Section C

The Implementation of a Community-Based Pediatric Ambulatory Experience

Albert P. Scheiner, M.D.

A community-based ambulatory educational experience for medical students should be an integral part of all third year pediatric clerkships.In 1984,the Association of American Medical Colleges Physicians for the 21st Century:General Professional Education of the Physician report (the GPEP report) emphasized that less than 5% of all physician/patient contacts results in hospitalization¹.The committee recommended that institutions of medical education provide educational opportunities in an ambulatory setting.Similar recommendations were made by the Josiah Macy Foundation in 1988² and were further emphasized by the American Academy of Pediatrics (AAP) in 1992.The urgency of the development of such appropriate educational experiences has been reinforced by the changing patterns of health care. More health care problems are treated as outpatient or asbrief admissions. The student pediatric inpatient experience often focuses on children with more severe or chronic diseases. There is now an obvious need to balance the skills gained in an inpatient setting with those that are required to provide continuity of care in a primary care ambulatory setting.Education about health maintenance, disease prevention, common illnesses, focused interviewing and clinical problem-solving as well as knowledge of community resources can best be provided by using community-based experiences.

The transfer of educational responsibilities for what will become a major component of the students' clinical general pediatric curriculum will require a significant investment on the part of the academic institution.There will be a need to address the selection of preceptors including their professional and personal assets, the selection of students, the implementation of the curriculum, and the establishment of the educational goals with regular site visits and methods of identifying and mediating problems.The neglect of the development of a structured meaningful experience will result in a poor educational experience for the students and frustration and dissatisfaction on the part of the community faculty.

The implementation of community-based educational experiences requires, at a minimum, recruitment, selection, and development of an effective core of teachers³.Therefore recruitment of preceptors is a major task.The presence of a student in a pediatric office provides intellectual stimulation and professional growth for the pediatrician and the office staff.However, this benefit may be offset by the need to provide cost-effective health care.Effective teachers indicate that the presence of students adds one to one-and-a-half hours to their work day^4,5, and somehow this loss of time (money) must be compensated.This compensation largely comes through personal satisfaction and opportunities for professional growth.Although some institutions provide reimbursement to community faculty for student education (e.g. University of Massachusetts,$100/week/student) as an expression of appreciation, this hardly compensates for the financial loss of an hour of the practitioner's time.Nonetheless, large numbers of practicing pediatricians find the experience rewarding and are willing to participate in student office-based education.

Before preceptor recruitment can occur the practicing pediatrician must be recognized by the academic institution as a valued and indispensable colleague in the education and health care process.The special body of knowledge, skills and attitudes that are necessary for the practice of primary care pediatrics should be identified.The recognition of the practitioner is an integral part of the educational process and can be accomplished by:

1) providing the practitioner with opportunities to round and provide seminars in themedical school pediatric curriculum,
2) providing CME education credits for teaching,
3) developing a clinical teaching track that provides practitioners with appropriate clinical faculty titles with opportunities for promotion.Other incentives to community preceptors should include the provision of clinical subspecialty consultation and opportunities for risk management seminars.

Preceptors are recruited by personal and professional relationships between individuals and members of pediatrics departments.Using the Guidelines for Pediatric Education in Community-Based Pediatric Offices^3, an educational partnership with community pediatricians can be forged between clerkship directors and AAP regional presidents and vice-presidents to provide medical students with a meaningful community-based educational experience.It is anticipated that the AAP state chapters will be an essential participant in the identification and recruitment of community sites and in community faculty development.

The initial outreach from the academic institution can start withsmall group dinner meetings that can be used to establish the necessary logistics to implement a community-based experience.At a minimum these meetings should include a discussion of programmatic educational goals, the methods of preceptor selection, malpractice liability, the nature of the learning contract between the student and preceptor, and the contract between the preceptor and the academic institution.These meetings should be followed by individual practice site visits and a personal dialogue with the practitioner. Active participation is importantwith students assigned to a site at least two or three times per year.

Program implementation can then occur using the Guidelines for Pediatric Education in Community-Based Pediatric Offices and the curriculum developed by COMSEP⁹.Guidelines for implementing a community-based experience developed by Health Resources and Service Administration, Bureau of Primary Health Care, National Health Service Corps⁶ can also be helpful.This extensive guide includes a precepting guide as well as educational modules that are directed at faculty development in assuming the role of a discussion leader along with more specific modules directed at adolescent pregnancy, child abuse, and HIV/AIDS.Also, many of the principles that focus on community-based residency training programs⁷ and their faculty development⁸ can be applied to medical student education. If a program starts with a few practices as a pilot effort they can develop the support structure for these sites before expanding to provide community-based experiences for all students. An iterative process with ongoing feedback is necessary for successful community experiences. In addition local practitioners participating can help in recruiting other practitioners.

In summary, medical students in all pediatric programs optimally should be required to complete a portion of their clerkship in a community-based primary care setting.These setting could include community health centers, private practices, health maintenance organizations, and other provider groups.The recruitment of preceptors in practice will require a major effort on the part of academic institutions.At a minimum, academic institutions will have to develop a community oriented administrative structure for the development, implementation and surveillance of an educational program, develop incentives for community faculty, and develop comprehensive educational goals, curriculum and ongoing faculty development.The effort invested in developing community experiences clearly gives programs enhanced general pediatric options. Developing community sites increases the number of generalist faculty, givesclerkshipsa site with a clear focus on teaching general pediatric issues and provides students with generalist role models.

REFERENCES

1. Physicians for the 21st Century:the GPEP Report: Report of the Panel on the General Professional Education of the Physician and College Preparation for `Medicine.Washington, DC: the Association of American Medical Colleges. 1984.
2. Rogers DE.Clinical education and the doctor of tomorrow.Final chapter from Proceedings of the Josiah Macy, Jr. Foundation, National Seminar on Medical Education.Gastel N, Rogers D, Eds. Adapting Clinical Medical Education to the Needs of Today andTomorrow. The New York Academy of Medicine. 1988.
3. Scheiner AP.Guidelines for Medical Student Education in Community-Based Offices.Pediatrics 93:956.1994.
4. Scheiner AP.A survey of community experiences in pediatric clerkships.Pediatric Educator:Council on Medical Student Education in Pediatrics. 1:8.1992.
5. Osborn LM, Sargent JR, Williams SD.Effects of time in clinic, clinic settings and faculty supervision on the continuity clinical experience. Pediatrics 91:1089.1993.
6. Levy J, Coca F. National Health Service Corps Educational Program for Clinical and Community Issues in Primary Care.Developed for Health Resources and Services AdministrationBureau of Primary Health Care National Health Service Corps by American Medical Student Association/Foundation, 1902 Association Drive, Reston, VA 22091.1994.
7. Sargent JR, Osborn LM, Roberts KB, DeWitt TG.Establishment of primary care continuity experiences in community pediatricians' offices: nuts and bolts. Pediatrics 91:11885. 1993.
8. DeWitt TG, Goldberg RL, Roberts KB.Community faculty development: principles, practices and evaluation.Am. J. Dis Child. 147:49. 1993.
9. Olson AL.Principal Investigator.General Pediatric Clerkship Curriculum.Federal Bureau of Health Professions; Olson AL.Department of Pediatrics, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756. 1993.