Components of an Active Learning Environment ( We hypothesized that residents could develop and implement a successful practice guideline as a way of gaining quality improvement experience. We studied their guideline development process and evaluated the effect of their guideline on patient care. METHODS: We asked a group of nine resident volunteers to develop a clinical guideline on a topic of their choice. The hospital funded the effort, extended after-hours availability to guideline-related diagnostic services and provided a nurse coordinator. We observed the process of guideline development, tracked guideline utilization, and measured physician satisfaction with it after six months of use. We also compared admission rate, length of stay and resource costs for a cohort of patients before and after guideline implementation. RESULTS: The residents selected acute chest pain evaluation and developed an evidence-based guideline. They focused on risk stratification and rapid diagnostic testing. They streamlined documentation by developing evaluation templates that substituted for written notes and orders. When applied to 319 patients 30 and older presenting with acute chest pain, 49% were classified as``possibly cardiac'' of which 41% were considered``high suspicion'' and 59%``low suspicion.'' An acute cardiac diagnosis was made in 12% overall (24% of possibly cardiac, 46% of high suspicion and 9% of low suspicion). This cohort of 319 patients was compared to 150 chest pain patients evaluated before the guideline was implemented. Median length of stay and cost of care both decreased by 34%. Admission rate was unchanged. Physician satisfaction with the guideline was uniformly positive six months after its implementation. Physicians rated 24-hour availability of a nurse ± coordinator and after-hours functional testing particularly highly. Guideline utilization remains high more than two years after its implementation. CONCLUSION: Resident physicians were the key participants in developing and implementing a successful clinical guideline that enjoys ongoing use. By experiencing the success of their own efforts, residents learned important lessons about quality improvement. Such experiences are an important addition to resident education and to the quality of care at academic health care centers. We asked students if they owned a computer with Web access, how many of their clinical sites had Web access, their level of comfort finding and using Web medical sources before and after the clerkship and the overall value of the site to their learning. A forward stepwise linear regression model was built to predict comfort and satisfaction in the use of the Web site as a learning resource. RESULTS: We surveyed 147 students (98% response rate) of whom 64% owned their own computer. On a scale of I to 5 (5= extremely valuable), 88% of students rated the value of the Web site > 3. While 76% were extremely or somewhat comfortable finding and using Web resources before the clerkship, 90% (p < .0001) reported the same at the end. The site was accessed on a weekly or greater basis by 58% of the students. Although 13% of the students experienced no clinical sites with Web access,61% had 1 or 2 sites with access and 26% had 3 or 4 sites with Web access. In a stepwise linear regression model, comfort in using Web medical resources at the end of the rotation was best explained by comfort in using the Web before the rotation, owning a computer and the number of clinical sites that had Web access (R2 =.48).