Impact of a 12 Week Continuity Clinic on Primary Care Interest Ryan Nall MD Robert Hatch MD Lou Ann Cooper PhD

Background With passage of Affordable Care Act and aging population the need for primary care physicians continues to grow Multiple studies have shown a decrease in primary care interest during medical school Will a continuity experience added to a standard block rotation improve interest in a career in primary care?

Literature Review Campos-Outcalt et al1, showed an increase in the proportion of students choosing family practice with the number of weeks on family medicine clerkship Emey et al2, randomized students to ½ day continuity experience and showed significant increase in those choosing primary care 21.3% vs. 10.9% Harris et al3, a limited number of students were accepted into a primary care track which included continuity experience. Compared those who applied and not accepted vs those accepted (46.3% vs. 16.1%) Topic of what drives decision to pursue primary care has been studied – Nice Summary of findings in Physician education and training in primary care, Valerie Stone (2010 report macy foundation) family medicine department, primary care track decline in interest thought to be secondary to uncontrollable lifestyle and decreased compensation Characteristics: older, female, married, from rural county, associated with high level of community service Acad Med. 64(1989):610-625. Acad Med. 66(1991): 234-236. J. Med. Educ. 57(1982): 609-614

New 3rd Year Clerkship Model 12 week clerkship combined with neurology 8 weeks outpatient primary care, 4 weeks two sites 4 weeks neurology Friday all-day lectures series Half-day 12 week continuity clinic with one preceptor Cover recent changes along with addition of continuity experience -- continuity experience --3 to 4 weeks on neuro -- 4 weeks two clinical sites instead of 3 weeks 3 clinical sites

Methods Voluntary survey administered before and after clerkship Two rotations prior to addition of continuity experience All groups since addition of continuity experience Students created a unique identifier so that their interest in a career in primary care could be monitored anonymously over time Performed Wilcoxon Sign Rank Test to identify statistical differences pre and post clerkship

Primary care is critical to patient care Things I appreciate about primary care The continuity of care with patients The management of chronic diseases The diversity of disease encountered The patient relationships The work/life balance The professional/personal satisfaction Are you considering a career in primary care? Factors that have influence your decision to pursue a career in primary care Faculty mentorship The clinic site(s) during my ambulatory rotation third year The 12 week continuity experience Another clinical experience during medical school 5 point likert scale (Strongly Disagree – Strongly Agree)

Response Rate Pre-Continuity 94% (64/68)pre-clerkship 80% (55/68)post-clerkship Continuity 96% (63/67)pre-clerkship 85% (57/67)post-clerkship

Results In general pre-continuity group responded more positively. Last two rotations of year and may have contained more students interested in career in primary care. Need to compare groups from the same time in the year to correct for this – we will be collecting this data. Both groups most strongly agree that primary care is critical to patient care, unchanged during rotation. May need broader scale to pick up smaller changes? Question if because of pre-clinical preceptorships and strong generalist representation in collaborative learning groups – importance may have already been well established No statistical difference in, “are you considering a career in primary care?” though pre-continuity group overall more strongly agreed (see point above regarding time in the year) Statistically significant differences pre and post Pre-continuity – Factor that influenced your decision to pursue a career in primary care, Faculty mentorship (p=0.005) continuity – Things I appreciate about primary care – the diversity of disease encountered, (p=0.05) Agree less with this statement after continuity/clerkship

Q1: Primary care is critical to patient care Pre-Continuity (n=43) 81% (35/43) strongly agree pre and post Continuity (n=48) 66% (32/48) strongly agree pre and post 8% (4/48) agree pre and post Now lets look at the two main questions we are interested in determining how the continuity experience impact. Because we had students create a unique identifier we can see how students change their answers. Primary care is critical to patient care I’m considering a career in primary care ** Because we are comparing pre-post surveys and students had to create the same unique identifier we loose numbers Few changes 1-5, 5-1 in each group, suspect these are from mixing up the likehart scale. Equal number both ways so a wash.

Q8: I’m considering a career in primary care Pre-Continuity (n=42) 54% agreed or strongly agreed that they were considering a career in primary care both pre and post clerkship 33% more interested in primary care career 5 students changed from neither agree or disagree to agree or strongly agree 36% less interested in primary care career 3 student changed from strongly agree or agree to disagree - Only noted specifics for answer which seem to have shown a change in possible career choice.

Q8: I’m considering a career in primary care Continuity (n=48) 50% pre clerkship and 35% post clerkship agreed or strongly agreed that they were considering a career in primary care 75% had same or better response pre to post 25% more interested in primary care career 3 students changed from neither agree or disagree to agree or strongly agree 25% less interested in primary care career 10 students changed from agree to neither agree or disagree or disagree

Results Very high baseline appreciation for the importance of primary care Based on data collected to date there is no evidence that the 12 week continuity experience added to a standard block rotation improves interest in primary care In pre-continuity group significant increase in agreement pre/post clerkship with the statement – Factors that have influenced your decision to pursue a career in primary care- faculty mentorship In continuity group significant decrease in agreement pre/post clerkship with the statement – Things I like about primary care - diversity of diseases encountered Baseline appreciation likely driven by strong family medicine department, preceptorships, strong primary care presence in collaborative learning group Did continuity experience introduce a reality about chronic disease mgmt that students had not appreciated before? Was this group more specialty focused and didn’t like the number a different things that are seen on a day to day.

Discussion Further faculty development needed to optimize continuity experience Compare same times in year Small numbers Does the 5 point likert scale provide a wide enough range to capture small changes in primary care career interest? Consider changes to survey to provide more qualitative information of the role of continuity clinic and clerkship on career choice continuity experience new – this was studied straight out of the gate, will be growing pains, faculty development needed are we missing things with out qualitative input from students on what influenced there decision to pursue or not pursue primary care as it relates to continuity experience

Questions? ryan.nall@medicine.ufl.edu

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