First-Year Medical Students' Contribution to Office Productivity in Primary Care Preceptorships Richard W Pretorius, MD, MPH Denise McGuigan, MSEd Basma Faris, MS, RD, MS-3 SUNY AT BUFFALO STFM 34th Annual Predoctoral Education Conference Portland, Oregon January 25, 2008

BACKGROUND Trend towards early clinical exposure “Shadowing” vs. active participation First-year medical students possess basic communication skills Interview skills are taught early

BACKGROUND Pros of Precepting: Helps physicians keep current Increase sense of value in own work Makes work more enjoyable Altruism Cons of Precepting: Time pressure Loss of productivity Loss of income

RESEARCH QUESTIONS 1. Can first-year medical students contribute to office productivity upon entering medical school, with minimal instruction? After interview skills training and six preceptor sessions? After 12 sessions? 2. Are there differences in the number of skills performed by students in university affiliated practices vs. community practices?

METHOD N = 144 students enrolled in a Clinical Practice of Medicine course over two semesters during the 2005-06 academic year Six half days sessions each semester with a primary care preceptor Students recorded and submitted data on 33 skills (20 interview skills & 13 office skills) at three points in time: After two sessions After six sessions (at end of fall semester) After 12 sessions (at end of spring semester)

METHOD Students recorded: number of each skill they completed of these, number not duplicated by the preceptor or other member of the health care team N=139 (97%) students completed clinical skills checklists for fall semester N=135 (94%) submitted data on unduplicated skills N=99 (69%) submitted data for spring semester N=92 (64%) submitted data on unduplicated skills

All done > 1 skill per student per 4-hour precepting session RESULTS Skills Assessed (top 14) All done > 1 skill per student per 4-hour precepting session Chief complaint History of present illness Agenda Pain assessment Past medical history Blood pressure Family history Social history Review of systems Update problem list Update med list Health risk profile Put patient in room Height and weight

RESULTS Skills Assessed (bottom 19) All done < 1 skill per student per 4-hour precepting session Review intake questionnaire Sexual/OB/gyn hx Discuss weight loss Discuss smoking cessation Fill out prescription Obtain temperature Get lab or x-ray from Get pt education materials Get drug sample Fill out lab or x-ray forms Calculate ideal body weight Suicide and homicide screen Depression screen (SIG E CAPS) Coping skills (BATHE) Culture eval (Kleinman’s 8 questions) Domestic violence (HITS or SAFE) Use of translator phone Adolescent interview (HEADS) Alcohol screen (CAGE)

RESULTS (top 14 skills)

RESULTS (top 14 skills—summary) unduplicated total % session 2 10.2 19.4 53% session 6 14.1 21.8 65% session 12 21.7 31.0 70% % increase 113% 60%

RESULTS (top 5 skills after 12 sessions) University vs. Community Preceptor Unduplicated skills 32% (13.6/10.3) more common with university preceptor Total skills 18% (19.3/16.3) more common with university preceptor

LIMITATIONS Recall bias Five patient write-ups required per semester according to assigned templates Single institution Time saving to preceptor not quantitated Total skills per patient visit—both preceptor and student—not recorded

DISCUSSION First-year students enter medical school with a high level of communication skills. After only two precepting sessions, students are performing many office and interview skills.

DISCUSSION Over the 1st year: # of total skills increased (by 60%). # of unduplicated skills increased (by over twofold—212%) % of unduplicated skills increased (by 1/3rd—from 53% to 70% This implies preceptors are satisfied with data obtained by the student. Since the preceptor does not repeat every skill done by the student, the preceptor can spend time on other aspects of the patient interaction.

DISCUSSION Both unduplicated and total skills are more common in academic than community preceptors. Students with academic preceptors have more autonomy and may be better integrated into the healthcare team.