Packman C H, Krackov S K, Groff G D, Cohen J
University of Rochester, School of Medicine, Mary Imogene Bassett Hospital, Cooperstown, NY.
Arch Intern Med. 1994 Jun 13;154(11):1253-60.
Recent changes in the organization and financing of medical practice have resulted in a shift of patient care from the hospital to ambulatory locations and dramatically changed the mix and severity of the inpatient population. Medical educators are concerned that hospitalized patients are not truly representative of the practice of internal medicine and may be unsuitable for the education of third-year medical students. The University of Rochester (NY) Department of Medicine recently established a "practice-based" component to complement the inpatient segment of the third-year medicine clerkship.
Participating students work with a practicing internist for the second half of the 12-week clerkship. Students evaluate office and hospital patients in the internist's practice and attend didactic conferences. We used a multi-measurement curriculum evaluation system to assess the new program and compare it with the established hospital experience. Evaluation components included the following: logs in which students profiled their clinical activities; questionnaires that assessed opinions and satisfaction about the clerkship; group interviews with students; and visits to practice-based sites to interview both preceptor and student.
Practice-based students saw many more patients with a broader range of illnesses and had more observation and supervision from faculty than hospital-based students. Practice-based students discussed all of their patients with their preceptors, who were perceived as being excellent teachers. Hospital-based students, although generally positive, were also generally less enthusiastic about the amount and quality of teaching, observation, and supervision. Practice-based and hospital-based students achieved similar grades on the final examination and received a similar number of honors grades. Preceptors were enthusiastic in their endorsement of the practice-based experience and patient acceptance of students was high.
The practice-based experience is feasible and of equal academic rigor to the hospital experience. This realistic immersion into the daily activities of an internist provides an enriching balance to the traditional hospital-based clerkship.
近期医疗实践的组织和资金安排发生了变化，导致患者护理从医院转向门诊场所，并极大地改变了住院患者的构成和病情严重程度。医学教育工作者担心住院患者不能真正代表内科实践，可能不适用于三年级医学生的教育。纽约罗切斯特大学医学系最近设立了一个“基于实践”的部分，以补充三年级医学实习的住院部分。
参与的学生在为期12周的实习后半段与一名执业内科医生合作。学生在该内科医生的诊所评估门诊和住院患者，并参加教学会议。我们使用了一个多维度课程评估系统来评估这个新项目，并将其与既定的医院实习经历进行比较。评估内容包括：学生记录其临床活动的日志；评估对实习看法和满意度的问卷；与学生进行的小组访谈；以及访问基于实践的场所，采访带教老师和学生。
与基于医院实习的学生相比，基于实践的学生诊治了更多患有更广泛疾病的患者，并且从教员那里得到了更多的观察和指导。基于实践的学生与带教老师讨论了他们所有的患者，这些带教老师被认为是优秀的教师。基于医院实习的学生虽然总体上持积极态度，但对教学、观察和指导的数量和质量普遍热情较低。基于实践和基于医院实习的学生在期末考试中取得了相似的成绩，获得荣誉成绩的数量也相似。带教老师对基于实践的经历给予了热情支持，患者对学生的接受度也很高。
基于实践的经历是可行的，并且在学术严谨性上与医院实习相当。这种对内科医生日常活动的真实体验为传统的基于医院的实习提供了丰富的补充。
