Journal Club

The impact of preclinical preceptorships on learning the fundamentals of clinical medicine and physical diagnosis skills. Nieman et.al.: Academic Medicine 2006; 81:342-346.

Reviewed by Randy Rockney, Brown Medical School

The authors set out to ascertain whether completion of a preclinical primary care preceptorship resulted in demonstrable clinical performance benefits to medical students. Two previous studies using actual clinical performance data to investigate the relationship between participation in a preclinical preceptorship and subsequent clinical performance yielded conflicting results.

Medical students at the University of Texas Medical School at Houston are offered the opportunity to participate in a four-week preclinical preceptorship in family medicine, general internal medicine, or pediatrics at the conclusion of the first year of medical school. Written curriculum goals for the preceptorships state that students would gain practical hands-on primary care experiences, skills, and objective exposures to a community-based primary care specialty. Participation was voluntary but the authors of this retrospective study could find no statistical differences between participants (267) and non-participants (310) at entry into medical school as measured by MCAT total scores or at the end of the first year of medical school as measured by the final examination of the Introduction to Clinical Medicine course administered at the end of the first year.

The results of the second year physical diagnosis course's final OSCE and the final examination of the second year Fundamentals of Clinical Medicine were used as outcome measures. Students who participated in the preclinical preceptorships performed better on average than non-participants on both outcome measures. The authors concluded that this was the "first demonstration that a primary care preceptorship as brief as four weeks can contribute to better subsequent academic performance of preclinical medical students." The authors admit that the results may have been influenced by selection bias because participation or non-participation in the preclinical preceptorship was voluntary and "students choosing a preceptor-ship early in their medical training may have been more self-motivated than their classmates to do clinical work and gain clinical knowledge from direct patient care."

As clerkship directors, we all know that students are not always adequately prepared for the clinical competencies necessary for success in the core clinical clerkships. This study demonstrates the benefits of expanding clinical education into early medical training, an effort that is already underway at most medical schools. What remains to be determined is the best way of introducing that early clinical education: brief focused clinical preceptorships like the ones studied in this paper or more longitudinal experiences in place or in development at many other medical schools. And what, more precisely, should be the expectations and content of these early clinical experiences to best prepare students for the clerkships?

(Comments: It is nice to have data to support what those of us who have strong preclinical clinical preceptorship programs have known for years, although I wonder if the effect is sustained after the first few clerkships? I would also be curious to know how many medical schools now offer an elective or required clinical experience in the "pre-clinical" years. The number is probably high enough that the first two years of medical school should probably be renamed the "pre-clerkship" years, instead. Hopefully this data may strengthen the argument for those of you who are starting or expanding a preceptorship program. - Leslie Fall)