Verby JE, Schaefer MT, Voeks RS Learning Forestry out of the Lumberyard: A Training Alternative for Primary Care, JAMA 246:6:645 August 1981
Abstract - tertiary short term rotations good for specialty learning, limiting for primary care, Long term preceptorship is an alternative with a more representative population and richer clinical experience. RPAP is example and is a legitimate alternative.
Summary - Previous presumption is 4 - 9 weeks for a rural preceptorship for learning purposes. The article presents an alternative, the 9 - 12 month RPAP long term preceptorship. The limitations in the traditional academic medical center format include
Tertiary training faces competition for the remaining good clinical experiences, residents and higher fellows are possessive. There is lack of follow up of patients seen. There is evidence that continuity improves outcomes (not given a reference for this). A long term preceptorship involves all phases of illness: before, during, and at follow up.
In a long term preceptorship a long term evaluation of the student is possible. In a short medical school rotation of 3 to 6 weeks, there is not enough time to find deficiencies, let alone begin to address them. Long term also means better exposure to primary care so that students can be better informed about decisions in this area.
RPAP overcame predictions of poor physician support from the start. Critique - Specialty faculty going out on rural visits have often been too specialized to relate to the consults and teaching.
Early Outcomes - The first 275 RPAP students - 179 in Family Medicine, 40 in IM, 3 in peds, 4 in ob-gyn, 14 in surgery, 35 in other specialties. Evaluations also noted the preceptorship as a legitimate form of education with decided advantages. Student evaluations were very high, in fact some have had difficulty returning to university environment where they are relegated to the passive observational role. Residency directors rate RPAP students very highly.
RPAP vs U MN Controls - The study included confidence ratings on 54 medical-biological and psychosocial skills with 5 point Likerd, before and just after the rotation, on 38 students and 49 controls. RPAP students averaged 344 encounters per month, 3 times their home-based peers at 115. RPAP students saw a greater number and greater variety of skills, RPAP students perceived a higher level of responsibility, greater continuity of care, more types of patients. On pretest in 67% there was equivalence between RPAP and control. In the remaining thirde, the RPAP group had less perceived confidence at the baseline. At post test this was reversed. There was a higher perceived confidence in 67% of the items measured. The RPAP group had no skills where they perceived less confidence than the controls.. No difference in board score changes, except public health