Showing papers in "Academic Medicine in 1993"
TL;DR: It is recommended that caution be exercised in making comprehensive, curriculum‐wide conversions to PBL until more is learned about (1) the extent to which faculty should direct students throughout medical training, (2) PBL methods that are less costly, (3) cognitive‐processing weaknesses shown by PBL students, and (4) the apparent high resource utilization by P BL graduates.
Abstract: The effects of problem-based learning (PBL) were examined by conducting a meta-analysis-type review of the English-language international literature from 1972 to 1992. Compared with conventional instruction, PBL, as suggested by the findings, is more nurturing and enjoyable; PBL graduates perform as well, and sometimes better, on clinical examinations and faculty evaluations; and they are more likely to enter family medicine. Further, faculty tend to enjoy teaching using PBL. However, PBL students in a few instances scored lower on basic sciences examinations and viewed themselves as less well prepared in the basic sciences than were their conventionally trained counterparts. PBL graduates tended to engage in backward reasoning rather than the forward reasoning experts engage in, and there appeared to be gaps in their cognitive knowledge base that could affect practice outcomes. The costs of PBL may slow its implementation in schools with class sizes larger than 100. While weaknesses in the criteria used to assess the outcomes of PBL and general weaknesses in study design limit the confidence one can give conclusions drawn from the literature, the authors recommend that caution be exercised in making comprehensive, curriculum-wide conversions to PBL until more is learned about (1) the extent to which faculty should direct students throughout medical training, (2) PBL methods that are less costly, (3) cognitive-processing weaknesses shown by PBL students, and (4) the apparent high resource utilization by PBL graduates.
2,695 citations
TL;DR: The results generally support the superiority of the PBL approach over more traditional methods in problem-based learning.
Abstract: The purpose of this review is to synthesize all available evaluative research from 1970 through 1992 that compares problem-based learning (PBL) with more traditional methods of medical education. Five separate meta-analyses were performed on 35 studies representing 19 institutions. For 22 of the studies (representing 14 institutions), both effect-size and supplementary vote-count analyses could be performed; otherwise, only supplementary analyses were performed. PBL was found to be significantly superior with respect to students' program evaluations (i.e., students' attitudes and opinions about their programs)--dw (standardized differences between means, weighted by sample size) = +.55, CI.95 = +.40 to +.70 - and measures of students' clinical performance (dw = +.28, CI.95 = +.16 to +.40). PBL and traditional methods did not differ on miscellaneous tests of factual knowledge (dw = -.09, CI.95 = +.06 to -.24) and tests of clinical knowledge (dw = +.08, CI.95 = -.05 to +.21). Traditional students performed significantly better than their PBL counterparts on the National Board of Medical Examiners Part I examination--NBME I (dw = -.18, CI.95 = -.10 to -.26). However, the NBME I data displayed significant overall heterogeneity (Qt = 192.23, p < .001) and significant differences among programs (Qb = 59.09, p < .001), which casts doubt on the generality of the findings across programs. The comparative value of PBL is also supported by data on outcomes that have been studied less frequently, i.e., faculty attitudes, student mood, class attendance, academic process variables, and measures of humanism. In conclusion, the results generally support the superiority of the PBL approach over more traditional methods. Acad. Med. 68 (1993):550-563.
1,491 citations
TL;DR: Skeptics are urged not to make judgments about the value of SPs until they have experienced the technique firsthand and reviewed the literature concerning the extensive and often high-quality research about this assessment tool.
Abstract: The author defines the term standardized patient (SP), the umbrella term for both a simulated patient (a well person trained to simulate a patient's illness in a standardized way) and an actual patient (who is trained to present his or her own illness in a standardized way). He first discusses the many values of simulated patients over actual patients as teaching and assessment tools in the classroom and refutes a few myths about the use of SPs. Then he recounts the origin and development of SPs over a three-decade period, beginning with his work as a neurologist at the Los Angeles County Hospital, where he trained a model from the art department to simulate a neurological patient and assist in the assessment of clinical clerks. He then describes additional roles of SPs that have developed, including: (1) their use in the Clinical Practice Examination created at Southern Illinois University School of Medicine and (2) the major use that has come into being over the last 10-15 years; facilitating the comprehensive assessment of clinical competence using multiple stations in examinations such as the objective structured clinical examination. He concludes with information about recent and current work on SPs, who are becoming more and more accepted in the assessment process, and urges skeptics not to make judgments about the value of SPs until they have experienced the technique firsthand and reviewed the literature concerning the extensive and often high-quality research about this assessment tool.
827 citations
TL;DR: In this article, the authors propose a method to solve the problem of homonymity of homophily in the context of homomorphic data, and no abstracts are available.
Abstract: No abstract available.
477 citations
TL;DR: The author describes the problems that occurred and the organizational behaviors on which they were based, analyzes the lessons learned, documents the progress that has been achieved, and outlines the challenges that remain.
Abstract: In 1988 the University of Virginia Medical Center began implementation of a medical information system based on mandatory physician order entry. The implementation process was much more difficult than expected. The program experienced considerable delays, and cost much more than was originally estimated. Although there were some legitimate questions concerning the user-friendliness of the new technology, these were less significant than the cultural and behavioral problems encountered. The new system challenged basic institutional assumptions; it disturbed traditional patterns of conduct and forced people to modify established practice routines. Real progress toward the integration of the system into the center's operational culture occurred only after a senior management team representing important sectors of the hospital staff and administration began meeting regularly to address the institution-wide issues that had been raised. The author describes the problems that occurred and the organizational behaviors on which they were based, analyzes the lessons learned, documents the progress that has been achieved, and outlines the challenges that remain. The center's experience provides insight into the issue of technology-driven organizational transformation in academic medical centers. Recommendations for successful introduction of similar agents of institutional change are presented.
269 citations
TL;DR: It is concluded that some components of ethical education must be participant-driven and developmentally stage-specific, focusing more attention on the kinds of ethical decisions made by medical students as opposed to those made by residents or practicing physicians.
Abstract: Many existing ethics curricula fail to address the subtle yet critical ethical issues that medical students confront daily. The authors report on the kinds of dilemmas students face as clinical clerks, using cases that students submitted in 1991-92 during an innovative and well-received ethics class given at a tertiary care hospital as part of the internal medicine clerkship. Analysis of these cases reveals that many dilemmas are intimately tied to the student's unique role on the medical health care team. Recurring themes included the student's pursuit of experience, differing degrees of knowledge and ignorance among team members, and dealing with disagreement within the hierarchical authority structure of the medical team. The authors conclude that some components of ethical education must be participant-driven and developmentally stage-specific, focusing more attention on the kinds of ethical decisions made by medical students as opposed to those made by residents or practicing physicians.
233 citations
TL;DR: The results suggest that knowledge of genetics and genetic tests is increasing among physicians, particularly among more recent graduates and physicians who are exposed to genetics problems in their practices, but deficiencies remain.
Abstract: PURPOSE. To assess primary care physicians' and psychiatrists' knowledge of genetics and genetic tests and the factors associated with differences in these physicians' knowledge. METHOD. Questionnaires were mailed in 1991 to 1,795 primary care physicians (family physicians, internists, pediatricians
196 citations
TL;DR: The results indicate that the assumption in the literature that tutors do not necessarily need content knowledge so long as they are skilled in the tutoring process is not entirely justified: the students who were guided by content experts achieved somewhat better and spent more time on self-directed learning.
Abstract: textPurpose. To investigate the effects of tutors' subject-matter expertise on students' levels of academic achievement and study effort in a problem-based health sciences curriculum. Also, to study differences in turors' behaviors and the influences of these differences on students' performances. Method. Data were analyzed from 336 staff-led tutorial groups involving student participants in seven four-year undergraduate programs at the University of Limburg Faculty of Health Sciences in 1989-90. Overall, 1,925 data records were studied, with each student participating in an average of 1.7 groups led by either content experts or non-experts. The basic analyses were of (1) students' achievement scores as a function of tutors' expertise levels and students' curriculum year; (2) students' estimates of self-study time as a function of tutors' expertise levels and students' curriculum year; and (3) the average ratings of the tutors' behaviors as a function of tutors' expertise levels. Statistical methods included analysis of variance and Pearson correlations. Results. The students guided by subject-matter experts were shown to spend more time on self-directed study, and they achieved somewhat better than did the students guided by non-expert tutors. The effect of subject-matter expertise on achievement was strongest in the first curriculum year, suggesting that novice students are more dependent on their tutors' expertise than are more advanced students. Also, the content-expert tutors made more extensive use of their subject-matter knowledge to guide students. However, in addition to the tutors' knowledge-related behaviors, the tutors' process-facilitation skills affected student achievement. Moreover, these two sets of behaviors were correlated, indicating that both are necessary conditions for effective tutoring. Conclusion. The results indicate that, at least for the curriculum studied, the assumption in the literature that tutors do not necessarily need content knowledge so long as they are skilled in the tutoring process is not entirely justified: the students who were guided by content experts achieved somewhat better and spent more time on self-directed learning. More important, tutoring skill and content knowledge seemed to be necessary and closely related conditions for effective tutoring.
186 citations
TL;DR: The findings were similar to those of previous studies in that they showed relatively poor agreement between external measures of students' performances and students' self-assessments of their performances.
Abstract: PURPOSE. To find predictors of students' initial self-assessments of their clinical performances, the predictive value of their self-assessments, and factors that relate to their final self-assessments. METHOD. Of the 142 third-year students at the University of Michigan Hospital in 1988–89, 137 (96
171 citations
TL;DR: In this article, the authors propose a method to solve the problem of homonymity of homophily in the context of homomorphic data, and no abstracts are available.
Abstract: No abstract available.
169 citations
TL;DR: The author presents a set of recommendations to those considering similar IT initiatives and wishing to reduce the disruptions that may accompany their introduction, and emphasizes the importance of extensive involvement and leadership of attending physicians in the planning and implementation of such a system.
Abstract: The introduction of an information technology (IT) system that mandates order entry by physicians had significant and often unexpected effects on medical education at the University of Virginia Medical Center. The system was deactivated briefly after the introduction of laboratory ordering,
TL;DR: The students' learning activities covered an average of 64% of the intended course content; in addition, the students generated learning issues not expected by the faculty, and half of these issues were judged relevant to the course content.
Abstract: textBackground. Problem-based learning (PBL) emphasizes active generation of learning issues by students. Both students and reachers, however, tend to worry that not all important knowledge will be acquired. To explore this question, problem effectiveness (i.e., for each problem, the degree of correspondence between student-generated learning issues and preset faculty objectives) was examined in three interdependent studies. Method. The three studies used the same participants: about 120 second-year students and 12 faculty tutors in a six-week course on normal pregnancy, delivery, and child development at the medical school of the University of Limburg in The Netherlands, 1990-91. The participants were randomly assigned to 12 tutorial groups that were each given the same 12 problems; the problems were based on 51 faculty objectives; the tutors were asked to record all learning issues generated by their groups. Study 1 addressed this question: To what degree are faculty objectives reflected by student-generated learning issues? Study 2: To what extent do students miss certain objectives, and are these objectives classifiable? Study 3: Do students generate learning issues not expected by the faculty, and are these issues relevant to course content, and finally, why do students generate these issues? To help answer these questions, the studies employed expert raters and a teacher familiar with the course content. Results. Study 1: For the set of 12 problems, the average overlap between learning issues and faculty objectives was 64.2%, with the percentages for individual problems ranging from 27.7% to 100%. Study 2: Of the 51 objectives, 30 were not identified by at least one tutorial group; these objectives were grouped into three categories; on average, each group failed to identify 7.4 objectives (15%). Study 3: Of 520 learning issues, 32 (6%) were unexpected; 15 of these were judged to be at least fairly relevant to course content; they were grouped into four categories. Conclusions. The students' learning activities covered an average of 64% of the intended course content; in addition, the students generated learning issues not expected by the faculty, and half of these issues were judged relevant to the course content. Thus, PBL seems to permit students to adapt learning activities to their own needs and interests.
TL;DR: It is possible to develop young people's moral reasoning in medical school as well as in earlier educational environments, and the course did have a positive influence on these students' moral reasoning.
Abstract: PURPOSE. To evaluate a project on teaching medical ethics to first-year students by using film discussion to develop the students' moral reasoning. METHOD. The participants were 114 first-year students at Texas A&M University Health Science Center College of Medicine in 1989–90, 1990–91, and 1991–92
TL;DR: For both tracks, MCAT scores, especially in the lowest and highest ranges, were most predictive of performances on the NBME I and II, while in the long run, the more student-centered problem-based curriculum better prepared the students for theNBME III.
Abstract: BACKGROUND. Problem-based learning curricula are growing in popularity, and questions have been raised about the appropriateness of standardized examinations, such as the National Board of Medical Examiners (NBME) Parts I, II, and III examinations, for assessing students in these new curricula. METH
TL;DR: In this article, the authors propose a method to solve the problem of homonymity of homophily in the context of homomorphic data, and no abstracts are available.
Abstract: No abstract available.
TL;DR: The “noncognitive,” or psychosocial, measures increased the magnitude of the relationships between the predictive and criterion measures of the students' academic performances, beyond the magnitude attained when only the conventional admission measures were used.
Abstract: Purpose To investigate the incremental effects of selected psychosocial measures--beyond the effects of conventional admission measures--in predicting students' academic performances in medical school. Methods In 1989-90, 210 second-year students at Jefferson Medical College were each asked to complete 11 psychosocial questionnaires that were then used as predictors of performance measures in medical school. The students' scores on three subtests of the Medical College Admission Test (MCAT) were also used as predictors. Three composite measures of performance were used as the criterion measures: basic science examination grades, clinical examination grades, and ratings of clinical competence. A multiple regression algorithm (general linear model) was used for statistical analysis. Results The response rate was 83% (175 students). When the psychosocial measures were added to the statistical models in which the common variances of the MCAT scores were already determined, significant increments in the common variances were observed for two of the three performance measures: basic science grades and clinical examination grades. Whereas only 4% of the common variance in the ratings of clinical competence could be accounted for by the MCAT scores, 14% could be accounted for by the psychosocial measures. Conclusion The "noncognitive," or psychosocial, measures increased the magnitude of the relationships between the predictive and criterion measures of the students' academic performances, beyond the magnitude attained when only the conventional admission measures were used. Therefore, psychosocial measures should be considered as significant and unique predictors of performance in medical school.
TL;DR: A program of educational research is advocated to develop a test format that can effectively assess the clinician's abilities to deliberate among alternatives, to recognize the role of values and preferences in decisions, and to weigh risks and benefits.
Abstract: This essay reviews the influence that research on psychological processes in clinical reasoning has had upon the characteristics and formats of licensing examinations such as the new United States Medical Licensing Examination (USMLE) and its predecessors, emphasizes the implications of such researc
TL;DR: The collective evidence from this extensive SP research base suggests that medical educators should move ahead to realize the benefits of the high-fidelity standardized approach provided by standardized-patient examinations.
Abstract: Eighteen questions are posed that the authors believe address the major technical issues involved in the application of standardized patients (SPs). Following each question, selected empirical evidence and commentary are provided in response to the question and as background for further consideratio
TL;DR: The authors detail hypothetical costs of running a four-hour OSCE for 120 medical students at one medical school, and the OSCE is uniquely capable of assessing many fundamental clinical skills that are presently not being assessed in a rigorous way in most medical schools.
Abstract: A major impediment to the use of the objective structured clinical examination (OSCE) is that it is a labor-intensive and costly form of assessment. The cost of an OSCE is highly dependent on the particular model used, the extent to which hidden costs are reported, and the purpose of the examination. The authors detail hypothetical costs of running a four-hour OSCE for 120 medical students at one medical school. Costs are reported for four phases of this process: development, production, administration, and post-examination reporting and analysis. Costs are reported at two ends of the spectrum: the high end, where it is assumed that little is paid for by the institution and that faculty receive honoraria for work put into the examination; and the low end, where it is assumed that the sponsoring institution defrays basic costs and that faculty do not receive honoraria for their participation. The total costs reported for a first-time examination were $104,400 and $59,460 (Canadian dollars) at the high and low ends, respectively. These translate to per-student costs of $870 and $496. The cost of running an OSCE is high. However, the OSCE is uniquely capable of assessing many fundamental clinical skills that are presently not being assessed in a rigorous way in most medical schools.
TL;DR: Nurses' ratings appear to provide a feasible and reliable method of evaluating the internists' communication skills and humanistic qualities, when used in conjunction with ratings by peer physicians.
Abstract: PURPOSE. To examine the feasibility and reliability of ratings completed by hospital-based registered nurses of the humanistic qualities, communication skills, and selected aspects of the clinical skills of practicing internists. METHOD. In 1988–1989, registered nurses who worked in the same 175 hos
TL;DR: That the influence of a faculty advisor was the significant factor in affecting students' decisions to choose primary care suggests that schools can increase the percentages of their students entering the primary care fields by increasing their students' contact with mentors in these fields.
Abstract: BACKGROUND. Because of the marked decline in the numbers of U.S. medical school graduates entering the primary care fields of internal medicine, pediatrics, and family medicine, medical educators are increasingly interested in determining the factors that influence students' choices of specialty. ME
TL;DR: Evaluating students' noncognitive professional attributes at the University of New Mexico School of Medicine can complement systems that evaluate academic performance and help an institution assure not only the cognitive competence of its graduates, but the competence of their professional behaviors as well.
Abstract: BACKGROUND Professional attributes such as honesty, integrity, and reliability are critical to success in medical school and postgraduate practice, yet such noncognitive attributes have traditionally been poorly evaluated METHOD A program of evaluating students' noncognitive professional attribut
TL;DR: The predictive validity of the NBME scores supports the use of USMLE scores as part of the review process to screen potential residents, and residency directors are encouraged to use their own program-specific data to establish and monitor particular cutoff scores for screening applicants.
Abstract: Many studies have examined the relationships between students' performances on the National Board of Medical Examiners (NBME) Part I and Part II examinations and their postgraduate clinical performances. Most studies have found a positive relationship between students' NBME examination scores and the ratings of residents' clinical performances and/or scores on specialty board certification examinations. Surveys of residency directors have also shown that NBME scores are used as part of the process for selecting residents, although other data and other selection criteria are considered more useful than the NBME scores. One area of continued concern is that a large body of data on the United States Medical Licensing Examination (USMLE) is not yet available. However, the predictive validity of the NBME scores supports the use of USMLE scores as part of the review process to screen potential residents. Residency directors should continue to use a variety of criteria in their final selection decisions and are encouraged to use their own program-specific data to establish and monitor particular cutoff scores for screening applicants.
Abstract: No abstract available.
TL;DR: CBI that uses simulated-patient cases and structured-performance feedback seems to be efficient and effective compared with traditional CBI methods, however, care should be taken to ensure that students do not become overconfident of their abilities.
Abstract: Purpose. To examine the relative efficacies of three types of performance feedback used with computer-based instruction (CBI) in making diagnoses. Method. In 1990, 75 final-year medical students at The University of Queensland were pretested for domain knowledge and diagnostic skill in the area of acute abdominal pain. The students were also asked to indicate their confidence in each of their diagnoses. Following these pretests, the students were randomly divided into five groups of 15 students each. One group received traditional CBI, using a “ques-tion-and-explanation” format, to learn domain knowledge. The other four groups received one of two types of CBI to learn diagnostic accuracy, and these four groups received one of three types of performance feedback (which differed considerably in the amounts of information imparted). Then the students took posttests. One-way analysis of variance, Student’s t- test, and the Tukey test were used to compare the performances of the different groups of students. Results. Although the students in the traditional CBI group significantly improved their performance on multiple-choice questions (by 58%) compared with the other groups of students (6-10% improvement), these students did not improve their diagnostic performance. In contrast, the CBI groups that used simulated-patient cases and structured-per-formance feedback did improve their diagnostic accuracy (by as much as 16%, compared with a 1% decline for the traditional CBI group). Contrary to expectation, the different types of feedback were equally effective. Except for the students in the traditional CBI group, the students’ confidence increased from pretest to posttest regardless of their performances. Conclusion. CBI that uses simulated-patient cases and structured-performance feedback seems to be efficient and effective compared with traditional CBI methods. However, care should be taken to ensure that students do not become overconfident of their abilities.
TL;DR: The results suggest that recent clinical experience and performance on standardized examinations are the two selection criteria most predictive of foreign-born IMGs' first-year performances as internal medicine residents.
Abstract: BACKGROUND: Recent growth in the number of international medical graduates (IMGs)--i.e., graduates of non-U.S. and non-Canadian medical schools--who fill positions in internal medicine residencies requires examination of the predictive validity of selection criteria. METHOD: Data were analyzed for 46 foreign-born IMGs who entered the internal medicine residency at Wright State University School of Medicine between January 1985 and January 1991. The t-test and Pearson correlation were used to relate ten selection variables (age, gender, foreign clinical experience, U.S. clinical experience, clinical experience in the two years prior to residency, time between medical school graduation and residency, performance on the Foreign Medical Graduate Examination in the Medical Sciences--FMGEMS--Parts I and II, interview language skill, and interview rank category) to performance ratings the IMGs received in the first year of residency. RESULTS: Only performance on the FMGEMS Part I (p = .045) and clinical experience in the two years prior to residency (p = .005) were related significantly to subsequent performance in residency. CONCLUSION: The results suggest that recent clinical experience and performance on standardized examinations are the two selection criteria most predictive of foreign-born IMGs' first-year performances as internal medicine residents.
TL;DR: Hands-on clinical experience was more important for building students' confidence than any other encounter variable.
Abstract: Purpose To investigate the relationship between medical students' confidence and their experiences in caring for patients within a primary care clerkship, because hands-on experience is assumed to be positively related to the development of confidence (a subjective marker of competence). Method The participants were 60 students from the class of 1992 who completed a required third-year ambulatory care clerkship at the University of Kentucky Medical Center. The students documented their one-on-one experiences in patient care (under the supervision of preceptors in family practice, general pediatrics, or general internal medicine) by completing data cards on each patient encounter. Also, for each encounter, the students used a Likert scale to rate their levels of confidence in dealing with the patient's primary diagnosis. The variables recorded on the cards were then used to predict the students' levels of confidence during the encounters. The statistical analysis included descriptive statistics, Pearson correlations, and a stepwise multiple-regression procedure. Results The mean number of patient encounters per student was 99. The regression procedure selected three variables from the data cards as significant independent predictors of the students' confidence: management responsibility for the patient's problem (R2 = .40), prior exposure to the patient's problem (R2 = .08), and performance of laboratory work during the patient encounter (R2 = .06). These variables were responsible for predicting 54% of the observed variance in the students' confidence (R2 = .54). Conclusion Hands-on clinical experience was more important for building students' confidence than any other encounter variable.
TL;DR: A solution that has proven popular at the Stanford University School of Medicine is described–an elective course in surgical skills developed in 1988–89 and continuing to the present, which incorporates techniques that have previously been shown to be successful.
Abstract: Background Although there is general agreement that the teaching of clinical procedures needs vast improvement, little appears to have been done to achieve this goal, particularly with regard to medical students. Method In the summer and fall of 1992, 60 U.S. medical schools participated in a telephone survey about how they taught clinical procedures to medical students. The schools were in 30 states and the District of Columbia; 36 were public and 24 were private. The schools were asked to describe what procedures were taught, how, and over what duration of time, with a focus on whether students were taught procedures prior to their clinical rotations. Results More than three-fourths of the schools (47 of 60) offered nothing other than an introduction to phlebotomy. Only four schools offered more extensive courses (40-50 hours) that covered a variety of topics. Conclusion Few schools had adopted any formal method for training students to perform clinical procedures. In light of this problem, the authors describe a solution that has proven popular at the Stanford University School of Medicine--an elective course in surgical skills developed in 1988-89 and continuing to the present. Although the content of this particular course focuses on surgical procedures, important topics from other disciplines could easily be added or substituted. The course incorporates techniques that have previously been shown to be successful, such as the use of plastic models and cadavers. It also enables students to learn by performing procedures on each other, and to benefit from continuity of supervision by being taught by one faculty member.
TL;DR: There were significant correlations between scores on all specialty board examinations and all NBME scores, with higher correlations for subscores more closely related to specialty content.
Abstract: This study investigated the relationship between the National Board of Medical Examiners (NBME) Part I and Part II examination scores and subsequent performances on the 1991 certification examinations of the American Boards of Orthopaedic Surgery (ABOS), Dermatology (ABD), and Preventive Medicine (ABPM). There were significant correlations between scores on all specialty board examinations and all NBME scores, with higher correlations for subscores more closely related to specialty content. Both NBME Part I and NBME Part II were useful predictors; however, the relationships with NBME Part II were generally stronger. Strong relationships were observed between specialty board pass-fail outcomes and NBME scores: examinees whose NBME scores were below 400 were at much greater risk for failing their specialty board examinations.
TL;DR: The variability and potentially worrisome gaps in the students' experiences in the ambulatory care settings studied are probably representative of students' experience in such settings, and should be considered in the implementation and evaluation of educational experiences in ambulanceatory care.
Abstract: BACKGROUND. Although ambulatory care settings are being used increasingly in undergraduate clinical education, variability in the depth and breadth of students' contacts with basic medical problems may compromise the educational benefits of this teaching modality. The present study examines the natu