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Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 87-90

Checking in on check-out: Survey of Learning Priorities in Primary Care Residency Teaching Clinics

1 Department of Internal Medicine, Division of General and Hospital Medicine, UT Health San Antonio, San Antonio, Texas, USA
2 Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
3 Department of Internal Medicine, Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA

Date of Web Publication18-Nov-2019

Correspondence Address:
Yvonne N Covin
Department of Internal Medicine, Division of General and Hospital Medicine, UT Health San Antonio, 7703 Floyd Curl Drive MC 7982, San Antonio, Texas 78229
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/efh.EfH_206_16


Background: Despite focus on increasing the quality of ambulatory education training, few studies have examined residents' perceptions of learning during case discussions with their preceptors (i.e., “check-out”). The objective of this study was to assess the difference between residents' and preceptors' perceptions of behaviors that should occur during check-out discussions. Methods: We conducted a cross-sectional survey of categorical internal medicine and family medicine residents and preceptors. The survey was distributed electronically and assessed 20 components of the check-out discussion. Results: Of 38 preceptors, 22 (61%) completed the survey. Of 172 residents, 82 (48%) completed the survey. For residents, we identified discrepancies in desired and perceived check-out behaviors. Specifically, utilizing a dependent sample t-test, residents felt that all 20 areas needed additional teaching during check-out (P < 0.05). Preceptors believed that demonstrating physical examination skills in the patient room during check-out was significantly more important than did residents (P = 0.01). Increasing years of preceptor experience did not statistically relate to their valuation of components important to residents. Discussion: Our research highlighted a major deficiency in training in the check-out process, with residents desiring more patient management education in all components. Moreover, faculty and residents do not necessarily agree with what is an important focus in the “teachable moment.” Our results serve as a training needs assessment for future faculty development seminars and highlight the need to consider resident learning needs in general.

Keywords: Ambulatory care, graduate medical education, patient care management, preceptorship, primary health care

How to cite this article:
Covin YN, Scielzo S, Kirk L, Barker B. Checking in on check-out: Survey of Learning Priorities in Primary Care Residency Teaching Clinics. Educ Health 2019;32:87-90

How to cite this URL:
Covin YN, Scielzo S, Kirk L, Barker B. Checking in on check-out: Survey of Learning Priorities in Primary Care Residency Teaching Clinics. Educ Health [serial online] 2019 [cited 2022 Jan 22];32:87-90. Available from:

  Background Top

The barriers to efficacy in ambulatory graduate medical education training are well established.[1],[2] Two predominant contributors to the lack of pedagogical value in this area of training have been proposed: resident frustration with health-care delivery issues (e.g., multilevel bottlenecks in workflow, and overwhelmed schedules), and dissatisfaction with supervision (i.e., teaching and feedback).[3]

Residents place high value on preceptor excellence in patient management discussions. Sisson et al. found that residents highly value continuity clinic when they perceived preceptors as positive role models for communicating clinical reasoning, managing medical issues effectively, and generating differential diagnoses skillfully.[3] Residents reported the largest deficit between measured and desired preceptor characteristics as teaching physical examination skills and giving feedback. Residents report an average of two unanswered clinical questions for every three patients after patient discussions. Unanswered questions most commonly relate to therapy and diagnosis.[4] Teaching quality improves (i.e., more teaching points and diagnostic help) when patient discussions involve a “face-to-face” patient encounter.[5] Despite this, Cyran et al. found that only 8% of patients were seen by a preceptor during check-out in a single-center survey.

Despite calls for increasing the quality of ambulatory graduate medical education training sites, few studies to date have examined resident and preceptor perceptions of specific teaching priorities of patient management discussions, or “check-out,” as a first step in faculty development curriculum design.[6],[7],[8],[9] In this study, we set out to compare preceptor and resident perceptions of learning priorities during check-out in primary care continuity clinics. Specifically, we needed to identify the areas of deficiency in training from the residents' perspective, to examine the correlation of resident and preceptor perceptions, and to explore the impact of preceptor clinical experience to the correspondence of priorities. This study was conceptualized as a needs assessment for future faculty development in ambulatory teaching.

  Methods Top

Participants and setting

Survey participants included categorical internal medicine and family medicine residents and primary care preceptors practicing across three primary care sites. Clinical sites included two safety-net primary care clinics at a public hospital and one Veteran's Health Administration primary care clinic. At the time of this survey, residents attended one clinic session per week during inpatient block schedule in resident-only clinics staffed by volunteer preceptors. This study was deemed exempt from review by our institution's institutional review board.


At the time of the study, validated learning environment instruments addressed staff and faculty perceptions of clinic.[8] A survey to investigate teaching multiple components within check-out was developed through structured interview with clinic leadership and piloted with resident representatives. The survey probed perceptions and expectations of 20 components of check-out discussions, behaviors of preceptors during and between check-out, clarity of clinic goals, and overall clinic experience. Resident and preceptor surveys differed in demographic data questions (e.g., resident future career plans and preceptor years in clinical practice); preceptors were asked to differentiate teaching priorities between interns and residents.

An anonymous electronic survey was distributed to all qualifying residents and preceptors. We used a 5-point Likert questionnaire to assess priorities (1 = very unimportant, 3 = no opinion, and 5 = very important) and practices (1 = very rarely or never, 3 = about half the time, and 5 = always). The survey closed 2 weeks after distribution. Participation was voluntary and not incentivized.


Data were obtained from resident and preceptor surveys and were extracted into Excel. Dependent sample t-tests were conducted to examine the discrepancy in the mean values between resident reported frequencies of check-out behaviors with their relative importance, when also controlling for within-individual variation. Independent sample t-tests were used to examine the differences between the average values of residents and preceptors in regard to their ratings of importance. Pearson's correlations were conducted to examine the relations of preceptors' years of clinical experience with their respective importance ratings. All statistical analyses were conducted in IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA).

  Results Top

The survey was completed by 22 of the possible 38 preceptors and 82 of the possible 172 residents for response rates of 61% and 48%, respectively. Over one-half of residents (56.1%) planned to pursue subspecialty training, whereas 17% indicated career plan of outpatient primary care. Seventy-two percent of resident respondents were in postgraduate year 1 or 2. Among preceptors, 82.6% practiced over 5 years. Nearly one-half of preceptors maintained over 75% clinical time. Two groups of preceptors emerged: a core group (39%) with >4 half-day sessions per week and a slightly larger group (52%) attending <2 half-day sessions per week. We found equal gender distribution in resident and preceptor respondents.

Comparing resident ratings of importance relative to frequency of preceptor behaviors, results suggest that all 20 components needed additional teaching during check-out [Figure 1] (P< 0.05). Preceptors and residents were also asked to pinpoint the single most important discussion of check-out [Figure 2]. Comparing preceptors to residents, we observed several discrepancies, especially pertaining to physical examination teaching. Preceptors believed that demonstrating physical examination skills in the patient room during check-out was important. Interestingly, nearly 91% of preceptors reported “most of the time” or “always” using primary care exemption during check-out, indicating that they do not see patients face-to-face. Residents confirm perception of lack of physical examination teaching [Figure 1]. Finally, no statistically significant relationships were observed between increasing number of years and preceptor agreement with resident priorities.
Figure 1: Resident responses of check-out discussion perceptions

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Figure 2: Resident and preceptor priority in check-out discussion

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  Discussion Top

Effective teaching in the ambulatory setting is a complex responsibility. Survey participants agreed that check-out discussions should prioritize clinical decision-making. We did observe an interesting tension between strong preceptor aspiration for physical examination demonstration, but substantial case discussion taking place outside of the patient room. Unexpectedly, we did not find preceptor experience to correlate with agreement of important check-out discussions from the resident's perspective.


Our study, although among two residency programs across three continuity sites, was a single-center study. Although perceptions should be diverse, they may not be generalizable. The potential for selection bias should be considered, given the low resident response rate. In an attempt to triangulate these findings, these data were presented at a national meeting for general internal medicine physicians. Comments and questions suggest high correlation to experiences of medical clinic directors, preceptors, and residents in attendance.

Due to a high number of ambulatory preceptor volunteers, we recognize the limitation of few enduring interactions between preceptor–resident pairs throughout training to develop individualized check-out priorities.

  Conclusion Top

Residents desire more patient management education in all components. We believe that our results are a potentially malleable aspect within graduate medical education delivery. Preceptors ought to value their contribution to the learning environment in the primary care clinic; they mold resident perception of clinical competence through agreement of priorities in learning. Preceptors must manage the responsibility of goal-setting for check-out with residents with whom relationships may be brief. Our results should serve as permission to capture the “teachable moment” whether in the patient room for physical examination demonstration or in the reassuring moment before offering input. Future work should focus on faculty development for ambulatory clinician–educators focused on efficient physical examination teaching.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Holmboe ES, Bowen JL, Green M, Gregg J, DiFrancesco L, Reynolds E, et al. Reforming internal medicine residency training. A report from the society of general internal medicine's task force for residency reform. J Gen Intern Med 2005;20:1165-72.  Back to cited text no. 1
Keirns CC, Bosk CL. Perspective: The unintended consequences of training residents in dysfunctional outpatient settings. Acad Med 2008;83:498-502.  Back to cited text no. 2
Sisson SD, Boonyasai R, Baker-Genaw K, Silverstein J. Continuity clinic satisfaction and valuation in residency training. J Gen Intern Med 2007;22:1704-10.  Back to cited text no. 3
Cyran EM, Albertson G, Schilling LM, Lin CT, Ware L, Steiner JF, et al. What do attending physicians contribute in a house officer-based ambulatory continuity clinic? J Gen Intern Med 2006;21:435-9.  Back to cited text no. 4
Green ML, Ciampi MA, Ellis PJ. Residents' medical information needs in clinic: Are they being met? Am J Med 2000;109:218-23.  Back to cited text no. 5
Chang A, Bowen JL, Buranosky RA, Frankel RM, Ghosh N, Rosenblum MJ, et al. Transforming primary care training – Patient-centered medical home entrustable professional activities for internal medicine residents. J Gen Intern Med 2013;28:801-9.  Back to cited text no. 6
Nadkarni M, Reddy S, Bates CK, Fosburgh B, Babbott S, Holmboe E. Ambulatory-based education in internal medicine: Current organization and implications for transformation. Results of a national survey of resident continuity clinic directors. J Gen Intern Med 2011;26:16-20.  Back to cited text no. 7
Roth LM, Severson RK, Probst JC, Monsur JC, Markova T, Kushner SA, et al. Exploring physician and staff perceptions of the learning environment in ambulatory residency clinics. Fam Med 2006;38:177-84.  Back to cited text no. 8
Wiest FC, Ferris TG, Gokhale M, Campbell EG, Weissman JS, Blumenthal D. Preparedness of internal medicine and family practice residents for treating common conditions. JAMA 2002;288:2609-14.  Back to cited text no. 9


  [Figure 1], [Figure 2]


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