From Passive Gatekeeper to Quarterback: Evolving Perceptions of Primary Care Among Medical Students in Longitudinal Outpatient Clerkships

Abstract

Background

Longitudinal clerkships provide students with meaningful clinical care roles that promote learning and professional development. It remains unclear how longitudinal primary care clerkships inform students’ perceptions of primary care.

Objective

To explore perceptions of primary care among medical students enrolled in longitudinal primary care clerkships.

Design

Qualitative, semi-structured interviews with medical students over 4 years.

Participants

Thirty-eight medical students participated at baseline; 35 participated in a 2-year follow-up interview; 24 participated at 4 years. Each student was enrolled in one of two longitudinal primary care clerkships: a team-based Education-Centered Medical Home (ECMH) or a one-on-one individual preceptorship (IP).

Approach

De-identified interview transcripts were analyzed using a process of open and axial coding, followed by elaborative coding for longitudinal analysis. Codes were compiled into a set of themes and compared across time periods and between clerkships.

Key Results

Students reported that primary care serves as a first point of contact, emphasizing longitudinal care with a wide scope of practice and approaching patient care with a biopsychosocial perspective. Student perceptions of primary care greatly expanded over the course of 4 years: for instance, initial perceptions of primary care physicians evolved from “passive gatekeeper” to a more nuanced “quarterback.” Students in ECMH, whose clerkship provided more opportunity for patient continuity, further reflected on the relationships they themselves developed with patients.

Conclusions

Regardless of their eventual specialty choice, longitudinal experiences may aid all students in fostering a sense of the broad scope and importance of primary care. However, without numerous opportunities to witness continuity of care, students may perceive primary care as having limited scope and importance. Longitudinal clerkships, emphasizing continuity with patients and preceptors, may foster in students a broad and nuanced perspective of the scope of primary care as a field.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-021-06914-2.

Longitudinal clerkships in undergraduate medical education infuse clinical experiences early in medical training.^1–4 These experiences reveal patient perspectives, expose students to clinical role models and career mentors, promote patient centeredness, and consolidate knowledge gained both in the classroom and through self-study.^5,6 Clerkships that enable continuity between students, patients, and preceptors may have important advantages in primary care education, namely, opportunities to learn about chronic care in an authentic setting and to participate meaningfully in managing patients over time.^7–10 Meaningful workplace roles improve student learning and legitimize students’ sense of place and purpose within the medical profession.^11,12 Participation in longitudinal clerkships improves the quality of feedback that students receive from preceptors and can serve as a forum for professional development to help students establish their identities as physicians.^12–14

Regardless of their eventual chosen specialty, medical students benefit from learning about the importance of primary care as a linchpin of the US healthcare system.¹⁵ In clerkships emphasizing continuity, trainees learn about care coordination, chronic care management, panel management, and medical home models, all important facets of contemporary primary care practice.^16–18 A primary care physician’s (PCP) scope of practice may be underappreciated by students in a system of discrete clerkship blocks that de-emphasize continuous learning.^16–18 Introducing students to the “heroism of incremental care” may increase student interest in primary care specialties.¹⁹ However, it is unknown how students themselves perceive primary care following exposure to continuity experiences, and how those perceptions of the field may change over time. In this study, we conducted a longitudinal, qualitative study to explore how exposure to outpatient, longitudinal continuity clerkships may inform how students perceive primary care as they progress through medical school.

METHODS

At the time of this study (2015–2019), the curriculum at Northwestern University Feinberg School of Medicine (FSM) contained two outpatient clerkships that begin in September of the first year. As described previously,²⁰ the Education-Centered Medical Home (ECMH) is a longitudinal, 4-year, team-based primary care clerkship in which four students from each medical school class (16 in total) are embedded into existing primary care clinics to care for a panel of medically high-risk patients overseen by a single preceptor.^2,21 The Individual Preceptorship (IP) pairs each student with a single outpatient preceptor in a longitudinal outpatient setting for 2 years, followed by a discrete 4-week primary care clerkship in M3 year. The IP provides students one-on-one access to an outpatient preceptor, creating some opportunities for clinic continuity and iterative feedback. Both clerkships participate in an 8-week Internal Medicine clerkship during M3 year.

Students matriculating to FSM in 2015 were randomly assigned to either the IP or ECMH primary care clerkships as part of a larger randomized trial.²⁰ Students were randomized regardless of interest in primary care; matriculated students had variable interest in primary care as a specialty.²⁰ In August 2015, we sent individual emails to students inviting them to participate in a series of semi-structured interviews.²² We purposefully sampled both by sex and by clerkship. We conducted baseline interviews within the first 3 months of medical school, with a goal of completing approximately 40 interviews, anticipating future loss to follow-up.^23,24 These students were again invited to participate in interviews at the end of each academic year: M1 (Spring 2016), M2 (Spring 2017), M3 (Spring 2018), and M4 (Spring 2019). Due to academic considerations, some students switched from their originally assigned clerkship; we elected to continue inviting them to participate in interviews to capture their unique perspectives, but noted when switches occurred for purposes of coding, analysis, and interpretation.

As described previously,^22,25 we developed the interview guide using an interpretivist paradigm, in which student perceptions of primary care are derived from their experiences rather than from a particular underlying “truth.”²⁶ At each time point, the semi-structured interview guides asked students to reflect on their perceptions of their longitudinal clerkships, their roles within the clinics, and their perceptions of primary care and patient-centered care. In prior work, we reported on students’ responses when queried about their perceptions of patient-centered care and how students perceived their role in clinical experiences. ^22,25 For this study, we focused on student responses over time to the following question: “Describe to me what the concept of ‘primary care’ means to you.” We asked this question at baseline, M2, and M4 interviews, retaining the same wording of the question over time.

One-on-one interviews were conducted with one of four interviewers: general internal medicine physician educators (B. L. H., B. P. G.), a communication and health services research scholar (K. A. C.), and a medical education and family and community medicine scholar (E. R. R.). No interviewee had prior professional or working relationships with their interviewers. All interviews were audio-recorded. Students were given a $20 gift card following each interview. This study was approved by the Northwestern University Institutional Review Board (STU00200764); interviewees provided written informed consent prior to their participation in the baseline interviews and verbally reconfirmed their desire to participate at each time point.

Interview recordings were de-identified and transcribed verbatim by an external company (TranscribeTeam, Arlington, VA for baseline interviews; GMR Transcription, Tustin, CA, for follow-up interviews). Five authors with expertise in qualitative research, patient-provider communication, medical education research, and the content area of ECMH (B. L. H., B. P. G., E. R. R., K. A. C., S. S.) analyzed transcripts over time using a team-based iterative inductive approach to coding with constant comparison across cases.^26–28 We created and maintained a detailed audit trail throughout the analytic process, including memos to record discussions and team decisions.^29,30 In our first coding phase for baseline transcripts, we employed a process of open coding, identifying distinct ideas and concepts, using two analysts for each transcript (B. L. H., K. A. C.) with a third serving as arbiter (E. R. R.). We continued with an axial coding phase to identify overarching themes within and between transcripts, discovering connections between identified codes. For M2 and M4 interviews, we employed elaborative coding, which involves using the codes identified from coding of prior interviews as a starting point, and refining the codebook during analysis of each time point, adding and removing codes and generating new themes based on our iterative discussions of the transcripts.^29,31 Analysts (B. L. H., B. P. G., K. A. C., and E. R. R. for M2; B. L. H., B. P. G., K. A. C., and S. S. for M4) met to compare findings and create a mutually agreed upon codebook for interviews at each time point. All transcripts were coded independently by two analysts. The analytic team met to discuss themes across interviews and draw final conclusions, comparing responses across the three time points and identifying variations in responses between students enrolled in ECMH and IP clerkships. After each set of interviews and data analysis, consistent with elaborative coding, we deliberately did not return to prior years’ transcripts with our updated codebooks.^29,31 Our aim was to explore the evolution of students’ perceptions of primary care over time; to re-analyze prior data using the M4 codebook would involve imposing an a priori framework during post hoc review that did not appear organically during analysis of data from prior years. Excluding post hoc review from our analysis enabled us to explore the thematic evolution of student perceptions of primary care over time.

RESULTS

We interviewed a total of 38 students at baseline (19 ECMH, 19 IP), 35 at M2 (19 ECMH, 16 IP), and 24 at M4 (14 ECMH, 10 IP; these students contributed data at all 3 time points). Two students switched from ECMH to IP (one after M2, another after M3), while three switched from IP to ECMH (two after M1, one after M2). Interviews across all years averaged 31 min in length. Across the three time points, we identified four overarching themes: First Point of Contact, Longitudinal Care, Scope of Practice, and Biopsychosocial Perspective. The table contains identified themes, associated codes, and representative student quotes (Table 1). Figure 1 depicts the evolution of themes and associated codes over time. Across all themes, students’ diversity of perceptions of primary care dramatically expanded across the 4-year study; Appendix illustrates select students’ evolution of their perceptions over time.

Table 1.

Representative Quotes for Each Code and Corresponding Theme Related to Medical Student Perceptions of Primary Care

Theme	Code	Representative quotes
First Point of Contact	Generic Without Elaboration	“The primary care, to me, is the first person that somebody would go to when they have any issue. They’re also a primary care provider would be someone who also follows up on their patient population, like the first caretaker.” (#106-Female-IP-Baseline)
	Gatekeeper (Generic)	“…not necessarily as the answer to everything, but they can at least guide you to the right treatment, the right physician to give you for your condition you have.” (#308-Male-IP-M4)
	Passive Gatekeeper	“If something benign or something that has the potential to become worse comes up, I think it’s the goal of the primary care to catch that and refer them to the proper person, the proper specialist, before something terrible happens.” (#307-Male-IP-M2)
	Active Gatekeeper	“…there’s definitely a management component of it as well…There’s lots of things that primary care, that’s as far as the patient needs to go into the healthcare system. And I would say its third function is more of a triage when screening for things…kind of just realizing who the best specialist is or whether or not something needs specialist care and then knowing who to refer to." (#215-Male-ECMH-M4)
	Coordinator/“Quarterback”	“Primary care to me means being the go-to for all initial health concerns and in that also managing chronic conditions as best you can until needing support from kind of a secondary source or specialist. I think as someone in primary care you are kind of the coordinator of their healthcare and also their partner in their own healthcare, but definitely you end up coordinating a lot for them and making sure all of their needs are met whether that’s by something that you’ve done or something that you can then refer them to get specialized care for something that maybe you can’t handle on your own.” (#209-Female-ECMH-M2)
Longitudinal Care	Continuity Care	“I actually have felt the benefit of longitudinal, slow, incremental progress. … two patients whom I see together whom I’ve been seeing since the beginning of M1 year… they were both taking Xanax… and they were both smoking a lot. … finally, one’s totally quit smoking and totally off the Xanax…” (#302-Male-ECMH-M2)
	Patient-Physician Relationship	“… three, being able to create that longitudinal relationship where the patient has someone to go to talk about life things or code status or understanding what the nuances of their various diseases are and being able to create that relationship.” (#211-Female-IP-M4)
	Trust	Primary care to me is a healthcare team that a patient interacts with over time, and that a patient trusts, feels comfortable coming to with any sort of health problems, and also the team is there in both a preventive and diagnostic role. (203-Female-IP-Baseline)
Scope of Practice	Scope of Practice—Generic	“And then also, it’s someone who has to kind of care for the overall health of the patients. Every aspect – it’s not any specific areas, but just everything they could get.” (#309-Female-IP-M2)
	Chronic Disease	“It’s not really specialized and they’re coming to you, it could be check-ups, medication refills, something that they’ve been feeling lately or just a management of some long term, diabetes or hypertension.” (#304-Female-ECMH-Baseline)
	Acute Care	“…As well as, hopefully, a place where you can go, maybe, if it’s an acute problem.” (#204-Male-IP-M4)
	Cohort	“I guess it means having a cohort of patients that you take care of for a long term.” (#103-Male-ECMH-M2)
	Juxtaposition	“When I think of primary care, I think of the physicians and the care they can provide when people – when they’re sick. That’s the first provider to go see, kind of like a frontline, but not in the same sense as EM doctors who really have to see the frontline of life and death kind of thing. Because, obviously, if you’re kind of dying, you’re not [going to] go see a primary care doctor; you’re [going to] go to the ED.” (#102-Female-ECMH-M4)
	Maintenance/Prevention	“I think primary care is probably maintenance and preventative. I think just trying to improve someone’s overall health over a long period of time, either with little changes or preventative-type treatments.” (#305-Male-IP-M2)
	Outreach	“So just kind of being the one to reach out if you haven't had a patient that hasn't shown up to clinic for a long time or has missed a bunch of appointments to, to reach out and be like "Hey, are you doing okay? Is there anything that is preventing you from coming in?” (#214-Male-ECMH-M2)
Biopsychosocial Perspective	Whole Person	“So, it’s taking care of the whole person. Their medical needs, social needs, what they need to be healthy, and whatever in all domains of what that encompasses.” (#301-Male-ECMH-M4)
	Mental/Emotional Health	“And then I think it also encompasses a large component of mental, emotional, and physical health combined.” (#210-Female-ECMH-M4)

ECMH Education-Centered Medical Home, IP Individual Preceptorship, ED Emergency Department

Figure 1.

Codes and themes demonstrating the evolution of medical student perceptions of primary care across three sets of qualitative interviews (a 4-year time period). * Indicates sub-theme was included as part of baseline theme definition or original baseline theme. † Gatekeeper was included as part of baseline First Point of Contact theme definition, but M2 participants differentiated between Active and Passive Gatekeeper.

First Point of Contact

At baseline, a majority of respondents perceived PCPs as a first point of contact for a patient to obtain access to the rest of the medical system. Some students described PCPs as gatekeepers, often in a passive or dismissive sense, suggesting that the primary role of the PCP was “just” to refer the patient to a specialist for care. In M2 and M4 interviews, divergent perspectives emerged. While some students continued to report a PCP’s role as being a passive gatekeeper, others describing the PCP as a patient’s “go-to person” for initial care while taking on an active gatekeeper, or quarterback role in which the PCP actively manages some conditions while referring others to specialists. As students progressed, many transitioned to speaking of PCPs as having this more active gatekeeper role. By M4 year, mentions of a passive gatekeeper were no longer evident.

Students in both clerkships reported witnessing their preceptors addressing, managing, and referring problems depending on their level of comfort and expertise. During M2 interviews, students further began to describe primary care as a coordinator between various parts of the health system, who followed up regularly with their patients and helped to close the loop on their ongoing issues. In their fourth year, although some students still reflected on primary care as being a generic gatekeeper, others began to reflect on their appreciation of primary care, noting that their experiences in their rotations led them to see primary care both as a gatekeeper, but also as a “shepherd of patients through what’s an increasingly complex healthcare system” (#207-Male-ECMH-M4). This progression was prevalent in both ECMH and IP clerkships.

Longitudinal Care

At baseline, students stated that primary care fostered the development of continuity via longitudinal patient-physician relationships. In defining primary care, some students reflected on their own personal relationships with their PCP, while others noted that primary care relies on trust between patient and physician.

Most M2s continued to discuss how PCPs care for patients over time. However, IP students, on the whole, appeared to reference continuity of care from the perspective of an observer. IP students noted the strong relationships their PCPs had with their patients: “It’s mostly my preceptor, who has longstanding relationships with several hundred or thousand, however many patients she has” (#202-Male-IP-M2). In contrast, many ECMH students described their own experiences providing care to patients over time, recalling stories of participating in health counseling or patient interviewing.

At M4, students in both clerkships discussed how caring for patients over time, and specifically building the patient-physician relationship, is a strength of primary care. ECMH students again provided examples of their own relationships with patients and the impact of those experiences; one stated “you can then be a better advocate for them because you know them” (ID#209-Female-ECMH-M4). ECMH students further described primary care as a partnership or journey, while IP students’ definitions implied a relationship that was more transactional in nature. Over time, many students in both clerkships noted a greater appreciation for primary care’s importance in patient’s lives, at times noting that primary care physicians are uniquely positioned to make in impact in patients’ lives through their close relationships (Appendix).

Scope of Practice

Although most students’ discussions at baseline focused on describing primary care in broad, thematic terms, some students remarked on both specific roles within the scope of practice of primary care, namely, preventing and managing chronic disease. Students mentioned vaccinations, cancer screenings, and management of hypertension and diabetes as examples. Many second-year students described expanded roles of the PCPs based on their experiences. Participants again mentioned primary care’s role in preventive care and chronic disease, although at times such management was described as simpler than the tasks of sub-specialists, who were perceived to manage complex diseases for patients. Some students named the critical importance of primary care in the maintenance of health rather than treatment of disease.

At M2, ECMH students identified additional key roles and perceptions of primary care not found thematically among IP students. Some ECMH students discussed a PCP’s responsibility to conduct outreach proactively to those in need, or noting that PCPs have a cohort of patients whom they manage. In contrast, IP students seemed to discuss out-of-office care in the context of managing patient phone calls initiated by patients.

At M4, ECMH students began to juxtapose the role of other fields in medicine with that of primary care, suggesting that others react while primary care is more proactive in its approach. Some participants also noted a focus on the implementation and maintenance of clinical quality metrics in primary care, which may be missing in other specialties.

Biopsychosocial Perspective

At M2, one student mentioned that primary care is “healthcare at a very baseline, all-encompassing approach… that health is not just absence of disease” (#210-Female-ECMH-M2). However, the biopsychosocial perspective theme did not fully emerge for students in both clerkships until M4 follow-up interviews. At this point, many students began to note primary care’s perspective as oriented around the whole person, rather than simply focused on the patient’s ailments: “I think it’s kind of the jumping point for patients’ health and the overseer of their whole being” (#212-Female-IP-M4). More than discussing preventive health, students directly addressed primary care as being oriented toward every part of a patient’s life. This theme was identified from students in both clerkships; a few M4 students noted that PCPs addressed more than physical symptoms and were often attentive to patients’ mental and emotional health.

DISCUSSION

In this study, we conducted qualitative, semi-structured interviews with a cohort of medical students across 4 years to explore their evolving perceptions of primary care. While specific experiences varied, students embedded in two different longitudinal primary care clerkships slowly developed deep and diverse perspectives articulating the wide scope, necessary skills, and key roles of primary care, including incremental care, panel and population management, and relationship building.

By investigating student perspectives over time, we witnessed an evolution in their perceptions regarding the role of primary care. At baseline, there appeared to be a prevailing notion that primary care was limited to “just” a system of triage, with limited scope of practice. Although part of this finding may be due in part to limited clinical experience, many students appeared to at first assume that primary care’s role, by being unspecialized, was unskilled—a “jack of all trades, master of none.” As students gained experience working in primary care settings, their perspectives became more nuanced. Many students began to view PCPs as “quarterbacks” of their patients’ care involving active management of acute and chronic disease, conducting outreach to a cohort of patients, and ascribing to a biopsychosocial model of care taking into account the whole person. ECMH students, having intensive experiential learning with patients and peers, may have experienced this evolution faster, as they noted primary care’s wide and varied scope of practice earlier than students in a more traditional one-on-one preceptor-based clerkship. Regardless of clerkship, however, students in longitudinal clerkships expressed an understanding of the transformative power, and the distinct perspective, of primary care as a field.

Professional societies have called for innovative approaches to recruiting new primary care physicians.³² Many factors influence medical students’ career choices, including personal interests, financial factors, and lifestyle considerations. However, prior studies demonstrate that the medical school experience shapes students’ perceptions of primary care.^33,34 In particular, medical students identified positive patient interactions and continuity of care as important experiences that promoted enthusiasm in primary care.³⁴ In our study, students identified similar factors in both ECMH and IP primary care clerkships—notably, longitudinal care and strong patient-physician relationships. Longitudinal clerkships may foster intrinsic motivation by promoting aspects of self-determination theory, including autonomy, competence, and relatedness, fostering internal professional development and imbuing students with positive experiences that attract them to the field of primary care.^35,36

Our study further supports the model proposed by Bennett and Phillips,³⁷ which noted that students committed to primary care specialties tend to choose them. For those students who are interested in, but not committed to, primary care specialties, longitudinal experiences in primary care, such as those studied here, may be an important factor in recruiting students to primary care. For those students committed to “specialty careers,” our study supports the concept that broad, longitudinal exposure to positive aspects of primary care can help foster effective professional relationships between primary care physicians and specialists as students transition into practitioners.³⁷ As medicine moves increasingly toward team-centric care models, strengthening perceptions of primary care among all physicians has the potential to strengthen all health care teams.¹⁰

Although all students demonstrated some evolution, differences between the IP and ECMH clerkships were evident. Students in the ECMH primary care clerkship were embedded in a team-based learning environment centered around peer mentorship and continuity.² This environment enabled students to serve as more than learners, playing the role of educator, health navigator, and advocate.²⁵ Compared to IP students, who were embedded in traditional practice settings, many ECMH students reflected on the partnerships they themselves created with patients. A randomized controlled trial comparing the ECMH and IP clerkships found that ECMH students achieved more continuity with patients and perceived a more supportive learning environment.²⁰ This study further supports the ECMH philosophy: that continuity with patients, peers, and preceptors leads to educationally richer experiences for students,³⁸ and a more nuanced understanding of the vital role of primary care.

Our study has a few limitations. Students in our study shared educational objectives but are exposed to different experiences during medical school, which may also influence these findings; our study was not designed to control for such influences. Additionally, although the participants in the interviews were all volunteers, willingness to participate and perceptions over time seem to be unlikely to be correlated.

Traditional primary care education, in the form of discrete, independent clinical clerkships lacking continuity, may prevent students from seeing the importance of primary care in the optimal care of patients. In our study, we found that students enrolled in two longitudinal clerkships witnessed, and at times participated in, formative experiences demonstrating the value of primary care. Longitudinal experiences are critical to providing all students, regardless of specialty choice, with a broad perspective on the scope of primary care as a field and may strengthen the future of health care by promoting interest in primary care as a career or facilitate more effective team-based care relationships between primary care physicians and specialists. Further study is needed to determine the impact of authentic longitudinal clerkships and curricular structure on career choice.

Author Contribution

The authors would also like to thank Rana Khalifeh and Ashley Truong for their assistance with interview coordination and administrative support. The authors also wish to thank David T. Liss, PhD, Molly McCahill, and Wivine M. Ngongo for their ongoing support of and contribution toward research around the Education-Centered Medical Home. Finally, the authors thank Stephen D. Persell, MD, MPH, and Deborah S. Clements, MD, for their leadership in obtaining funding support.

Funding

Grant support specific for educational research and dissemination was provided to support authors B. L. H., S. S., L. A. G., D. B. E., E. R. R., and K. A. C. by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UH1HP29963, Academic Units for Primary Care Training and Enhancement. The information, content, and conclusions expressed in this manuscript are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government.

Declarations

Other Disclosures

The authors have no additional disclosures.

Ethical Approval

Ethical approval has been granted for this study by the Northwestern University Institutional Review Board (STU00200764), initial approval granted 3/26/15.

Conflict of Interest

Drs. Henschen and Shaunfield, Ms. Gard, and Drs. Bierman, Evans, Ryan, and Cameron received funding from the US Department of Health and Human Services (HHS) under grant number UH1HP29963, as described above.