The effects of patient characteristics and practice settings on students' participation in a primary care clerkship

To explore the effects of practice, patient, and encounter variables on students' participation in a third-year primary care clerkship.

In 1995-96, 154 students, randomly assigned to ambulatory teaching sites, completed for each patient encounter a scannable card indicating the patient's age range, gender, and insurance type, the setting of care, the type of visit, whether it was a repeat or first visit to the student, and the student's level of participation. Conventional measures of students' satisfaction (post-clerkship survey) and performance (preceptor ratings, USMLE Step 2, standardized-patient examination scores) were examined.

The students reported significantly higher levels of participation for patient encounters taking place in clinic and emergency room settings than for those in private offices; for repeat rather than for first visits; for patients over 12 years old than for those 12 years old or younger; and for sick visits rather than for follow-ups or checkups. Students' participation had a modestly positive correlation with students' satisfaction and performance.

Several practice and patient variables influence the level of students' participation in the care of ambulatory patients. The strongest predictor of active student participation is the clinical setting of the encounter. Monitoring students' self-reported levels of participation is an important tool for tracking the impact of practice variability on the quality of the learning environment in ambulatory clerkships.