Appendix 1: Selected Quotes from Monthly Student Feedback Surveys (edited for grammar)

Theme / Class / Quote
Continuity / M2 / [In one visit], there simply wasn't enough time to adequately explore [a patient's] past medical history and also discuss lifestyle changes for the future. We made some good headway but ultimately there was a lot of information yet to be covered and I was getting the feeling that it was a lot for the patient to take in already. The ECMH experience will allow me to see this patient again and focus on providing the continuity of care that will be essential for his long-term management.
Continuity / M3 / As I see/call/visit the same patients week to week, they are beginning to see me as their "doctor." This new sensation is not something I ever valued before, or ever thought I would value, but it is turning out to have a large impact on my decision of what specialty to pursue.
Continuity / M3 / I had a patient who was hospitalized during the entire month of January, so I was able to see up close the details of her complicated inpatient course, and now will be able to try and pick things up again after discharge. It's almost like watching an ER admission coming to the medicine floor, but in reverse--you're watching things on the inpatient side knowing that the discharge is coming, so you're planning and thinking about what needs to be done "on the other side" once the hospitalization ends. Being on both sides like this gives you a deepened appreciation for how crucial primary care management and care coordination is for people with chronic illnesses.
Continuity / M3 / The most unique parts of the ECMH experience thus far have been the opportunity (and responsibility) to meet with the same patient in multiple different settings, and the obligation to learn how to be a continuity provider instead of an acute care provider. Being able to see in person the outcomes, both positive and negative, of primary care has been incredibly valuable and humbling. Overall, this experience is making our medical education a far more complicated, but far richer and, most importantly, a far more realistic experience of what a life spent using medicine to care for people truly is like.
Continuity / M3 / Over the last few months I've taken the time to get to know [my patient] and build a relationship. Each visit we've chipped away at one problem or another. At our last visit her hemoglobin A1C was 6.8%, down from above 9 earlier in the year; she was taking her blood pressure medication daily; and she is now eating fewer bags of peanut M+Ms and walking a few miles each day. At the end of the visit I was proud to have her as one of my patients and to have seen the progression in her health status. I felt ownership for her as a patient. In the coming months I hope to be able to focus on some of her other problems to continue to improve her health outcomes.
Peer teaching / M1 / The ECMH allows for the cooperative interactions of all the classes. Last week the M4s were asking the M1s about anatomy and basic physiology at the same time that the M1s were wanting clarification of the medications that were being used to treat the conditions [we saw in clinic].
Peer teaching / M2 / A couple of weeks ago, we had our sensitive exams for our PEX course. I had my pelvic exam class the day after being in clinic, and so while we were there, I had asked one of the M3s to show me how to properly use the speculum. It was great having the chance to learn from the upperclassmen, and having worked with them all year, we have developed very much of a sibling relationship. I think that all of the M1s/M2s are comfortable asking any of the M3s/M4s for help/advice, and peers outside of the ECMH program are constantly telling me how much they wished they knew more of the upperclassmen. I feel privileged to have developed a close relationship with the upperclassmen at my clinic.
Peer teaching / M4 / As a fourth year medical student, I have had the opportunity to work closely with medical students from other classes during my experience at ECMH. It has provided a unique vantage point from which to view my education as an M4. Interacting with first years allows me to remember how it feels to see your first patient in a clinical setting and the anxiety that getting a patient's history provokes. In addition, I have marveled at the dedication of all the medical students who work hard on their patients' behalf and strive to bring the best care to those patients that we see. Regardless of their class (M1- M4), our shared mission to treat our patients and teach each other has made the experience very rewarding.
Peer teaching / M4 / I definitely feel the M1s in our ECMH are significantly more comfortable doing all of those things than I was as an M1, and I think that's largely due to ECMH being a great incubator for M1s to get focused clinical experience with a lot of guidance from upperclassmen and a clinical preceptor.
Care Coordination / M3 / I have been most affected by "outside the clinic" follow-up for patients. Being involved in calling patients to see how recommendations we made at their last visit are being implemented truly makes me feel like part of a healthcare team and makes me more aware of the obstacles involved in practically addressing barriers to healthcare.
Care Coordination / M4 / Last week I served as the Provider of the Week at PCC Austin and for the first time I began to understand the logistics that are necessary to keep the clinic running. I had to figure out when patients needed to be scheduled for follow-up and then call patients to schedule an appointment. I realized how easy it could be to lose track of a patient and not see them for a year when they should have followed-up only a few weeks later. There are many valuable lessons to be learned from the non-medical aspects of patient care and unfortunately we do not have these opportunities as part of a traditional curriculum.
Early Clinical Experience / M1 / I am being exposed to so many new problems, conditions, and diseases that I would otherwise not be exposed to. Topics I have seen in clinic are reinforced in other portions of my M1 curriculum, and when we cover in class something that I have observed in a clinical setting, I feel slightly ahead of the curve.
Early Clinical Experience / M2 / During the interview, the patient admitted that she is a smoker, even though she feels guilty for doing it and has intentions to stop. The team engaged in motivational interviewing, elucidating reasons that might help her stop smoking, as well as ways that might make it easier to do so. She agreed to set a quit date and set her plan into action. At the time of a follow up phone call, the patient had been smoke-free for 3 days. Without the ECMH experience, we would not have been able to coach a patient on behavioral change, and be able to follow up with her progress, which has been successful thus far.
Health Care Systems Awareness / M4 / We've been given opportunities to learn about quality in medical school. There are many classroom sessions and discussion groups, but until now it has come with little practical application. I am excited about the opportunity to learn about quality through actually measuring it in our clinic. I think that we will learn a great deal about the logistics and management of assessing outpatient quality of care, and it is exciting to think that we may be able to measure the "clinical performance" of medical students not just by their evaluations but also by their patients' health.
Lifestyle change / M4 / I am a fourth year student nearly done with all required clerkships. I have never had an experience like this. I have been invested in patients before, but not on a long-term basis, and I understand the power of lifestyle changes after seeing such a dramatic difference in this patient.

Appendix 2: Sample Quality Indicators Selected for an ECMH Quality Report Card

Indicator
Last office visit <90 days
BMI measured and <30
Blood Pressure on last visit
CAD on anti-platelet agent
CAD & prior MI on beta blocker
CAD on statin
Prior Ischemic event and LDL <100
CHF (EF <40%) on ACE inhibitor
CHF (EF <40%) on beta blocker
Atrial Fibrillation on anti-coagulation
Diabetes and eye exam last 12 months
Diabetes and foot exam <12 month
Diabetes and A1c test in last 12 months
Diabetes and A1c <8
Diabetes on home insulin with evidence of home glucose monitoring
Diabetes and nephropathy screen or Rx <12mths
Diabetes with LDL < 100
Depression screen <12months
Tobacco screen & intervention at last visit
Breast Cancer Screen <12 months
Colon Cancer Screen up-to-date
Cervical Cancer Screen up-to-date
Annual flu shot
Pneumococcal vaccine for Age >65 or chronic condition
Asthma on appropriate medication for severity
Number of ER visits last 1year
Number of Hospital admissions last 1year
Re-admission to hospital within 30 days
Follow-up visit within 10 days of hospital discharge