do not have the personality and/or skills that are compatible with a career as a family physician. That column suggested strategies that preceptors could use, since a family medicine clerkship will be a requirement for graduation at most US medical schools.

Sometimes, we encounter students at the opposite end of the spectrum, those who are interested primarily (if not solely) in family practice. When you encounter these “true believer” students, what strategies should you use to make precepting a meaningful and productive educational experience for the student, your staff, your patients, and yourself?

In general, we all enjoy teaching students who appreciate what we do and what we have to offer them. When a student volunteers that family practice is “tops on my list for next year’s Match,” you might get even more enthused about spending the next month attached at the hip. Or, maybe, you become wary because of what happened the last time you had a student who proved to be less than sincere about future career options. Here are some issues to consider as you work with students who have announced their interest in family practice as a career.

Separate Specialty Choice Preference of Any Kind
From Your Clinical Teaching and Evaluation Activities
Just as you would not lower the grade of a student interested in surgery who has performed appropriately, you should not artificially inflate the grade of a student considering family practice. Whenever possible, you should apply the same standards for quality education and evaluation regardless of the career direction of the learner.

Do Not Make Assumptions
Do not make assumptions about students, such as expecting that they will have good patient interaction skills or will understand the value of prevention just because they are interested in family practice. Students should still be expected to demonstrate the ability to perform these and other skills. You should try to avoid the “halo effect,” where you make judgments about a student’s abilities based on personality, or strengths in one area, rather than actual performance in another area. Say, for example, that a student is interested in family practice and has good interpersonal skills. You should not assume that the student’s career aspirations and interpersonal skills automatically make the student an astute clinician without direct observation of student interactions with patients or reviewing student progress notes or charting.

Do Not Save All the Good Stuff; Avoid Playing Favorites
It is always important to show all students a representative view of family practice. Avoid saving the special patient or the easy or interesting patient or diagnosis just for the student going into family practice, particularly if there are other learners in the office at the same time who can observe this favoritism.

Some folks disagree on whether to show the student everything (at the risk of scaring one off) versus showing only the good or easy things (at the risk of not showing a representative slice of family practice). One of my junior colleagues recently out of residency phrased it this way:

There are different ways to learn about wild animals. You can learn about them by going to the zoo, or you can learn about them by observing them in their natural habitat in the wilderness.

While I am not advocating throwing students to the wolves, there is something to be said for showing students the more realistic “wilderness” of your daily life rather than giving them a guided trip through the zoo that misses the behind-the-scenes reality of short or no lunches, working with limited sleep, rushing to pick up children at day care or sporting events, or staying late to catch up on dictation. While it is not recommended that you focus solely on the less-glamorous aspects of life as a family physician, it is educationally sound to present the good with the bad and show a balanced view of the world in which you live and work.

If the student has proven to be capable of working effectively in the office setting, remember to challenge the student by giving more responsibility, autonomy, difficult patients, or patient problems to solve. Provide some suggestions on how to survive the wilderness and encourage the student to set higher goals for the experience.

It’s been suggested that career choice be separated from instruction and evaluation and that all students be treated similarly. This rule of thumb can be violated if you have concerns about the validity of the match between the student and family practice. It is particularly helpful to make sure that the student is considering family practice for the right reasons, not because it is easy, has no on-call responsibilities, or other reasons that might indicate a mismatch between the student’s perception of the discipline/specialty and the reality of life as a family physician.

You should not feel pressured to give a high grade to a student because of a stated interest in family practice. Despite what students would have you believe, it is possible to match into a quality residency program without an honors grade in the family medicine clerkship. You will not ruin someone’s life by giving them the grade they have earned and deserve, particularly if the clerkship occurred early in the third year. If you have further questions about this issue, you should contact the director of the clerkship in which you participate and see what students are told about grading and how much your evaluation of students’ clinical experience contributes to the final clerkship grade.

Having focused on ideas for how to deal with the challenges of working with students interested in family practice, let’s close by discussing the benefits. My view is that all of us involved in family medicine education teach both medicine and family medicine. We teach medicine to all students as we contribute to their general medical education in that we can teach the generic knowledge and skills needed by all students just as we can surgeons, anatomists, and pathologists. We also teach family medicine when we teach topics and approaches from the unique perspective of a family physician in the context of how and where family physicians provide care to their patients. If you are teaching a good student who is interested in family practice for all the right reasons and seems to be a good match for the specialty, then you are likely to get excited about teaching students the art and science of family practice, particularly the art. You will be reminded of what it was like to be at that level and to be excited to see the principles of family medicine applied by a skilled role model. These can be extremely rewarding situations when they occur and are among the reasons that you and other preceptors continue to teach year after year.

The ultimate outcome of student specialty choice is often unknown to the preceptor unless a relationship was developed and continued to the point were the student kept the preceptor informed of the residency application process. In response to a request from one of our preceptors, we have started sending the Match results to our preceptors, highlighting the student(s) who worked in that office. This closes the loop and informs the preceptor of where the student has chosen to begin the next phase of medical education.
Working with any student has its challenges and rewards. I hope some of these strategies will prove useful to you as you work with students interested in family practice in the coming months and years.

References
1. Sheets KJ. Working with students not interested in family practice. Fam Med 1997;29(6):389-90.

Correspondence: Address correspondence to Dr Sheets, University of Michigan, Department of Family Medicine, 1018 Fuller Street, Box 0708, Ann Arbor, MI 48109-0708. 734-998-7138. Fax: 734-998-7342. E-mail: ksheets@umich.edu.