1. Robert M. Saywell, Jr., PhD, MPH Terrell W. Zollinger, DrPH
Comparing Student Encounter Distributions in a Family Medicine Clerkship with 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

2. 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.

3. 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

4. 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.

5. 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

6. Study Purpose
Compare the distribution of diagnoses by students during clerkships between and
Compare the distribution of diagnoses encountered by students during clerkships in with the diagnoses seen by office based physicians nationally in 2010.

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

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

9. 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.

10. Changes in Reported Patient Encounters
Results
Changes in Reported Patient Encounters

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

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

13. Results (cont’d)
Of the 18 major diagnoses categories, 7 increased the relative percentage of total encounters
Change
Mental Disorders ( )
4.5
9.1
+102.2%
Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders ( )
7.5
13.0
+73.3%
Diseases of Blood and Blood Forming Organs ( )
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 ( )
8.8
10.2
+15.9%
Diseases of the Circulatory System ( )
10.4
10.7
+2.9%
Diseases of the Genitourinary System ( )
4.3
4.4
+2.3%

14. Results (cont’d)
Of the 18 major categories, 8 decreased the relative percentage of total encounters
Change
Neoplasms ( )
1.4
0.3
-78.6%
Infectious and Parasitic Diseases ( )
4.6
1.9
-58.7%
Disease of the Nervous System ( )
6.0
3.2
-46.7%
Symptoms, Signs and Ill-Defined Conditions ( )
10.4
7.0
-32.7%
Diseases of the Respiratory System ( )
15.5
11.8
-23.9%
Injury and Poisoning ( )
2.2
1.8
-18.2%
Diseases of the Digestive System ( )
3.9
3.7
-5.1%
Diseases of the Skin and Subcutaneous Tissue ( )
4.7
-0.2%

15. Three (3) categories with < 150 cases reported were excluded
Results (cont’d)
Three (3) categories with < 150 cases reported were excluded
Complications of Pregnancy, Childbirth and the Puerperium ( )
140 69
Congenital Anomalies ( )
114 83
Certain Conditions in the Perinatal Period ( ) 54 35

16. Results (cont’d)
Absolute Percent Difference of 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%

17. Results (cont’d)
Absolute Percent Difference of 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

18. Results (cont’d)
Absolute Percent Difference of 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

19. 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

20. 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

21. 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

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