A review of longitudinal community and hospital placements in medical education: BEME Guide No. 26

Figures & data

Table

Practice points

Longitudinal placements have been developed in contrast to more traditional shorter clinical placements and come in a variety of formats including longitudinal integrated clerkships (LICs). The major factors, or mechanisms, associated with their effectiveness, appear to be continuity of patient care, quality of participation, continuity of preceptor/mentor, learning environment and, where there are different types of placements within the same medical school, students feeling that there is equity in learning and assessment. Longitudinal placements enhance students’ understanding of patient-centredness, and the importance of the life perspective, family dynamics and social contexts of patients’ presentations. The immersion aspects of longitudinal placements reinforce the community of practice model and students, as adult learners, learn through experience and problem solving.

Table 1.  Inclusion and exclusion criteria

INCLUSION	EXCLUSION
• Medical students	• Health professional students other than medical
• Placements longer than 13 weeks	• Placements of less than 13 weeks
• Access to and continuity of patient population in same location and/or continuity of tutor/preceptor/mentor	• No continuity of patients and location and/or tutors
• Evaluation data relating to	• No evaluation data
effectiveness of placements	• Not in English
• In English	• Commentaries or opinion pieces

Table 2.  Citations from databases

Database	Total number of abstracts	Number of abstracts excluded	Duplicates	Number of full papers retrieved	Number of full papers excluded	Number of full papers coded
PubMed	441	369	1	71	39	32
Medline	201	151	50	0	0	0
CINAHL	97	78	15	4	3	1
EMBASE	512	444	63	5	3	2
WoK (Web of Knowledge)	428	349	72	7	5	2
TOTAL	1679	1391	201	87	50	37
Journal scan						16
TOTAL PAPERS IN REVIEW						53

Table 3.  Coding of included papers

Outcome evaluation	Rating level	Number of papers
Kirkpatrick	1 – student reaction	37
level	1/2a – student career intention	4
	2a – change in attitude	6
	2b – change in knowledge	24
	3 – change in behaviour	0
	4 – patient impact	1
	(Preceptor reaction)	1
Strength of findings	1: No clear conclusions can be drawn. Not significant	0
	2: Results weak/ambiguous but there appears to be a trend	7
	3: Conclusions can probably be based on the results.	31
	4: Results are clear and very likely to be true.	15
	5: Results are unequivocal	0
Overall	Poor	3
impression	Acceptable	27
	Good	19
	Excellent	4

Table 4.  Geographical location

Location	Number (n = 53)
UK	2
Other Europe	1
Asia	1
North America	34
N America + Australia	1
Africa	0
Australasia	14

Table 5.  Year of publication

Year	Number (n = 53)
2012	3
2011	6
2010	5
2009	5
2008	7
2007	3
2006	3
2005	2
2004	3
2003	0
2002	0
2001	2
2000	2
1990–1999	8
Pre-1990	4

Table 6.  Number of student participants in papers

TOTAL NUMBER undertaking placements and involved in evaluation	NUMBER of papers (n = 52)*	PAPERS
Fewer than 50	33	Bell et al. 2008; Berger & Schaffer, 1986; Couper & Worley, 2010; Denz-Penhey et al. 2004; Denz-Penhey & Murdoch, 2008; Frattarelli & Kamemoto 2004; Geyman et al. 1984; Hadac et al. 1979; Hamilton et al. 1998; Hauer et al. 2012; Hirsh et al. 2012; Konkin & Suddards, 2011; Lewin et al. 1999; McLaughlin et al. 2011; Mihalynuk et al. 2008; O’Brien et al. 2012; Ogur et al. 2007; Ogur & Hirsh, 2009; Oswald et al. 2001; Poncelet et al. 2011; Poole et al. 2010; Power et al. 2006; Ringdahl et al. 2009; Schauer & Schieve, 2006; Stagg et al. 2009; Walmsley et al. 2009; Walters et al. 2011; Wilson & Cleland, 2008; Worley & Lines, 1999; Worley et al. 2000, 2004, 2006; Zink et al. 2010b
51–100	8	Couper et al. 2011; Denz-Penhey & Murdoch, 2009; Denz-Penhey et al. 2004; Florence et al. 2007; Henley et al. 2000; Herold et al. 1993; von Below et al. 2008; Zink et al. 2008
101–200	4	Carney et al. 2005; Deterding et al. 1999; Lubetkin et al. 1999; Peters et al. 2001
Over 200	6	Denz-Penhey & Murdoch 2010; Halaas, et al. 2008; Prislin et al. 1998 (across 5 institutions); Verby 1988; Wee et al. 2011; Zink et al. 2010a
Not given/unclear	1	Lemon et al. 1995

Note: Teherani et al. (2009) includes data from preceptors only

Table 7.  Methods of evaluation data collection

Type	Number (n = 53)	Papers
Student surveys	22	Bell et al. 2008; Berger & Schaffer, 1986; Denz-Penhey et al. 2004; Hadac et al. 1979; Hamilton et al. 1998; Henley et al. 2000; Hirsh et al. 2012; Lemon et al. 1995; Lewin et al. 1999; Lubetkin et al. 1999; Ogur et al. 2007; Peters et al. 2001; Poncelet et al. 2011; Poole et al. 2010; Prislin et al. 1998; Ringdahl et al. 2009; Schauer & Schieve, 2006; Stagg et al. 2009; Verby 1988; von Below et al. 2008; Wee et al. 2011; Wilson & Cleland, 2008
Student 1:1 interviews	14	Couper et al. 2011; Denz-Penhey et al. 2004, 2005; Denz-Penhey & Murdoch 2008; 2009; 2010; Hamilton et al. 1998; Hauer et al. 2012; Konkin & Suddards, 2011; Oswald et al. 2001; Walmsley et al. 2009; Walters et al. 2011; Worley et al. 2000; Worley et al. 2006
Change in students’ attitudes	6	Bell et al. 2008; Florence et al. 2007; Hirsh et al. 2012; Konkin & Suddards, 2011; Ogur & Hirsh, 2009; Ogur et al. 2007
Student focus/small groups	9	Bell et al. 2008; Couper & Worley 2010; Couper et al. 2011; Lemon et al. 1995; Mihalynuk et al. 2011; Ogur et al. 2007; Peters et al. 2001; Poncelet et al. 2011; Wilson & Cleland, 2008
Direct observation of students in clinical environment	2	O’Brien et al. 2012; Peters et al. 2001
Student narratives/essays/case reports	3	Geyman et al. 1984; Ogur & Hirsh, 2009; Zink et al. 2008
Analysis of student performance during OSCEs	1	Zink et al. 2010b
Graduate surveys or career choice data	4	Florence et al. 2007; Halaas et al. 2008; Herold et al. 1993; Stagg et al. 2009
Staff interviews	8	Couper & Worley 2010; Couper et al. 2011; Denz-Penhey et al. 2004; Denz-Penhey & Murdoch, 2009; Peters et al. 2001; Teherani et al. 2009; Walters et al. 2011; Worley et al. 2000;
Staff surveys	6	Lemon et al. 1995; Lubetkin et al. 1999; Ogur et al. 2007; Poole et al. 2010; Power et al. 2006; von Below et al. 2008;
Patient surveys/interviews	2	Berger & Schaffer, 1986; Wee et al. 2011;
Student assessments (not necessarily comparison data)	24	Bell et al. 2008, Carney et al. 2005; Denz-Penhey & Murdoch, 2010; Deterding et al. 1999; Frattarelli & Kamemoto, 2004; Hirsh et al. 2012; Lewin et al. 1999; Lubetkin et al. 1999; McLaughlin et al. 2011; Ogur et al. 2007; Oswald et al. 2001; Poncelet et al. 2011; Poole et al. 2010; Power et al. 2006; Ringdahl et al. 2009; Schauer & Schieve, 2006; Verby 1988; Wee et al. 2011; Wilson & Cleland, 2008; Worley & Lines, 1999; Worley et al. 2000; Worley et al. 2004; Zink et al. 2010a, 2010b

Table 8.  Research design

Papers with comparison data	24	Bell et al. 2008; Denz-Penhey & Murdoch, 2010; Florence et al. 2007; Frattarelli & Kamemoto, 2004; Hauer et al. 2012; Herold et al. 1993; Hirsh et al. 2012; Lewin et al. 1999; McLaughlin et al. 2011; Mihalynuk et al. 2008; Ogur et al. 2007; Oswald et al. 2001; Poncelet et al. 2011; Poole et al. 2010; Power et al. 2006; Ringdahl et al. 2009; Schauer & Schieve, 2006; Verby, 1988; Wilson & Cleland, 2008; Worley & Lines, 1999; Worley et al. 2000; 2004; 2006; Zink et al. 2010a
Data collected pre and post placements	3	Bell et al. 2008; Hirsh et al. 2012; Wilson & Cleland, 2008
Data collected during/mid and post placements	13	Denz-Penhey et al. 2004, 2005; Denz-Penhey & Murdoch, 2009; Hauer et al. 2012; Lubetkin et al. 1999; Mihalynuk et al. 2008; O’Brien et al. 2012; Ogur et al. 2007; Oswald et al. 2001; Poncelet et al. 2011; Walters et al. 2011; Worley et al. 2000, 2006
Data collected post placements only	37	Berger & Schaffer, 1986; Carney et al. 2005; Couper et al. 2011; Couper & Worley, 2010; Denz-Penhey & Murdoch, 2008, 2010; Deterding, et al. 1999; Florence et al. 2007; Frattarelli & Kamemoto, 2004; Geyman et al. 1984; Hadac et al. 1979; Halaas et al. 2008; Hamilton et al. 1998; Henley et al. 2000; Herold et al. 1993; Konkin & Suddards, 2011; Lemon et al. 1995; Lewin et al. 1999; McLaughlin et al. 2011; Ogur & Hirsh, 2009; Peters et al. 2001; Poole et al. 2010; Power et al. 2006; Prislin et al. 1998; Ringdahl et al. 2009; Schauer & Schieve, 2006; Stagg et al. 2009; Teherani et al. 2009; Verby, 1988; von Below et al. 2008; Walmsley et al. 2009; Wee et al. 2011; Worley & Lines, 1999; Worley et al. 2004; Zink et al. 2008; 2010a; 2010b
Data collected more than 3 months following the placements	9	Denz-Penhey & Murdoch, 2008; Florence et al. 2007; Halaas et al. 2008; Herold et al. 1993; Mihalynuk et al. 2008; Ringdahl et al. 2009; Stagg et al. 2009; Verby, 1988; Worley et al. 2006

Table 9.  Case studies (placements with multiple papers)

Case study name	Number of papers	References
UWA: University of Western Australia rural clinical school	5	Denz-Penhey et al. 2004 Denz-Penhey et al. 2005 Denz-Penhey & Murdoch, 2008 Denz-Penhey & Murdoch, 2009 Denz-Penhey & Murdoch, 2010
HMS: Harvard Medical School – includes the HMS-Cambridge Integrated Clerkship (HMS-CIC) & Beth Israel Deaconess Medical Center (BIDMC) sites	5	Bell et al. 2008 Hirsh et al. 2012 Ogur et al. 2007 Ogur & Hirsh, 2009 Peters et al. 2001
PRCC: Parallel Rural Community Curriculum, Flinders University, Australia	8	Couper et al. 2011 Couper & Worley, 2010 Stagg et al. 2009 Walters et al. 2011
		Worley & Lines, 1999
		Worley et al. 2000
		Worley et al. 2004
		Worley et al. 2006
RPAP: Rural Physician Associate Program, Minnesota	6	Halaas et al. 2008 Power et al. 2006 Verby, 1988
		Zink et al. 2008
		Zink et al. 2010a
		Zink et al. 2010b

Table 10.  Format and length of placements

MODEL	FORMAT	EXAMPLES
A.	From between 1 evening or ½ day/week to 2 ½ days per week for between 6months to 1 year	Berger & Schaffer, 1986; Frattarelli & Kamemoto 2004; Geyman et al. 1984; Hadac et al. 1979; Hamilton et al. 1998; Henley et al. 2000; Lubetkin et al. 1999; Ringdahl et al. 2009; Wee et al. 2011
B.	About 4 hours/week for 2 years	Carney et al. 2005;
C.	One day per month for 2 years	von Below et al. 2008
D.	½ to one day/week for 3 weeks per month or weekly for 3 years	Deterding et al. 1999; Florence et al. 2007; Lemon et al. 1995;
E.	½ day/week for 4 years	Herold et al. 1993
F.	Full time for 7 to 9 months	HMS; Konkin et al. 2011; McLaughlin et al. 2011*; Poole et al. 2010; RPAP; Schauer & Schieve 2006;
G.	Full-time for 1 year	UWA; Hauer et al. 2012; Lewin et al. 1999; McLaughlin et al. 2011*; Mihalynuk et al. 2008; O’Brien et al. 2012; Poncelet et al. 2011; Teherani et al. 2009; Walmsley et al. 2009; Wilson & Cleland 2008.
H.	Full-time for more than 1 year	Oswald et al. 2001; Prislin et al. 1998**

*McLaughlin et al. (2011): includes three medical schools with slightly different formats.

**Prislin et al. (1998) includes five medical schools with different formats.

Table

Term	Acronym	Definition
Attachment		Location, supervisor or team, and time for an activity, which a medical student attends for learning purposes. Equivalent to ‘placement’
Block clerkship	BC	Time spent by medical students in a placement or attachment focussing on one specialty discipline, and usually followed sequentially by similar placements in other disciplines. Usually not longer than 8 weeks duration.
Block rotation	BR	Same as block clerkship
Clerkship		Time spent by medical students in a placement or attachment for experiential clinical learning
Continuity		(In the context of this paper) used more or less synonymously with ‘longitudinal’. Students have repeated, on-going contact with a clinician or clinicians/clinical team and their patient bases
Community Partnership Program	CPP	Longitudinal experience in rural Tennessee
Harvard Medical School	HMS
in-training evaluation reports	ITER	Reports providing assessment of student progress during clinical training
Immersion		Deep experience to exclusion of most other activities
Integrated		(In clinical education) Combining components of the medical course so that they are learned concurrently. Most often refers to either: biomedical sciences being integrated with clinical learning; or, clinical learning of all core specialist disciplines
Longitudinal		Involves a regular, recurrent placement in the same setting with the same preceptor (and thus with access to the same patient base) over a period of time.
Longitudinal integrated clerkship	LIC	Time spent by medical students in a regular, recurrent placement in the same setting with the same preceptor for experiential clinical learning of all core specialist disciplines concurrently
Mentor		(Often used interchangeably with supervisor or preceptor) person who guides, oversees and teaches medical students, particularly in clinical settings.
Objective structured clinical examination	OSCE	Practical examination of clinical skills widely used for formal assessment purposes in medical schools
Placement		Location, supervisor or team, and time for an activity, which a medical student attends for learning purposes. Equivalent to ‘attachment’
Patient practitioner orientation scale	PPOS	A tool used to measure attitudes to patient-centred care
Parallel rural community curriculum	PRCC	Rural LIC program at Flinders University South Australia
Preceptor		(Often used interchangeably with supervisor or mentor) person who guides, oversees and teaches medical students, particularly in clinical settings
Rotation		Time spent by medical students in a placement or attachment focussing on one specialty discipline, and usually followed sequentially by similar placements in other disciplines (hence the rotation of placements). Usually not longer than 8 weeks duration (often used synonymously with block clerkship/block rotation)
Rotation-based clerkship	RBC	Time spent by medical students in a placement or attachment for experiential clinical learning, structured as rotations
Rural physician associate program	RPAP	Rural LIC at University of Minnesota
Rural clinical school	RCS	Clinical school (for training in health professions) based in a rural area
Supervisor		(Often used interchangeably with mentor or preceptor) person who guides, oversees and teaches medical students, particularly in clinical settings
Tasks of medicine scale	TOMS	Tool used to assess prioritization of biomedical and psychosocial tasks in a patient encounter
Traditional track		Refers to the rotation-based clerkship which has long been, and still is, the commonest structure for clinical learning in medical schools
Topic review group	TRG	The group of academics who undertook this BEME review
Tutor		(Often used interchangeably with mentor, supervisor or preceptor) person who guides, oversees and teaches medical students, particularly in clinical settings. Often refers to person who works with a small group of students rather than one-to-one

Table

Authors	Source/ database	Journal	Year	Loctn	No of students in evaluation + number in comparison if applic	Students	No of others/non students	Year of prog	Location	Time	Yr began	Groups	Timing of eval	K level	Strength of findings	Grade of paper
Bell et al	J Scan	Acad Med	2008	N Am	8 + 18	volunteers	0	3	Hospital/ambulatory	Full yr	2005	Single + comparison	pre/post	1, 2a, 2b	3	good
Berger & Schaffer	J Scan	J Med Ed	1986	N Am	10 + 24	volunteers	0	2	Primary care	0.5 days a week for 9/12	1984	2 yr groups	post	1	3	acceptable
Carney et al	Pub Med	Acad Med	2005	N Am	155	required	0	2	Academic medicine clinic	4 hrs/wk for 2 yrs	2002	2 yrs, 3 sites	post	2b	4	excellent
Couper et al	Pub Med	MJA	2011	Aus/N Am	45 Aus; 7 N Am	volunteers	87 Aus 39 N Am	3	Rural	Full yr	1997/2008	2 sites	post	1	2	acceptable
Couper & Worley	Pub Med	RRH	2010	Aus	45	volunteers	87	3	Rural	Full yr	1997	Single year	post	1	3	excellent
Denz-Penhey & Murdoch	J Scan	Med Teach	2008	Aus	8	volunteers	0	5	Rural	Full yr	2003	2 yr groups	post	1	3	acceptable
Denz-Penhey & Murdoch	PubMed	Med Teach	2009	Aus	60 (of 62)	volunteers	27 acad 15 admin	5	Rural	Full yr	2003	single	mid/post	1	3	good
Denz-Penhey & Murdoch	PubMed	RRH	2010	Aus	245	volunteers	0	5	Rural	Full yr	2003	Multi yrs + comp	post	1. 2b	4	good
Denz-Penhey et al	J Scan	RRH	2004	Aus	21	volunteers	Staff	5	Rural	Full yr	2003	Staff & students – single yr	mid/post	1	2	acceptable
Denz-Penhey et al	WoK	RRH	2005	Aus	29 WA 25 SA	Volunteers	0	5	Rural	Full yr	2003	2 yrs 2 sites (WA & SA)	mid/post	1	3	acceptable
Deterding et al	Pub Med	Arch Ped Ad	1999	N Am	109 of whom 56 did self-assessment	required	0	1st 3 years	Community	0.5 days per wk, 3.52 per month	1996	1 yr group	post	2b	3	acceptable
Florence et al	Pub Med	J Rur Health	2007	N Am	58 of 84 + 72 of 168 comparison	volunteers	0	1st 3 years	Community	1/7 per week	1990–2002	Multi yrs + comparison	post	1, 2a career	2	acceptable
Fraterelli & Kamemoto	Pub Med	Am J Ob Gyn	2004	N Am	40 + 227	volunteers	0	3	Community	0.5 days per wk for 5/12	1995	Multi yr + comp	post	2b	3	good
Geyman et al	Embase	J Fam Pract	1984	N Am	44	elective	0	2	Family medicine	0.5 days per wk 9/12	1974	single	post	1	3	acceptable
Hadac et al	Pub Med	J Med Ed	1979	N Am	30	elective	0	2	Family medicine	0.5 days per wk 9/12	1974	single	post	1	2	acceptable
Halaas et al	Pub Med	Ed Rur Pract	2008	N Am	1175	Apply + interview	0	3	Rural	9/12	1971	Multi yrs	post	Career	3	acceptable
Hamilton et al	WoK	J Nat MA	1998	N Am	29	required	0	3 & 4	Primary care	0.5 days per wk for 40 wks	1995	single	post	1	2	poor
Hauer et al	J Scan	Med Ed	2012	N Am	29 + 25	Rank preference most receive 1st choice	0	3	Ambulatory clinics	Full yr		3 sites + comparison	mid/post	1	3	good
Henley et al	Pub Med	Acad Med	2000	N Am	97	required	0	2–4	Primary care	0.5 to 1 day per wk for 3 yrs	1986	Yr 3 & yr 4 students of 1 yr	post	1	2	acceptable
Herold et al	Pub Med	Acad Med	1993	N Am	93 + 108	volunteers	0	All 4	Community	0.5 days per wk	1987	Multi yrs + comp	post	career	3	poor
Hirsh et al	J Scan	Acad Med	2012	N Am	27 + 45	volunteers	0	3	Different venues of care	Full year	2004	Multi yr + comp	Pre/post	2a, 2b	3	good
Konkin & Suddards	Pub Med	AHSE	2011	N Am	25 of 33	volunteers	0	3	Community	9/12	2007	Multi yrs	post	1, 2a	3	acceptable
Lemon et al	Pub Med	Acad Med	1995	N Am	180 students per year but not clear how many evaluated	Volunteers for 1st 3 yrs, then mandatory	Evaluation includes staff but numbers not given	Yrs 1–3	Primary care	Variable over the 3 yrs	Mandatory from 1994	Multi yrs	post	1	2	poor
Lewin et al	Pub Med	Acad Med	1999	N Am	24 + 81	volunteers	0	1–3	Primary care	Yr 3 full year	1994	Single + comp	post	1, 2b	3	good
Lubetkin et al	Pub Med	Acad Med	1999	N Am	114	required	74/114 precept	1	Community	0.5 days per week	1996	single	mid/post	1, 2b	3	acceptable
McLaughlin et al	J Scan	Acad Med	2011	N Am	27 + 108	voluntary	0	3	Family medicine	9–12/12		3 sites 1 year + comp	post	2b	3	acceptable
Mihalynuk et al	Pub Med	Med Ed	2008	N Am	6 + 6	voluntary	0		Family medicine	Full yr		Single + comp	mid/post	1	4	acceptable
O’Brien et al	J Scan	Med Ed	2012	N Am	Dakota: 9 + 25 HMS: 10 + 50 UCSF: 16 + 39	Volunteers through ranking	0	3	3 different models	Full yr or block	1994 Dakota 2004 HMS 2007 UCSF	3 sites	mid/post	observed	3	acceptable
Ogur & Hirsh	J Scan	Acad Med	2009	N Am	14 of 38	volunteers	0	3	Urban ambulatory clinic	Full yr	2004	single	post	1, 2a,	3	acceptable
Ogur et al, 2007	J Scan	Acad Med	2007	N Am	8 + 11	volunteers	0	3	Urban ambulatory clinic	Full yr	2004	Single + comp	mid/post	1, 2a, 2b	3	excellent
Oswald et al	Pub Med	Med Ed	2001	UK	13 of 14	volunteers	0	3 &4	General practice	15/12	1993	Multi yrs + comp	mid/post	1, 2b	4	good
Peters et al	Pub Med	Acad Med	2001	N Am	103 of 132	required	0	3 & 4	Primary care	9/12	1997	single	post	1	3	acceptable
Poncelet et al	Pub Med	Med Ed	2011	Aus	23 + 206	Volunteers lottery	0	3	Family medicine	Full yr	2007	2 yrs + comp	mid/post	1, 2b	4	good
Poole et al	CINAHL	RRH	2010	Aus	19	volunteers	0	5	Rural	27/52	2008	Single + comp	post	1, 2b	3	acceptable
Power et al	J Scan	T Learn Med	2006	N Am	33 + 35	Selected volunteers	0	3	Rural	9/12	1971	Single + comp	post	1, 2b	3	good
Prislin et al	Pub Med	Acad Med	1998	N Am	429	Not clear	0	Variable	Primary care	12/12; 21/12; 44/12		5 sites	post	1	3	acceptable
Ringdahl et al	Pub Med	Fam Med	2009	N Am	40 + 128	Volunteers + selection	0	4	Family medicine	0.5 days per wk	1992	Multi yrs + comp	post	1, 2b	4	good
Schauer & Schieve	Pub Med	Acad Med	2006	N Am	29 + 296	volunteers	0	3	Rural	7/12	1998	Multi yrs + comp	post	2b	4	good
Stagg et al.	Pub Med	RRH	2009	Aus	46 of 86	volunteers	0	3	Rural	Full yr	1997	Multi yrs	post	career	4	acceptable
Teherani et al	J Scan	Acad Med	2009	N Am	0	Volunteers + lottery	27 precep	3	Ambulatory integrated clinics	Full yr	2007	single	post	Preceptor reaction	4	good
Verby	J Scan	J Med Ed	1988	N Am	462	volunteers	0	3	Rural	Full yr	1971	Multi + comp	post	1, 2b	4	good
Von Below et al	Pub Med	BMC Med Ed	2008	Eur	60 of 86	required	15 facil	1 & 2	Primary & secondary care	2 yrs	2001	Single yr	post	1	4	acceptable
Walmsley et al	Pub Med	Med Ed	2009	N Am	12 of 154	required	0	3	Primary care	Full yr	2006?	Single yr	post	1	4	good
Walters et al	Pub Med	Med Ed	2011	Aus	7	volunteers	21 GPs 4 pr man	4	Rural	Full yr	1997	Single yr	During/post	1	3	acceptable
Wee et al	Pub Med	Acad Med	2011	Asia	222/240	volunteers	355 patients	variable	Community	6/12 – x2 per wk and then monthly	2009	Single yr	post	2b, 4	3	acceptable
Wilson & Cleland	Pub Med	RRH	2008	UK	14	volunteers	0	4	Rural	Full yr	2006	Single + comp	Pre/post	1, 2b	3	acceptable
Worley et al	J Scan	BMJ	2004	Aus	40 + 331	volunteers	0	3	Rural	Full yr	1997	Multi yrs + comp	post	2b	4	good
Worley & Lines	J Scan	Med Teach	1999	Aus	8	volunteers	0	3	Rural	Full yr	1997	Single + comp	post	2b	3	acceptable
Worley et al	J Scan	Med Ed	2006	Aus	6 + 16	volunteers	0	3	Rural	Full yr	1997	Single + comp	During/post	1	3	good
Worley et al	Embase	Med Ed	2000	Aus	8	volunteers	0	3	Rural	Full yr	1997	Single + comp	During/post	1, 2b	3	good
Zink et al	Pub Med	JRH	2008	N Am	95	volunteers	0	3	Rural/family med	9/12	1971	Multi yrs	post	1	3	acceptable
Zink et al	Pub Med	Fam Med	2010a	N Am	201 + 1129	volunteers	0	3	Rural/family med	9/12	1971	Multi + comp	post	2b	4	excellent
Zink et al	Pub Med	Fam Med	2010b	N Am	8 high performers 8 low performers	volunteers	0	3	Rural/family med	9/12	1971	2 groups from single yr	post	2b	4	good

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