THE CURRENT STATUS OF MEDICAL STUDENT EDUCATION IN FAMILY MEDICINE
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* Thomas C. Rosenthal
* Joseph Hobbs
* Paul James
* Warren Newton

To assure safe, effective, patient-centered, timely, efficient, and equitable health care for all Americans, the Future of Family Medicine Project concluded that family physicians should practice evidence-based care over a continuum, utilize the biopsychosocial model to create effective physician-patient relationships, measure outcomes, and incorporate information technology. The STFM Curriculum Resource Project recommended teaching prevention, acute and chronic illness management, and population-based medicine in family medicine clerkships.

This agenda translates to medical school curriculum through interdisciplinary responsibility for physical diagnosis and interviewing and nearly total responsibility for clerkships. Family medicine clerkships are intense, mostly outpatient experiences in the third year. All medical students learn the importance of personalized care that addresses patient needs throughout the life cycle; students decide whether their talents, skills, financial goals, and personalities match up to a career centered on disease management or the broader responsibilities of patient management.

Clerkship students are expected to absorb concepts of “whole person” and “humanized health care,” along with differential diagnosis and management from community physicians who may be intuitively talented but not trained in teaching. Infusing proficiency in behavioral and family management while teaching hard-core skills of disease management and assuring consistency across sites is an educational challenge. The Medical College of Georgia and others have standardized the experience by assuring students experience a mix of medical problems, ethnic backgrounds, age, and gender through repeated interaction between faculty, students, and community preceptors.

Standardizing instructional quality has been the goal of the MedED IQ, which assesses outpatient experiences from the learner’s perspective. It has shown that the clinical environment, learner assimilation into the office, and progressive independence at a pace that allows reflection, are markers for instructional quality.1,2 MedED IQ confirms that teaching in community offices is on par with other medical center locations even though more patients are seen and practical management skills are emphasized.

The costs of education in the community are substantial. A 4-week clerkship can cost an office between $959 and $2,713.3 Efficient preceptors add 1 minute per patient when hosting a student, but many preceptors’ workdays are lengthened by 1 hour or more. Electronic health records add challenges. Medical schools recognize the contribution of preceptors in part by bestowing faculty appointments, providing Internet access, supporting faculty development, and offering reduced CME tuition. Some schools pay a limited stipend.

Given the scope and complexity of medical student education, departments of family medicine are uniquely responsible for recruiting medical students into family medicine. Exposure to competent family medicine faculty predicts selection of a family medicine residency. At the same time, departments must educate all students.

Chairs play a critical role in the process, ensuring that redesigned curricula fit the realities of the future of family medicine and assure comparability across sites. More broadly, chairs must also ensure that larger issues are being addressed: cost-effective teaching, preceptor support, and measurement and improvement of clerkship outcomes. Finally, chairs need to ensure that faculty have the resources and the incentive to lead innovation in teaching, evaluation, and community-based learning.

Inevitably, departments must make hard choices: should we continue relatively minor adjustments of our present model— or should we be much more proactive in monitoring experiences for weaknesses, testing for achievement, and creating better physicians in all specialties? Are the pre-doc divisions in our departments afforded the importance that our residency divisions are? Will we need to choose between adding another researcher or paying preceptors? These questions are fundamental as we create the future of family medicine.

*   © 2005 Annals of Family Medicine, Inc.

## REFERENCES

1.  James PA, Kreiter CD, Shipengrover J, Crosson J. Identifying the attributes of instructional quality in ambulatory teaching sites: a validation study of the MedED IQ. Fam Med. 2002;34:268–273.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=12017141&link_type=MED&atom=%2Fannalsfm%2F3%2F6%2F559.atom) 

2.  Manyon A, Shipengrover J, McGuigan D, Haggerty M, James P, Danzo A. Defining differences in the instructional styles of community preceptors. Fam Med. 2003;35:181–186.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=12670111&link_type=MED&atom=%2Fannalsfm%2F3%2F6%2F559.atom) 

3.  Ricer RE, Filak AT, David AK. Determining the costs of a required third-year family medicine clerkship in an ambulatory setting. Acad Med. 1998;73:809–811.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=9679474&link_type=MED&atom=%2Fannalsfm%2F3%2F6%2F559.atom)