Improving Education and Care in Student-Run Clinics : A Didactic Intervention for Pre-Clinical Medical Students

Background: Merging education with clinical care is essential at student-run clinics. Methods: First year medical students participated in 15-minute small-group didactic sessions monthly from January through May 2011. Topics included diabetes, hypertension, mood disorders, and back pain. After the intervention, a 10-question survey comprised of eight 7-point Likert items and two narrative response questions was made available online to all eligible students. Patient encounter times during the intervention period were recorded and compared to the year prior to intervention. Results: Fourteen of 26 students (54%) responded to the survey. All students found the intervention to offer more information about standards of practice than their courses. Of respondents, 64.3% agreed or strongly agreed they provided better patient care with the intervention. Students reported a higher probability of using standards of practice: 57.1% agreed and 21.4% strongly agreed. When accounting for confounders, mean patient encounter time was 69.9 (95%CI, -92.4 to -39.4, p<0.001) minutes shorter with the intervention. Conclusions: Decreased patient encounter time and survey responses support the intervention’s educational and clinical efficacy.


Introduction
Student-run clinics make an important contribution to community care.Recently, educators and clinicians have formally explored the intersection of quality care and education at student-run clinics.To date, curricula have approached individual topics such as screening or depression [1][2][3] or focused on interprofessional systems education. 4,5owever, there is potential for an all-encompassing curriculum for select, high-yield topics to bridge traditional medical education with the clinical experiences pre-clinical students have at a student-run clinic.
The Community Health Clinic (CHC) in Chicago, Illinois is the largest free health clinic in the United States 6 and is staffed in part by pre-clinical medical students and faculty from the University of Chicago Pritzker School of Medicine one day a week.As part of a more vertical curriculum, 7 an informal course was piloted that sought to use the synergy of classroom lectures and CHC clinic volunteer experience to provide students more applicable patient care knowledge and improve care patients received.
The course design was informed by principles within situated cognition and cognitive apprentice educational theories.Both theories emphasize a mind-body environmental learning approach with cognitively focused experiences to foster learning. 8,9ur primary outcome was student perception of the course's impact on their education and ability to care for patients.The secondary outcome was patient encounter time to ensure the didactic intervention during clinic time did not prolong patient time at the clinic.

Study Setting and Participants
We conducted a prospective observational trial.Pre-clinical medical student volunteers from the [1] SIGECAPS is a screening tool for depression that stands for Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, and Suicidal.[2] The Healthcare Effectiveness Data and Information Set is a tool to measure performance on key patient care measures.
University of Chicago who volunteered at the CHC were eligible to participate in the intervention and study.The clinic was staffed each week by a different group of 5-6 students from the school who each volunteered monthly (i.e. the clinic had a different group of 5-6 students each week, but it was the same 26 students each month).
As a pilot intervention, the course was voluntary and posted no grades or formal credit hours.Participation was anonymous, and participants received no compensation.Informed consent was obtained.Study protocols were granted exemption status by the staffing medical center's institutional review board and approved by the clinic's executive director.Students received pre-notification by email and during a monthly board meeting.The survey was emailed to the potential respondents, and they were given two email reminders.

Study Design
Monthly topics were presented by a fourth year medical student teaching assistant (AP) to preclinical medical students from January to May 2011.The topics (diabetes, hypertension-sympathetic control, hypertension-renal control, mood disorders, and low back pain/outpatient analgesia) were chosen based on clinic prevalence.
In June 2011 a 10-question survey comprised of eight 7-point Likert items (Table 1) and two narrative response questions was made available online to all eligible students (Appendix 1).The survey was piloted by former student volunteers of the clinic and evaluated for content validity by education and internal medicine experts (AP, KB).
Patient encounter times for patients seen by students were recorded and compared to encounter time in 2010 before the intervention was initiated.Thus, the prior year (2010) served as a relative control group against which to measure encounter times when the intervention was taking place.

Instruction Methods
When possible, topics discussed during the lessons overlapped with current topics in students' formal basic science courses.Each lesson was 15 minutes long and included a handout (Appendix 2) 2-5 pages long with high-yield outlines, tables, and figures.January through April topics were presented onsite at the clinic in a small group each week just before clinic began and included near-peer teaching 10 for students who had to leave the lesson early to see a patient.Students were only permitted to participate in the lesson and peer teaching if they did not have patient care obligations.The May topic was presented to the aggregate student volunteer group at their campus in a standard lecture format that also included a handout.
Each lesson focused on making explicit connections between physiology/biochemistry, pathophysiology, patient presentation, and common therapeutics.The lessons provided an overview of each of these disease aspects and the relationships between them.For example, down-regulation of the serotonin production pathway during a major depressive episode was discussed with respect to the classical clinical presentation that screens positively for SIGECAPS [1].Handouts intentionally contained much more detail than could be discussed in 15 minutes, and students were encouraged to explore the handouts further between seeing patients and at home.Additionally, lesson handouts and signs posted during clinic contained society guidelines and HEDIS [2] measure 11 tables.Standards of practice were discussed with respect to the underlying mechanisms of disease.Each lesson was intended to provide information in the context of students' basic science knowledge that would help them care for patients in clinic that same evening to reinforce the didactic and practical knowledge.Three of the lessons were delivered at the clinic when students first arrived and were eating dinner before seeing patients, and two of the lessons were delivered during the monthly board meeting to evaluate which setting students preferred.

Data Analysis
Likert questions were analyzed with descriptive statistics including means and frequencies.Patient encounter time was analyzed by multivariate linear regression to account for other theoretical influences including the attending physician, number of attending physicians, month, year, number of residents, number of students, and number of patients.Narrative response question analysis is not included in this paper.
Participants entered survey data online (Google Forms, Google Corporation, Mountain View, California), and patient encounter data was maintained by the clinic in Excel 2007 (Microsoft Corporation, Seattle, Washington).Authors had no role in recording encounter times and were blinded to them until after the study.All statistical analyses were calculated with SPSS version 18 (Statistical Package for the Social Sciences Corporation, Chicago, Illinois).

Results
Fourteen of 26 (54%) eligible students responded (American Association for Public Opinion Research Response Rate Definition 6). 12,13Survey items were reduced from 7-to 5-point responses to account for narrow response distributions.Please see Table 1 for response distributions and means.All but one of 14 respondents (93%) agreed or strongly/very strongly agreed that the new curriculum provided unique information to their education.All respondents thought the course material provided more information about standards of practice than their current pre-clinical courses.Twelve respondents (85.7%) agreed or strongly/very strongly agreed that the intervention course helped them understand their patients' conditions and reported directly using information taught during the course in a mean 2.4 times over the 5 clinic evenings worked during the study period.Importantly, 78.5% of the 14 learners reported that the course made them more likely to use standards of practice with their patients when possible.
Total encounter time (patient check-in to check-out from the clinic front desk) was recorded to evaluate the pace of the clinic when dedicated teaching time was added.The encounter time mean ± standard deviation (SD) was 101.5 ± 42.3 and 79.3 ± 36.5 minutes in 2010 and 2011, respectively, for 158 total patient encounters.The year the intervention was implemented, 2011, was associated with a 69.9 minute shorter mean patient encounter time when adjusted for confounders in the model (95% CI -92.4,-39.4,p<0.001), (RModel = 0.589, adjusted R2Model = 0.283).See Table 2 for the full model.Other factors that significantly improved the model were the month; the attending; and the number of patients, attendings, residents, and students.Only some months, attendings, year, and number of residents were significant within the model, however (Table 2).

Discussion
Students generally found the intervention to be helpful for both their own education and caring for patients, defined by both direct questions to the students and the fact that they used the didactic material to care for patients.The vast majority of students preferred the didactic sessions held at the clinic location, anecdotally because it provided motivation for learning the material and helped integrate medical knowledge with care.
Additionally, the total encounter time dropped precipitously year-to-year when the students received the educational intervention.Rather than slowing clinic, the extra, dedicated teaching time reduced the time patients spent in clinic, which was likely well received by patients.(Anecdotally patients complained of the long total time spent in clinic).The reduction is likely because students were more familiar with clinically relevant information and did not have to research diseases and medications outside the room as much prior to presenting the patients, which is supported by the reported frequent use of the information presented in our intervention.Although faster clinic time is not directly indicative of better care, it reflects a more efficient experience that is likely explained by better care.
Our findings are consistent with other studies that demonstrate the educational value of medical students volunteering at clinics. 5,14,15They further suggest that the educational intervention improved the patient experience, which has also been previously demonstrated. 16This educational intervention is unique compared to prior literature because it covers broad educational topics and impacts both education and perception of patient care.
In a practical sense, the didactic sessions were relatively simple to enact.Fourth year medical students or faculty can easily lead the small group didactic sessions without more than a few minutes of preparation time, and the total session time is a mere 15 minutes.Yet, the impact appears quite clinically and educationally significant.
There are several limitations to our study, most notably the relatively small sample size and unique characteristics of students from a single school at a specific clinic.Additionally, there is an association between year-to-year change in patient encounter time, but no cause/effect conclusions can be drawn.Different staff, different patients, and different students are a few of the potential contributors to the time difference.Nonetheless, the time change is drastic and likely multifactorial, including an educational intervention that should streamline student-patient interactions.
Future studies should evaluate measurable patient care outcomes, such as percentage of HEDIS measures met, hemoglobin A1c, and patient perceptions of care.It would also be informative to compare student grades with and without the CHC didactic intervention.

Conclusion
This simple intervention is a model upon which other short, high-yield didactic interventions can be developed for student-run clinics across the country.It effectively bridges physiology, pathophysiology, and therapeutics in a clinical context that students found helpful for both their own education and for the care of their patients.

Table 2 .
Total Encounter Time Model