Frank S H, Stange K C, Langa D, Workings M
Department of Family Medicine, Case Western Reserve University, Cleveland, OH 44106-4950, USA.
JAMA. 1997 Sep 3;278(9):712-6.
The current shift of predoctoral medical education from inpatient tertiary settings to community-based, ambulatory practice has raised questions about the effect of the medical student on the process of patient care.
To determine how the presence of a medical student during the ambulatory medical encounter affects the use of clinical time and patient satisfaction.
Cross-sectional, multimethod study using direct observation of ambulatory care by research-trained nurses.
A total of 16 community-based family practice offices accepting family practice clerkship students.
A total of 452 outpatient visits with and without student involvement.
Clinical time use as measured by the Davis Observation Code; patient satisfaction was assessed with the Medical Outcomes Study 9-item visit rating scale.
When students were involved, physicians spent more time discussing visit expectations (P=.03) and less time in history taking (P=.007), providing assessment (P=.01), and answering questions (P=.04). Despite these differences, patients were equally satisfied with explanations received, and there was no change in the rank order of the 5 most commonly observed physician behaviors. There was no difference in time spent in treatment planning, physical examination, health education, or social chatting. The physician spent equal time with the patient with (10.3 minutes) and without (9.9 minutes, P=.6) student involvement. There was no decrease in patient satisfaction when students were involved. Physicians were more likely to discuss another family member's problems when a student was present (P=.001). Students were directed to care for minority patients at a disproportionate rate (P=.001), controlling for confounding variables.
Medical student involvement alters the content but not the duration of the ambulatory medical encounter. Application of validated measures indicate that students did not impair patient satisfaction or hinder the physicians' ability to ensure that patient expectations for the visit were met.
当前博士前医学教育从住院三级医疗机构向以社区为基础的门诊实践转变，引发了关于医学生对患者护理过程影响的问题。
确定门诊医疗问诊过程中医学生的在场如何影响临床时间的使用和患者满意度。
采用经研究培训的护士对门诊护理进行直接观察的横断面、多方法研究。
总共16个接受家庭医学实习学生的社区家庭医疗诊所。
总共452次有或没有学生参与的门诊就诊。
通过戴维斯观察代码测量临床时间使用情况；使用医学结果研究9项就诊评分量表评估患者满意度。
当有学生参与时，医生花更多时间讨论就诊期望（P = 0.03），而花在病史采集（P = 0.007）、提供评估（P = 0.01）和回答问题（P = 0.04）上的时间减少。尽管存在这些差异，但患者对所接受解释的满意度相同，并且5种最常观察到的医生行为的排名顺序没有变化。在治疗计划、体格检查、健康教育或社交聊天方面所花时间没有差异。医生在有学生参与（10.3分钟）和没有学生参与（9.9分钟，P = 0.
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