The influence of teaching setting on medical students' clinical skills development: Is the academic medical center the "gold standard"?

PURPOSE: Many medical schools have revised their curricula to include longitudinal clinical training in the first and second years, placing an extra burden on academic teaching faculty and expanding the use of community-based preceptors for clinical teaching. Little is known about the impact of different learning settings on clinical skills development. METHOD: In 2002-03 and 2003-04, the authors evaluated the clinical skills of two sequential cohorts of second-year medical students at Dartmouth Medical School (n = 155) at the end of a two-year longitudinal clinical course designed to prepare them for their clerkship year. Students' objective structured clinical examination (OSCE) scores were compared on a cardiopulmonary and an endocrine case according to precepting sites (academic medical center [AMC] clinics, AMC-affiliated office-based clinics, or community-based primary care offices) and core communication, history taking, physical examination, and patient education skills were assessed. Study groups were compared using descriptive statistics and analysis of variance (mixed model). RESULTS: Ninety-five students (61%) had community-based preceptors, 31 (20%) AMC clinic-based preceptors, and 29 (19%) AMC-affiliated office-based preceptors. Students' performances did not differ among clinical learning sites with overall scores in the cardiopulmonary case of 61.2% in AMC clinics, 63.3% in office-based AMC-affiliated clinics, and 64.9% in community-based offices (p = .20). Scores in the endocrine case similarly did not differ with overall scores of 65.5% in AMC clinics, 68.5% in office-based AMC-affiliated clinics, and 66.4% in community-based offices (p = .59). CONCLUSIONS: Students' early clinical skill development is not influenced by educational setting. Thus, using clinicians for early clinical training in any of these settings is appropriate.