S P E C I A L T H E M E A R T I C L E
A Collaborative Model for Supporting
Community-based Interdisciplinary Education
Patricia A. Carney, PhD, Karen E. Schifferdecker, PhD, Catherine F. Pipas, MD, Leslie H. Fall, MD,
Daniel A. Poor, MEd, Deborah A. Peltier, MD, David W. Nierenberg, MD, and W. Blair Brooks, MD
ABSTRACT
Development and support of community-based, interdis-
ciplinary ambulatory medical education has achieved
high priority due to on-site capacity and the unique ed-
ucational experiences community sites contribute to the
educational program. The authors describe the collabo-
rative model their school developed and implemented in
2000 to integrate institution- and community-based in-
terdisciplinary education through a centralized office, the
strengths and challenges faced in applying it, the educa-
tional outcomes that are being tracked to evaluate its ef-
fectiveness, and estimates of funds needed to ensure its
success.
Core funding of $180,000 is available annually for a
centralized office, the keystone of the model described
here. With this funding, the office has (1) addressed re-
cruitment, retention, and quality of educators for UME;
(2) promoted innovation in education, evaluation, and
research; (3) supported development of a comprehensive
curriculum for medical school education; and (4) moni-
tored the effectiveness of community-based education
Dr. Carney is associate professor, community and family medicine (C&FM)
and assistant dean for medical education and research; Dr. Schifferdecker
is program director, Office of Community-based Education and Research,
and research associate in C&FM; Dr. Pipas is family medicine clerkship
director, assistant professor of C&FM, and assistant dean for community-
based education; Dr. Fall is ambulatory pediatrics clerkship director and
assistant professor of pediatrics; Mr. Poor is computer education specialist
and research associate, C&FM; Dr. Peltier is ambulatory medicine clerkship
director and assistant professor of medicine; Dr. Nierenberg is professor of
medicine and associate dean for medical education; and Dr. Brooks is rural
primary care residency director and associate professor of medicine; all at
Dartmouth Medical School, Hanover, New Hampshire.
Correspondence and requests for reprints should be addressed to Dr. Carney,
Dartmouth Medical School, 1 Medical Center Dr., HB 7925, Lebanon,
NH 03756; telephone: (603) 650-7773; fax: (603) 650-6333; e-mail:
Patricia.A.Carney@dartmouth.edu.
610 ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002
programs by tracking product yield and cost estimates
needed to generate these programs. The models Teaching
and Learning Database contains information about more
than 1,500 educational placements at 165 ambulatory
teaching sites (80% in northern New England) involving
320 active preceptors. The centralized office facilitated 36
site visits, 22% of which were interdisciplinary, involving
122 preceptors. A total of 98 follow-up requests by com-
munity-based preceptors were fulfilled in 2000. The cur-
rent submission-to-funding ratio for educational grants is
56%. Costs per educational activity have ranged from
$811.50 to $1,938, with costs per preceptor ranging from
$101.40 to $217.82. Cost per product (grants, manu-
scripts, presentations) in research and academic scholar-
ship activities was $2,492. The model allows the medical
school to balance institutional and departmental support
for its educational programs, and to better position itself
for the ongoing changes in the health care system.
Acad. Med. 2002;77:610620.
I
nterdisciplinary relationships are serving as important
vehicles to improve teaching and learning in medical
schools across the country. Initially, these collaborations
were launched in primary care via external funding
from sources such as The Robert Wood Johnson Generalist
Physician Initiative,15 Interdisciplinary Generalist Curricu-
lum (IGC) grants,6,7 and Undergraduate Medical Education
for the 21st Century.8 Currently, many medical schools take
integrated interdisciplinary approaches in their educational
organization and planning. These activities have enhanced
coordination in medical school curriculum content and ed-
ucational processes within and across institutions, particu-
larly for those that have received grant support, and, impor-
 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION, CONTINUED

tantly, have promoted dedication of resources toward
interdisciplinary collaborations.911
One goal at our medical school is to expand this inter-
disciplinary collaborative approach from the institution to
community-based education to ensure both quality and sus-
tainability of our educational programs. Like many institu-
tions, our ambulatory educational programs have extended
into community settings due largely to changes in health
care delivery; currently more than 95% of health care is
delivered in ambulatory settings.12 Our primary teaching hos-
pital and clinic do not have the capacity needed to provide
ambulatory experiences for all our students on-site. In ad-
dition, experiences with patient diversity in disease states,
cultures, and socioeconomic status, and the roles of physi-
cians in communities and office practice settings, are impor-
tant educational objectives that cannot fully be met on-site.
Table 1 illustrates the extent of community-based teaching
that occurs by primary care department in our ambulatory
education programs. Data reflect annual estimates between
1998 and 2000.
The 13th Report of the Council on Graduate Medical
Education13 indicates that the selection, support, and rec-
ognition of community preceptors is a fundamental priority
of graduate medical education, an issue that is equally rele-
vant for undergraduate medical education (UME). This view
is, in part, due to the significant variability that exists in the
quality of teaching and learning in ambulatory settings.14 A
recent survey conducted by Walling et al.15 found that all
responding U.S. medical schools used community preceptors
as clinical teachers. Of these, 94% had at least 100 com-
munity preceptors, and 30% had between 1,000 and 3,500
preceptors. This survey also found that the majority of
schools (67%) supported community preceptors through in-
dividual departments, with only 4% supporting faculty
through a centralized office.
Our school, Dartmouth Medical School, has benefited
greatly from school-based interdisciplinary planning. This
has resulted in the creation of a centralized office, the Office
of Community-based Education and Research (OCER), to
expand our interdisciplinary educational collaborations to
the community. Centralized support has allowed us to work
effectively with community-based faculty to: (1) address re-
cruitment, retention, and quality of educators; (2) promote
innovation in education, evaluation, and research; (3) de-
velop and implement a comprehensive curriculum; and (4)
monitor the effectiveness of community-based education
programs by tracking product yield and cost estimates needed
to generate it. Such centralized support also helps balance
the competing needs of our schools educational programs
and their participants.
We wrote this article to outline our collaborative model
for integrating institution- and community-based education
and educational research through a centralized office, the
strengths and challenges we face in applying it, the edu-
cational outcomes we are tracking to assess it, and cost
estimates needed to ensure its success. We believe that
interdisciplinary and multidisciplinary collaborations will
continue to evolve due to market influences on the exceed-

Table 1

Annual Estimated Training Efforts in Primary Care, Community-based Sites, Dartmouth Medical School (DMS), 19982000

Total No. Students % of These That

Total No. DMS % of These That Are Trained at DMS Clinical Are Trained at
Medical School Clinical Course Clinical Training Sites Community Sites Teaching Sites* Community Sites

On Doctoring
Year 1 56 94.6 76 75.3
Year 2 61 73.7 80 56.3

Primary care ambulatory clerkships (year 3)

Internal medicine 15 53.3 74 27.0
Family medicine 13 69.2 27 66.7
Pediatrics 16 56.3 70 58.6

Womens health clerkship (year 4) 14 64.3 67 53.5

TOTAL 155 65.8 324 66.4

*Data expressed as raw numbers, so there is overlap in clerkships.
Not based at DMS. (Does not include distant community-based sites, such as Miami, FL; Providence, RI; Augusta, ME; Tuba City, AZ; Bethel, AK.)

ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002 611

 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION,
ingly dynamic U.S. health care delivery system, which has
a profound influence on undergraduate and graduate medical
education. We also believe that studying processes and costs
involved in successful applications of such models as the one
we propose is critical if our educational institutions are to
respond efficiently and effectively to a rapidly changing
health care environment.
COMMUNITY-BASED TEACHING AT DARTMOUTH
MEDICAL SCHOOL
The Past
Community-based education in primary care was initiated at
Dartmouth in the 1970s with the Family Medicine Longi-
tudinal Elective (FMLE). The Department of Community
and Family Medicine faculty directed this elective, and
though the focus was on family medicine, students were also
exposed to medicine and pediatrics throughout their clinical
experiences. The development of the six-week year-four pri-
mary care clerkship followed the FMLE in the mid-1980s. It
was interdisciplinary in scope and administered through the
Department of Community and Family Medicine. During
this time, the Department of Internal Medicines clinical ro-
tations remained hospital-based, not expanding to commu-
nity-based ambulatory settings until the late 1980s. The De-
partment of Pediatrics followed suit shortly afterwards. All
community-based teaching during this period (19701990)
was managed independently by the individual departments.
The Present
Early clinical training (in years one and two) was initiated
in 1994 with On Doctoring: A Longitudinal Clinical Ex-
perience, in which all first- and second-year medical students
work with office-based physicianpreceptors one half day
every other week. The vast majority of On Doctoring pre-
ceptors are primary care physicians based in community
practice. In 1996, a 16-week integrated primary care clerk-
ship (IPCC) became the required ambulatory third-year
clerkship; it consisted of four weeks of outpatient pediatrics,
four weeks of outpatient medicine, and eight weeks of am-
bulatory family medicine. In 1998, the Department of Ob-
stetrics and Gynecology expanded its educational programs
into the community as well, when they developed a separate
four-week outpatient womens health clerkship. All of these
courses require interdisciplinary collaboration, since over-
lapping or integrated course content and recruitment,
retention, and development of common preceptors exists.
Collaboration is especially important, since 20% of our com-
munity-based faculty have students from one or more of these
courses or clerkships at any given time. As indicated in Table
612 ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002
CONTINUED
1, 66% of our ambulatory teaching in primary care depart-
ments takes place at community (non-medical center) sites.
This history illustrates our institutions increasing depen-
dence on community-based faculty and how primary care
clinical education changed from being solely department-
based to developing curriculum and ambulatory clinical ex-
periences through an integrated collaborative model.
Support for Community-based Teaching
An important factor in curricular change occurred in the
1990s, when Dartmouth Medical School (DMS) received a
Robert Wood Johnson Generalist Physician Initiative
grant.16 This grant created the Office of Generalist Education
(OGE), which provided both leadership and resources to de-
velop stronger linkages with community-based faculty. The
major successes of the OGE at DMS were the development
of computer linkages for educational purposes17 and its as-
sistance in establishing the Community Preceptor Education
Board (CPEB).18 The OGE was also successful in facilitating
interdisciplinary collaboration in course planning among on-
site faculty, obtaining community-based teaching honoraria,
organizing faculty development activities, and collaborating
with the NH AHEC to create the Teaching and Learning
Database, which could track all student placements and be
used to identify areas that needed educational support.
The Robert Wood Johnson Generalist Physician Initiative
grant and the fiscal support it provided ended in 2000. Our
institution saw the need to support ongoing community-
based teaching activities and decided to apply a centralized
approach to achieve this. In July 2000, the OGE evolved
into the OCER (described earlier). In addition to the suc-
cessful elements of the OGE, faculty leaders of the new office
were charged with (1) generating an evaluation and research
agenda that would provide a foundation for academic schol-
arship in teaching and (2) furthering the integration of com-
munity faculty as important members of our institution, us-
ing our interdisciplinary collaborative approach.
In the next section of this article, we present an overview
of our collaborative model and its individual components.
We identify where collaboration and interactions take place,
including the structure for support of these activities. We
provide cost estimates for operational elements of the model
and indicate how we benchmark our success using measur-
able criteria. Last, we discuss the challenges we face in ap-
plying the model.
THE MODEL
Overview
When the OCER was launched, a steering committee was
established that consisted of the chairs of the three primary
 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION,
care departments (pediatrics, medicine, family medicine),
the directors of graduate medical education and continuing
medical education, the associate dean of medical education,
the chief operating officer of the medical school, and the
assistant deans of community-based education and of re-
search in medical education. The latter two co-directors
were charged with providing leadership for OCER activities
that addressed educational support, research, and academic
scholarly activities in community-based education. This
committee reviewed and approved one- and five-year stra-
tegic plans and an annual operating budget of $180,000 for
core OCER activities; it meets semiannually to review prog-
ress and projected goals, and to advise on challenges and the
institutional vision.
During the pre-planning period, an internal needs assess-
ment identified two primary goals for the model: (1) to pro-
vide educational support to expand the linkages previously
developed among interdisciplinary on-site faculty to those
off-site, which would enhance integrated curriculum devel-
opment and preceptor and site recruitment and would pro-
vide ongoing community-based faculty development; and (2)
to promote medical education evaluation, research, and ac-
ademic scholarship in a manner that allows for evaluation
of our programs performance by monitoring specific outcome
measures.
Our model addresses our institutions ambulatory educa-
tional mission by promoting interdisciplinary collaboration
between on- and off-site faculty while continuously assessing
fiscal tradeoffs. Medical students, course directors, and clin-
ical courses taught are at the center of the model. They serve
as the primary interface between students and preceptors on
a day-to-day basis. Administrative, educational support, and
research or academic scholarship services are provided by the
OCER. The ambulatory clinical courses and the curricu-
lar activities for which they are responsible are outlined in
Table 2.
Educational Support Activities
Just as the core ambulatory clinical courses have evolved in
ways that necessitated increased interdepartmental interac-
tion and planning, the OCER facilitated a more compre-
hensive approach to collaboration between on- and off-site
faculty. Using this approach, we identified the following pri-
ority areas: (1) recruitment, retention, and faculty and site
development to ensure sustainability and quality of com-
munity-based teaching; (2) outlining of generic and equita-
ble benefits, including compensation, for community precep-
tors; (3) support for the Community Preceptor Education
Board (CPEB); and (4) support for and enhancement of the
computer network and the Teaching and Learning Database,
which tracks student placements throughout the year.
ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002
CONTINUED
We have adopted a strategy of organizing working group
meetings around overarching support needs of preceptors as
a way of bringing all the courses together toward collabo-
ration. The OCER has been primarily responsible for orga-
nizing and providing administrative support for these work-
ing groups. Staff in the office work directly with course
directors to identify and discuss issues to be addressed. Below
we profile two regular and one ad hoc working group, the
Community Site Development Working Group, the Com-
munity-based Faculty Development Working Group, and the
Web Development Working Group. We then describe activ-
ities we undertake to support the computer network and da-
tabase for community-based teaching activities.
The Community Site Development Working Group.
This group developed out of an identified need to provide a
systematic approach to recruiting, developing, and support-
ing community-based preceptors. The group meets biweekly
and provides support structure and staffing for primary care
course directors in recruitment of new sites and site visit
preparation and follow-up. The Teaching and Learning Da-
tabase, maintained by the OCER, aids this group by tracking
site visits, pre-visit needs, post-visit requests, and the dates
when requests are fulfilled, in addition to tracking student
placements.
This group was instrumental in standardizing preceptor
benefits across the primary care disciplines and in revising
site-visit approaches so that they would be interdisciplinary
whenever possible. These efforts have enhanced new pre-
ceptor registration processes in the DMS system, including
the receipt of faculty appointments and benefits (Table 3).
Staff in the OCER are responsible for keeping all appoint-
ment and benefit information current, preparing materials
for site visitors, and assisting with the provision of benefits
or supplemental requests when needed.
The Community-based Faculty Development Working
Group. This group has worked closely with and will even-
tually merge into the Site Development Working group,
once program planning activities are well established. The
Community-based Faculty Development Working Group has
identified topics of interest for community faculty develop-
ment through the CPEB and site visits and has generated a
menu of different educational methods to address preceptors
educational needs (e.g., institution-based workshops, one-
on-one meetings, regional mini-workshops). These are in-
corporated into a yearly calendar, and each activity is cham-
pioned by a community preceptor in the region where the
program will be held. This ensures that the connection be-
tween the institution and the community faculty is well es-
tablished. This working group will continue to respond to
what is needed, based on requests from course directors and
preceptors.
The Web Development Working Group. When topics
613
 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION, CONTINUED

Table 2

Required Core Ambulatory Clinical Curriculum at Dartmouth Medical School, 19992000

Academic Preceptor Time

Level of Commitment
Required Course Trainee Practical Experience Educational Methods (per Student)

On Doctoring Year 1 Role of the physician Large-group lectures and small-group skills 16 half days per
Year 2 Doctorpatient relationship sessions alternating half-day per week academic year
Basic interviewing and physical with a clinical practice ambulatory experi-
examination skills ence

Family medicine clerk- Year 3 Assessment and treatment of Community practice rotation four days per Four days per week
ship common problems in ambula- week with one day per week on campus for eight weeks
tory patients for lecture-based curriculum*
Clinical reasoning
Prevention
Office management
Community health

Internal medicine out-
patient clerkship
Year 3 Community-oriented care Community practice rotation four days per Four days per week
Differential diagnosis week with one day per week on campus for four weeks
Testing for and treatment of for lecture-based curriculum
common problems in primary
care
Management of chronic illness
Health maintenance

Pediatrics outpatient Year 3 Assessment and treatment of Community practice rotation four days per Four days per week
clerkship ambulatory patients week with one day per week on campus for four weeks
Differential diagnosis for lecture-based curriculum
Testing and treatment of com-
mon problems in pediatrics
Health maintenance

Womans health clerk- Year 4 Assessment and treatment of Community practice rotation five days per Five days per week
ship women seen in ambulatory week for the first two weeks, then four for two weeks,
settings days per week for the last two weeks then four days
with one day per week on campus for per week for two
lecture-based curriculum weeks
*For local placements only (distant placements do not come back for lecture sessions).

arise that cannot be handled by any of the established work-
ing groups, ad hoc meetings are organized. An example of
this approach involved Web development, which is carried
out by the Web Development Working Group. The identi-
fied need involved coordination of Web-site design with the
departments and among faculty teaching in community-
based courses. OCER staff schedule a meeting or series of
meetings for all necessary parties to attend. In cases where
this is not possible, OCER staff and faculty ensure that com-
munication among necessary parties takes place through
face-to-face meetings or meeting minutes. Biweekly OCER
leadership meetings provide core planning activities for the
OCER, including addressing those issues identified in work-
ing groups, policy decisions, future directions, and institu-
tional vision as it relates to community-based education and
research.
The OCER faculty supporting the computer network18 as-
sist community physicians with selecting hardware and soft-
ware; accessing traditional library-related resources (card file,
journals, text, Medline); accessing the Internet and the
OCER Home Page; and accessing the DartmouthHitch-
cock Medical Centers Clinical Information System, which
gives referring physicians access to their patients clinical
information. Course directors distribute curricula electroni-

614 ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002

 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION, CONTINUED

cally to community-based preceptors regularly and rely on
the network for student and course evaluation. Students are
required to use the network to access medical literature in
the community setting. Preceptor e-mail communication
and access to computerized patient clinical information oc-
cur at regular rates, with e-mail usage predominating. This
system, because of its ease of implementation and use, will
form the foundation for the introduction of additional tools
to enhance and support community-based teaching.
The computer network, though clearly innovative and
state-of-the-art when initiated several years ago, must now
be updated. Many physicians have upgraded their systems,
though we do not know specifically how many have done
so. The OCER recently surveyed preceptors to determine
what hardware and software they had and how they used it
to educate themselves, their students, and their patients.
OCER will use this information both to offer guidance to
those preceptors who have not already upgraded their hard-

Table 3

Support Services and Resources That the Office of Community-based Education and Research (OCER) Provide to Foster Community-based
Teaching, Dartmouth Medical School, 20002002

Service/Activity Category Support Resources

Administrative OCER processes adjunct faculty appointments through the Dartmouth College ID follows faculty appointment
DMS system and is needed for access to additional resources

Computer services OCER provides consulting support for computer hardware and
software issues
OCER provides computer help and referrals for solving com-
puter-related help questions at the college, the biomedical
libraries, and the medical center
Discounts at Kiewit computer store
E-mail, Internet browser, clinical information sys-
tem and affiliated information system software
Access to community-based teaching and learning
databasefor preceptor mailing lists, personal
teaching history, course lists, etc.
OCER Web site access

Library services Document delivery and librarian support Access to databases, including Ovid (Medline) and
full-text journals
Access to all Dartmouth libraries and stacks (Dart-
mouth College ID is the library card)
Electronic Library Resources and mailing lists

College services Assistance from travel office for meeting travel Access to Dartmouth Outing Club activities and
Outing Club cabins
Course auditing

Practice-based services Honorarium to recognize certain types of teaching (range is Access to locum tenens
$750 to $7,200 per student per year paid for by depart- Recruitment potential
ment, depending on duration and intensity of teaching) Student clinical improvement projects

Faculty development services
OCER provides faculty development workshops and teaching
materials
Continuing medical education (CME) in standard
courses
Mini-fellowships (individually structured CME credit
options)
Other online educational resources

DMS representation activities Honorarium is available for individual community preceptor Community preceptor education board
education board members. Other DMS committees
Departmental activities

NH AHEC* resources Student support (e.g., clinical placements) Continuing education programs
Discount on MD Consult Library workshops
Educational materials (including textbooks)
*Area Health Education Consortium.

ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002 615

 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION,
ware and also to offer software and training activities for
those who have. In addition, the OCER Web site will be
revised to serve both DMS learners looking for community-
based experiences and their preceptors looking to enhance
their knowledge to better serve their patients and students.
OCER continues to maintain the Teaching/Learning Da-
tabase, which involves keeping clinical placements updated,
ensuring that the appropriate sites are designated as under-
served ones, using appropriate definitions, and providing reg-
ular downloads of data to collaborators who need the infor-
mation for grant reporting or submission requirements.
Additional community-based experiences within the four-
year DMS program, such as clinical and non-clinical com-
munity-based electives and summer preceptorships, have
been added to better track all community placements.
Promoting Medical Education Evaluation, Research, and
Academic Scholarship
At our school, a foundation for research and scholarly ac-
tivities related to community-based education has been es-
tablished by recently funded innovative education and re-
search projects8,20,21 and by the OCER Teaching and
Learning Database. This database is becoming an essential
tool for tracking and describing characteristics of students
and preceptors (e.g., number of student rotations in under-
served areas). These are important data for grant reporting
and proposal development as well as for manuscripts sub-
mitted for publication that necessitate a description of our
study populations.
Our evolving research program has focused on developing
tools to enhance the quality of teaching through effective
evaluation systems,19increasing the efficiency of teaching in
ambulatory settings using intensively tested interventions,20
and enhancing the consistency of teaching in multiple sites
using computer-assisted instruction.21 Currently funded pro-
jects have provided us with a source of data about commu-
nity-based education, which we use to evaluate and improve
such education and plan for the future. We are developing
a plan of grant submissions across primary care departments
that will build on the successes of currently funded grants,
such as Undergraduate Medical Education for the 21st Cen-
tury,8 which provided funding for the expansion onto hand-
held computers of a paper-based documentation system of
students community-based experiences and training (de-
scribed elsewhere in this issue19,22). We have analyzed data
from this documentation system to study aspects of ambu-
latory-based encounters, such as how type of health care visit
and genders of the student and his or her teacher influence
educational experiences of students.23,24 This has resulted in
academic productivity in education that mirrors that which
occurs in clinical academic tracks: there is institutional sup-
616 ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002
CONTINUED
port for promotion, an important enticement for faculty re-
quired to choose between clinical research and clinical
teaching tracks.
The staff and members of OCER support the academic
development cycles by (1) providing a library of funding
possibilities for topics related to medical education; (2) pro-
viding data in support of grant submission; (3) promoting
interdisciplinary research collaborations and mentorships;
(4) transforming research ideas from the course directors or
other individuals into measurable objectives; (5) revising
and editing grant submissions; (6) developing evaluation sec-
tions for grant submissions; (7) serving as the evaluators on
funded grants; and (8) collaborating with or mentoring oth-
ers in the development of manuscripts for publication.
Cost-estimate Analysis
To estimate costs for OCERs activities, we approximated
how time was spent by faculty and staff in each of our main
mission categories. We then used full-time-equivalent (FTE)
or operating costs from our core budget to calculate costs for
specific activities and came up with two figures: a cost per
event (educational mission) or submission (research mission)
and a cost per preceptor (educational mission) or product
(research mission). (See the end of the next section for more
discussion of these cost estimates.)
IMPLEMENTATION OF THE MODEL
Presently, the Teaching and Learning Database contains
more than 1,500 educational placements at 165 ambulatory
teaching sites (80% of which are in northern New England)
involving 320 active preceptors. Tables 4A and 4B illustrate
the OCERs productivity in its first year (20002001) for its
core activities. Working collaboratively with both primary
care departments and faculty via externally funded projects,
the OCER has sponsored or cosponsored five faculty devel-
opment programs, one of which was a half-day workshop
held at our medical school. The remaining four were two-
to-three-hour regional workshops held at regional facilities
throughout New Hampshire and Vermont. In addition, the
OCER has facilitated scheduling 36 site visits, 22% of which
were interdisciplinary. These site visits involved 122 precep-
tors, and OCER staff ensured that follow-up activities on 98
requests by community-based preceptors were accomplished
(e.g., literature searchers, database reports, curriculum up-
dates sent).
Providing up-to-date computer support to community sites
is an extremely challenging goal; we still are not able to
accurately estimate the costs of such support, especially since
more and more curricular activities require Internet access.
Computer support has been provided to 30 preceptors to
 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION, CONTINUED

Table 4A

Academic and Research Productivity in Academic Activities That Support Education Fostered by the Office of Community-based Education and
Research, Dartmouth Medical School, 20002001

No. Activities No. Preceptor Cost per Activity Cost per Preceptor
Carried Out Participants Subtotal* Subtotal*

Faculty development Total cost $38,555

Institution-based workshops 1 27
Regional workshops 4 28
Site visits 36 122
Subtotal 41 177 $940.00 $217.82

Computer connectivity and Teaching and Learning Database Total cost $6,492
Computer support 30 30
Student placements 318 243
Subtotal 348 273 $18.66 $25.67

Community preceptor education board meetings Total cost $6,492

8 64
Subtotal 8 64 $811.50 $101.40
*Costs estimated using the core cost estimates presented in Table 5.

Table 4B

Academic and Research Productivity in Academic Activities That Support Research and Academic Scholarship Fostered by the Office of
Community-based Education and Research, Dartmouth Medical School, 20002001

No. (%) Funded or

No. Submitted Accepted Cost per Submission Cost per Product

Grants 9 5 (56%) Total cost $34,882

Manuscripts 4 4 (100%)
Presentations 7 5 (71%)
Subtotal 18 14 (76%) $1,937.91 $2,491.57

connect them via computers to faculty and services at Dart-
mouth Medical School for access to Medline, evidence-based
medicine tools, clinical information systems, curriculum on
the Web, the OCER Web page, etc. Issues have included
forgotten passwords, antiquated hardware, advice about new
hardware purchases, and general recommendations concern-
ing computer connectivity to Dartmouth Medical School
and the DartmouthHitchcock Medical Center. Preliminary
results from our recent computer-connectivity survey suggest
that about 21% of current preceptors use Macintosh com-
puters, with the remaining using Windows-based (PC-re-
lated) computers. This indicates the extent of computer sup-
port platforms that need to be addressed. Although OCER
staff are working with DMS Computing to accomplish these
goals, the resources available are small.
To date, the OCER team of faculty and staff has supported
nine grant submissions, including those made by faculty in
the New Hampshire Area Health Education Center (NH
AHEC), and in the Departments of Medicine, Family Med-
icine, and Obstetrics and Gynecology. Of the nine grants
submitted, five have been funded, two are still pending, and
two were not funded. This indicates that our current sub-
mission-to-funding ratio is 56%, and for this submission year
(2002) it is likely to range between 56% and 78% after all
reviews are completed. The OCER provides ongoing eval-
uation and technical support for three of the four above-
mentioned funded projects (predoctoral training in family
medicine, Partners in Quality Education, and NH AHEC
REACH grant), as well as space and administrative support
to the pediatrics predoctoral training grant (Computer-as-

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 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION, CONTINUED

sisted Learning in Pediatrics Project). Last, one other grant DISCUSSION

submission, which is still pending, received significant con-
tributions from OCER faculty and staff. All four manuscripts
we have submitted to date have been published, and 71%
of our abstract submissions to national meetings have been
accepted.
Cost estimates in Tables 4A and 4B were generated from
data in Table 5, which outlines the core cost estimates of
the OCER in both MD and non-MD FTE and operating
costs (including meeting travel). As illustrated, the core
OCER team includes two faculty leaders (one MD and one
PhD), one (PhD) at 10% and the other (MD) at 15% effort,
one full-time director, one half-time computer and education
specialist, one full-time administrative support person, a di-
rector of special projects (10%), and a community liaison
(5%). As indicated in Table 4, costs per OCER educational
activity ranged from $811.50 to $1,937.91, with costs per
preceptor ranging from $101.40 to $217.82. The cost per
product in the research and academic scholarship activities
was $2,491.57.
Accomplishments
Our institution has developed a centralized office to foster
interdisciplinary community-based education. We have suc-
ceeded in developing a uniform system of rewarding com-
munity-based faculty, and identifying and recruiting sites us-
ing an interdisciplinary approach, and using interdisciplinary
leadership and input to guide community-based educational
support and research activities that will ultimately span the
entire medical education continuum (UME to GME to
CME). Early indicators of our success in taking this approach
include the ability to monitor the balance between (1)
achieving educational and research project outcomes and (2)
raising sufficient funds to pay the direct costs needed to sus-
tain the central infrastructure.
The OCER provides better support than was previously
available when using a department-based structure because
it assists faculty in recruitment and development of new sites

Table 5

Working Data to Help Generate Cost Estimates for the Activities of the Office of Community-based Education and Research, Dartmouth Medical
School, 20002001

Activities Funded by the Core OCER Budget*

PhD/MS/MEd/Other
MD Faculty Full-time Faculty Full-time Staff Full-time
Equivalent Equivalent Equivalent Operating Costs

Academic activities that support education

Leadership .10 .07 .05
Faculty development .08 .25 .40 .45
Computer connectivity and Teaching and Learning .50 .25 .20
Database
Community preceptor education board .05 .05 .05 .05
Subtotal $38,250 $43,710 $25,500 $18,200

Academic activities that support research and

academic scholarship
Leadership .05 .13 .15
Grants .01 .20 .25 .10
Manuscripts .01 .15 .05
Presentations .05 .15
Subtotal $11,250 $37,365 $8,500 $7,800

GRAND TOTAL $49,500 $70,500 $34,000 $26,000

*The core OCER budget is $180,000 per year (85% FTE; 15% operating costs). Full-time-equivalent computations represent actual full-time equivalents, while percentage
estimates used to calculate operating costs are based on a total equal to 100%. The other aspects of OCER funding are department cost-sharing and grant support, not shown
in this table.
Includes MD leader of OCER.
Of this, .10 is PhD leadership.

618 ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002

 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION,
and in coordinating teaching requests of current preceptors.
It has also helped the medical school as a whole begin to
look at coordinating community-based placements in gen-
eral. Similarly, information from the database has been
used to support grant applications, presentations, and
publications, while the computer network promotes en-
hancements to the educational setting that would not oth-
erwise be so well coordinated, which was the case in our
previous department-based structure. Our cost estimates in-
dicate a range in fiscal support for OCER activities using a
centralized structure ($101$2,492), with some areas having
more predicable yields than others. Certainly grant submis-
sions are time-consuming, and the yields can be variable.
We are pleased with our 56% funded-to-submitted ratio,
though we hope to improve this to 70% for the upcoming
year. Our investment in academic scholarship of $2,492 per
product (see Table 4B) may seem high, but from a grants-
manship perspective, the total investment in scholarship
yielded over $1,000,000 in direct costs for the institution,
allowing it to conduct innovative educational projects that
would not have been possible otherwise. The precise con-
tribution of OCER is difficult to determine because of the
departmental overlap in activities, but providing an orga-
nized structure of review, revision, and grant development
expertise was certainly a valuable contribution. Unfortu-
nately, because neither have we seen such figures published
in the educational literature nor have our departments
tracked such information, we cannot compare these results
with data from other institutions or with our own previous
individual departmental results, though we do plan to use
them to monitor our successes over the coming years.
Challenges
Despite the obvious benefits of collaboration, our model has
also posed a number of challenges. These include carefully
nurturing relationships and preserving identities among
OCER faculty and staff, course directors, course coordina-
tors, and community preceptors; making effective commu-
nication a top priority; and promoting a broader institutional
view (deans office, department chairmen, OCER faculty,
and on- and off-site faculty) about the importance of work-
ing together to achieve our unified and individual program-
matic goals.
With over 320 preceptors, disseminating information
about the OCER to every preceptor has been a challenge,
as many preceptors had have longstanding relationships with
the individual departments and with the OGE. Correspon-
dence regarding site visits that had once come from the
course director now comes from the OCER, and it is im-
portant that community preceptors understand how the
structure has evolved. We have addressed this issue through
ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002
CONTINUED
mailings, by discussing the OCER at site visits, and by en-
couraging distant members to participate in faculty devel-
opment programs sponsored or co-sponsored by the OCER.
Also, course directors generally maintain previous levels of
individual contact with preceptors to discuss student or cur-
ricular issues. This occurs in addition to the site visits that
take place every one to two years, depending on the level
of teaching experience of the preceptors at a site.
Some course directors and department chairmen worried
about a loss of departmental identity with this revised struc-
ture. Specific concerns stemmed from beliefs that coordi-
nated recruitment, where preceptors are provided with a full
list of courses and clerkships requiring student placements,
would lead preceptors to choose one course or clerkship over
another because of learner level or different time commit-
ments. To address this, OCER faculty and staff and course
directors and coordinators devoted significant time to as-
sessing the current programs and priorities of each course.
When recruiting new practices, the OCER strives to portray
all course options equally to new preceptors, which did not
occur under the previous department-based structure. The
course directors now have a broader institutional view,
which promotes a commitment to recruit enough preceptors
for all courses. New issues, such as varied compensation for
community preceptors in different clerkships, were also
brought to light and required resolution before further prog-
ress could be made. Establishing common goals and priorities
for services and communications with preceptors was also a
challenge, as each course director had already determined
these individually. We have addressed this by spending many
of the meetings of the Community Site Development Work-
ing Group and the Community-based Faculty Development
Working Group to develop processes and content agreed
upon by all but with enough flexibility to meet each course
directors needs.
Busy schedules and a geographically split campus have
made it difficult to schedule meetings and to ensure that all
key faculty members can participate. We have addressed
these difficulties by changing the meeting times for key
working groups to early or late in the day and by alternating
meeting sites and days to accommodate clinic schedules.
When it is not possible to schedule a time that can work
for all key faculty, then we ensure good communication
through one-on-one meetings and by circulating compre-
hensive meeting minutes promptly.
Without a centralized office that receives basic operating
costs from the medical school, a collaborative approach is
likely to be fragmented in its organization and success. Core
support for a centralized office reduced the vulnerability
caused by high turnover of department-specific faculty in
clinical courses and fluctuating waves of success with grant
funding, while not eroding the infrastructure needed to keep
619
 SUPPORT FOR COMMUNITY-BASED INTERDISCIPLINARY EDUCATION,
these important activities moving forward. A centralized of-
fice also supports a refocus of teaching faculty on their own
scholarly productivity so that promotion based on a teaching
career is more likely to be successful. Our community faculty
also view our office as a primary point of contact, and the
activities of the Community Education Preceptor Board as
well as discussions at faculty development workshops, site
visits, and regional meetings bring a consistency to the
voices of our community colleagues that assists in meeting
their needs as faculty and ensuring the quality of our edu-
cational programs.
It is clear that the U.S. health care system is continuing
to evolve. What is now managed care will probably tran-
sition into a different model for attempting to achieve cost-
and clinically-effective care. Our interdisciplinary collabo-
rative approach to achieving educational excellence in this
rapidly evolving setting will allow us to be more responsive
than reactive to the changes coming our way.
The authors gratefully acknowledge the valuable contributions of Dale S.
Gephart, MD, for his commitment to community-based education and the
consultation he provided in representing the views of community-based
teachers. They also thank Elaine Small for her assistance in the preparation
of the manuscript; the members of the Community Preceptor Education
Board for their contributions, which have shaped the program reported
here; and the community-based teachers, for their valuable efforts toward
improving medical students education.
REFERENCES
1. Matson CC, Ullian JA, Boisaubin EV. Integrating early clinical expe-
rience curricula at two medical schools: lessons learned from The Rob-
ert Wood Johnson Foundations Generalist Physician Initiative. Acad
Med. 1999;74 (1 suppl):S53S58.
2. Lasser DH, Chuman A, Ferrara E, Gurwitz J. Use of a mini-grant pro-
gram to stimulate generalist training at the University of Massachusetts
Medical Center. Acad Med. 1999; 74 (1 suppl):S30S35.
3. Colwill JM, Perkoff GT, Blake RL, Paden C, Beachler M. Modifying
the culture of medical education: the first three years of the RWJ Gen-
eralist Physician Initiative. Acad Med. 1997;72:74553.
4. Politzer RM, Hardwick KS, Cultice JM, Bazell C. Eliminating primary
care health professional shortage areas: the impact of Title VII gener-
alist physician education. J Rural Health. 1999;15:1120.
5. Lynch DC. Macro program evaluation: an approach to evaluating a
generalist physician initiative program. Acad Med. 1997;72:4112.
6. Wartman SA, Davis AK, Wilson ME, Kahn NB Jr, Kahn RH. Emerging
lessons of the Interdisciplinary Generalist Curriculum (IGC) Project.
Acad Med. 1999;74:299300.
7. Kahn NB Jr, Davis AK, Wartman SA, Wilson ME, Kahn RH. The
620 ACADEMIC MEDICINE, VOL. 77, NO. 7 / JULY 2002
CONTINUED
interdisciplinary generalist curriculum project: a national medical
school demonstration project. Acad Med. 1995;70 (1 suppl):S75S80.
8. Rabinowitz HK, Babbott D, Bastacky S, et al. Innovative approaches
to educating medical students for practice in a changing health care
environment: the National UME-21 Project. Acad Med. 2001;76:
58797.
9. Scherger JE, Rucker L, Morrison EH, Cygan RW, Hubbell FA. The
primary care specialties working together: a model of success in an
academic environment. Acad Med. 2000;75:6938.
10. Pringle D, Levitt C, Horsburgh ME, Wilson R, Whittaker MK. Inter-
disciplinary collaboration and primary health care reform. Can J Public
Health. 2000;91:858.
11. Pringle D, Levitt C, Horsburgh ME, Wilson R, Whittaker MK. Inter-
disciplinary collaboration and primary health care reform. Statement
from the Ontario Chairs of Family Medicine and Council of Ontario
University Programs in Nursing. Can Fam Physician. 2000;46:7635,
7714.
12. Grum CM, Richards PJ, Woolliscroft JO. Shifting medical student ed-
ucation to the outpatient setting: what are we losing? Acad Med. 1995;
70:447.
13. Council on Graduate Medical Education. Physician Education for a
Changing Health Care Environment. DHHS Publication HRSA-99-
18. Rockville, MD: U.S. Health Resources and Services Administra-
tion, 1999.
14. Irby DM. Teaching and learning in ambulatory care settings: a thematic
review of the literature. Acad Med. 1995:70:898931.
15. Walling AD, Sutton LD, Gold J. Administrative relationships between
medical schools and community preceptors. Acad Med. 2001;76:
1847.
16. Brooks WB, Orgren R, Wallace AG. Institutional change: embracing
the initiative to train more generalists, Acad Med. 1999;74 (1 suppl):
S3S8.
17. Gephart D, Donahue D, Orgren R, Brooks WB. Education Online: a
community preceptor computer network. Teach Learn Med. 1998;10:
2329.
18. Kollisch DO, Gephart D, Brooks WB, Gagne R, Allen C, Donahue D.
Engaging community faculty: impact of a preceptor education board
and computer network. Acad Med. 1999;74 (1 suppl):S70S74.
19. Pipas CF, Carney PA, Eliassen MS, et al. Development of a handheld
computer documentation system to enhance an integrated primary care
clerkship. Acad Med. 2002;77:6009.
20. Dietrich AJ. Center of Excellence in Family Medicine. HRSA funded
Predoctoral Training Grant in Family Medicine, 2000. [Grant awarded
to a faculty member.]
21. Fall L, Berman N, Olson A. HRSA funded Predoctoral Grant: Com-
puter-assisted Learning in Pediatrics Project (CLIPP), 2000. [Grant
awarded to faculty members.]
22. Carney PA, Pipas CF, Eliassen MS, et al. An analysis of students clin-
ical experiences in an integrated primary care clerkship. Acad Med.
2002;77:6817.
23. Carney PA, Pipas CF, Eliassen MS, et al. An encounter-based analysis
of the nature of teaching and learning in a family medicine clerkship.
Teach Learn Med. 2000;12:217.
24. Carney PA, Dietrich AJ, Eliassen MS, Pipas CF, Donahue DA. Differ-
ences in ambulatory teaching and learning by gender match of precep-
tors and students. Fam Med. 2000;32:6205.