The Rochester practice-based experience. An experiment in medical education

Recent changes in the organization and financing of medical practice have resulted in a shift of patient care from the hospital to ambulatory locations and dramatically changed the mix and severity of the inpatient population. Medical educators are concerned that hospitalized patients are not truly representative of the practice of internal medicine and may be unsuitable for the education of third-year medical students. The University of Rochester (NY) Department of Medicine recently established a "practice-based" component to complement the inpatient segment of the third-year medicine clerkship.

Participating students work with a practicing internist for the second half of the 12-week clerkship. Students evaluate office and hospital patients in the internist's practice and attend didactic conferences. We used a multi-measurement curriculum evaluation system to assess the new program and compare it with the established hospital experience. Evaluation components included the following: logs in which students profiled their clinical activities; questionnaires that assessed opinions and satisfaction about the clerkship; group interviews with students; and visits to practice-based sites to interview both preceptor and student.

Practice-based students saw many more patients with a broader range of illnesses and had more observation and supervision from faculty than hospital-based students. Practice-based students discussed all of their patients with their preceptors, who were perceived as being excellent teachers. Hospital-based students, although generally positive, were also generally less enthusiastic about the amount and quality of teaching, observation, and supervision. Practice-based and hospital-based students achieved similar grades on the final examination and received a similar number of honors grades. Preceptors were enthusiastic in their endorsement of the practice-based experience and patient acceptance of students was high.

The practice-based experience is feasible and of equal academic rigor to the hospital experience. This realistic immersion into the daily activities of an internist provides an enriching balance to the traditional hospital-based clerkship.