Robert M. Saywell, Jr., PhD, MPH Terrell W. Zollinger, DrPH Comparing Student Encounter Distributions in a 2009-11 Family Medicine Clerkship with 1997-99 Data and the 2009 NAMCS Data Scott E. Renshaw, MD Robert M. Saywell, Jr., PhD, MPH Jennifer L. Burba, BS Ashley L. Butler, BSN Indiana University School of Medicine Terrell W. Zollinger, DrPH Indiana University School of Public Health Presented at the Society of Teachers of Family Medicine Annual Conference May 2013

Introduction Every medical student should have a third-year family medicine clerkship using previous learned basic skills and cognitive structures to understand the role of family physicians in delivering primary care.

YET Providing medical students with adequate patient encounters is challenging; Assuring consistency is difficult given size, number, structure and location of clinical sites; and Tracking what medical students observe and perform during clerkship provides important information for students, preceptors, and directors. STFM (n.d.). The Family Medicine Clerkship Curriculum. Retrieved from www.stfm.org/documents/fmcurriculum(v3).pdf

Yearly trends of students’ diagnoses encounters are useful to document both positive and negative changes affecting medical student ability to achieve overall competency goals. In addition, comparing diagnoses encounters provides evidence of clerkship experiences similar to ambulatory care physicians nationally.

Background 1991: IU Family Medicine Clerkship begins 4-week, required, third year medical school 4 days per week—community faculty office 1994: Implements patient encounter log Paper booklets 2004: IU School of Medicine implements electronic patient encounter logging system PDAs 2011: IU School of Medicine implements smartphone patient encounter logging system

Study Purpose Compare the distribution of diagnoses by students during clerkships between 1997-99 and 2009-11. Compare the distribution of diagnoses encountered by students during clerkships in 2009-11 with the diagnoses seen by office based physicians nationally in 2010.

Methods 1997-99: All third-year Family Medicine Clerkship students required to record all patient encounters on paper instrument. 2009-11: All third-year Family Medicine Clerkship students required to record a minimum of 110 patient encounters and 100 diagnoses (not mutually exclusive).

Methods (cont’d) Encounter Data Retrieval 1997-99 Paper Logbook Data 446 Students 56,151 Encounters 78,854 Diagnoses 2009-11 PDA Encounter Tracking 511 Students 81,296 Encounters 149,447 Diagnoses

Methods (cont’d) 2010 National Ambulatory Medical Care Survey (NAMCS) provided latest percent distribution of office-based physician visits in U.S. Institutional Review Board approval granted from Indiana University. IBM SPSS Statistics (v.20) used for statistical analysis.

Changes in Reported Patient Encounters Results Changes in Reported Patient Encounters

Changes in Demographic Characteristics Results (cont’d) Changes in Demographic Characteristics

Changes in Demographic Characteristics Results (cont’d) Changes in Demographic Characteristics

Results (cont’d) Of the 18 major diagnoses categories, 7 increased the relative percentage of total encounters 1997-99 2009-11 Change Mental Disorders (290-319) 4.5 9.1 +102.2% Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders (240-279) 7.5 13.0 +73.3% Diseases of Blood and Blood Forming Organs (280-289) 0.4 0.6 +50.0% Supplementary Classification of Factors Influencing and Contact with Health Services (V01-V91) 15.0 17.5 +16.7% Diseases of the Musculoskeletal System and Connective Tissues (710-739) 8.8 10.2 +15.9% Diseases of the Circulatory System (390-459) 10.4 10.7 +2.9% Diseases of the Genitourinary System (580-629) 4.3 4.4 +2.3%

Results (cont’d) Of the 18 major categories, 8 decreased the relative percentage of total encounters 1997-99 2009-11 Change Neoplasms (140-239) 1.4 0.3 -78.6% Infectious and Parasitic Diseases (001-139) 4.6 1.9 -58.7% Disease of the Nervous System (320-389) 6.0 3.2 -46.7% Symptoms, Signs and Ill-Defined Conditions (780-799) 10.4 7.0 -32.7% Diseases of the Respiratory System (460-519) 15.5 11.8 -23.9% Injury and Poisoning (800-999) 2.2 1.8 -18.2% Diseases of the Digestive System (520-579) 3.9 3.7 -5.1% Diseases of the Skin and Subcutaneous Tissue (680-709) 4.7 -0.2%

Three (3) categories with < 150 cases reported were excluded Results (cont’d) Three (3) categories with < 150 cases reported were excluded 1997-99 2009-11 Complications of Pregnancy, Childbirth and the Puerperium (630-679) 140 69 Congenital Anomalies (740-759) 114 83 Certain Conditions in the Perinatal Period (760-779) 54 35

Results (cont’d) Absolute Percent Difference of 2009-11 FM Clerkship Encounters Compared to 2010 NAMCS Clerkship NAMCS % Difference Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders 13.0 6.3 +6.7% Mental Disorders 9.1 4.8 +4.3% Diseases of the Circulatory System 10.7 7.4 +3.3% Diseases of the Respiratory System 11.8 10.0 +1.8% Disease of the Musculoskeletal System and Connective Tissue 10.2 9.3 +0.9% Diseases of the Digestive System 3.7 3.6 +0.1%

Results (cont’d) Absolute Percent Difference of 2009-11 FM Clerkship Encounters Compared to 2010 NAMCS Clerkship NAMCS % Difference Diseases of the Genitourinary System 4.4 4.7 -0.3% Infectious and Parasitic Diseases 1.9 2.3 -0.4% Diseases of the Skin and Subcutaneous System 4.6 5.0 *Included as All Other Diagnoses 0.7 2.2 -1.5% Supplementary Classifications/Preventive and Follow-up Care 17.5 19.4 -1.9% Add reference

Results (cont’d) Absolute Percent Difference of 2009-11 FM Clerkship Encounters Compared to 2010 NAMCS Clerkship NAMCS % Difference Injury and Poisoning 1.8 4.5 -2.7% Neoplasms 0.3 3.9 -3.6% Disease of the Nervous System 3.2 8.8 -5.6% Congenital Anomalies * Certain Conditions Originating/Perinatal Period Complications of Pregnancy, Childbirth and the Puerperium

Summary Notable collection changes Notable demographic changes Students recorded more patient encounters when a minimum was set (159 vs. 126) Notable demographic changes Patient population has aged— near 10% (8.7) increase in geriatric population More males encountered

Summary (cont’d) Notable patient diagnoses data Increases in encounters (>50%) Mental Health Endocrine Blood and Blood Forming Organs Decrease in encounters (>30%) Neoplasms Infectious and Parasitic Diseases Nervous System Symptoms, Signs and Ill Defined Conditions

Summary (cont’d) Notable comparisons with NAMCS IU Family Medicine Clerkship students have similar patient encounters to national data for ambulatory physicians Students receive greater contact on the top two diagnoses categories compared to the national average Mental Health Endocrine

So What! Data will guide future clerkship practice Example: Endocrine conditions more than doubled from 1997-99 data to 2009-11. Review population data/disease prevalence Increase minimum requirements Develop focused preventive care module