The Cost of Training Third-Year Primary Care Medical Students in an Ambulatory Setting
Lawson, Raef A., Research in Healthcare Financial Management
The role of the primary care physician (PCP) has undergone a significant change. These physicians are being called upon to play an enlarged role in the coordination of medical services provided to patients, resulting in a tremendous increase in the demand for PCPs (Seifer 1996). Attempts to address the imbalance between specialists and general practitioners have also contributed to this increased demand (Huang 1999). The proper venue for the training of these physicians has been extensively debated. Classically, medical education has been carried out in the teaching hospital ward and outpatient clinic. However, there has been a substantial increase in the training of medical students in ambulatory settings. This increase has been driven by several factors.
Changes in the health care environment have led to a narrower, more chronic, case mix in teaching hospitals. This skewed patient population is not representative of the patient problems that the majority of physicians will treat after they graduate. Additionally, with the increasingly sophisticated diagnosis and treatment methodologies that are now available on an outpatient basis, the ambulatory care setting has become a major site for making important patient care decisions. Finally, there is increased emphasis on preventive care and the care of chronic diseases, which may be learned best by working with ambulatory patients (Delbanco & Calkins 1988).
In order to encourage students to choose careers in primary care areas and to provide the skills they need, medical schools have developed programs which include training at alternative ambulatory care sites (Bazell & Kahn 2001). These include private practices, health maintenance organizations (HMOs), community health centers, and reorganized teaching hospital ambulatory practices.
Few academic health centers make payments for clinical education rotations. (Holder 1988; Kumar et al. 1999). Furthermore, the presence of medical students can lengthen the workday of the teaching physician and reduce the number of patients seen per day (Vinson et al., 1997). These facts have been cited as the reason for the limited participation of alternative ambulatory care sites in teaching programs (Dorsey 1973). While preceptoring physicians are largely motivated to teaching due to intangible rewards such as the love of teaching, a desire to "give back" to the profession, or increased enjoyment of the practice of medicine (Grayson et al. 1998; Kollisch et al., 1997), it has been noted that neither an HMO with fixed income and fixed salaries, nor a private group can tolerate inefficiency in patient care and physician usage (Olness 1975).
The increase in ambulatory medical education requires that a number of issues be addressed. These include a determination of the cost of ambulatory teaching, an examination of how this teaching can be conducted more efficiently, and exploration of the implications for financing medical education if more teaching occurs in ambulatory settings (Delbanco & Calkins 1988). The objective of this study was to examine this first issue, and provide a basis for future exploration of the other issues.
A substantial amount of research has been conducted examining the impact of training medical students in ambulatory care settings. Employing inconsistent methodologies, they report contradictory findings. Some studies (Delbanco & Calkins 1988; Garg et al. 1991; Gavett & Mushlin 1986; Kirz & Larsen 1986; Kosecoff et al. 1987; Lindenmuth et al. 1972; Paulson et al. 1979; Pawlson et al. 1980; Usatine et al. 2000; Vinson & Paden 1994; Wollstadt et al. 1979) indicate a reduction in physician productivity when undergraduate medical students are present, while others indicate no effect (Frank et al. 1997; Pawlson et al. 1980; Kearl & Mainous 1993), or even an increase (Lindenmuth et al. 1972) in physician productivity (Isaacs & Madoff 1984). …