Ambulatory Medical Education Research Articles

Fitting It All In: An Interactive Workshop for Clinician-Educators to Improve Medical Education in the Ambulatory Setting.

Despite the demonstrated benefits that ambulatory teaching has for patients, learners, and preceptors, there have recently been significant reductions in time allocated to bedside teaching. In response to this decline, multiple techniques have been developed to improve the ability of clinician-educators to teach effectively within busy learner-focused continuity clinics. This 90-minute interactive workshop helps participants improve their ability to effectively teach in the ambulatory care setting. The session opens with learners exploring the benefits of and barriers to ambulatory teaching within their unique environment. Two evidence-based techniques are then presented: the Five Microskills model and Summarize, Narrow, Analyze, Probe, Plan, Select (SNAPPS) model. Participants analyze videos depicting these techniques, then practice in structured role-plays. Participants then revisit their initial reflections and discuss ways to both overcome common challenges and integrate the newly learned skills into their roles as clinician-educators. This workshop has been presented five times at academic medical centers, at a medical school in the U.S. during departmental and divisional grand rounds, and at an internationally attended medical education conference. Institutional survey data are available from 98 learners. Over 90% of respondents rated the session very good or excellent. Comments suggested the need for more detailed techniques to overcome barriers and additional time for practice. These suggestions have been included in the current session. This interactive workshop is designed for clinician-educators in ambulatory medical education. It has been well received in a variety of national academic settings and modified to be applicable in a variety of educational environments.

A Review of Learner Impact on Faculty Productivity

A Review of Learner Impact on Faculty Productivity

A shift to ambulatory medical education in Israel

The Council for Higher Education in Israel published an extensive report in 2007, calling for a significant increase of undergraduate medical education in Israel in ambulatory care settings. The objective of this article is to propose an action plan aimed at shifting undergraduate medical education in Israel towards ambulatory education. The main barriers to increasing ambulatory education in Israel are lack of academic recognition for teaching and excellence, conflict between patient care, income and teaching, lack of an adequate educational infrastructure and faculty in ambulatory care, and insufficient support and involvement of the health organisations. However, there is great potential for developing ambulatory education in Israel based on existing resources: Israel has a well-established primary care network, has chronic disease management programmes, community-based preventive medicine and health promotion activities, and an emerging structure for home, palliative and terminal care in the community. The proposed action plan presents a framework for enhancing ambulatory education in undergraduate medical education in Israel, and allows site-specific adjustments according to the preferences, resources and capabilities of each of the four medical schools. A national shift to ambulatory education in Israel can be implemented through the existing coordination mechanism of the four medical schools. A government funding policy that encourages the collaboration between four medical schools will be beneficial both in terms of resource utilisation and the engagement of other stakeholders. The recognition of community services and educational excellence can be advanced by establishing academies of teaching scholars.

Opinions of physicians about the content relevance of M.D curriculum and their professional needs

Background and purpose: Medical education is a complex process that intends to train the students in situation like they should work in future such as hospital, clinics, health care center and theire oficess. So, first, it should be clear that, how much the curriculum of medical education meets the professional needs. Method: Questionnaires were designed and distributed among 125 physicians (GP) with one to tow years experience. The questionnaire scaled from 1 to 10 (at least relevance to the most relevance). Results: General practitioners graded the relevancy of content of medical curriculum to professional needs as 7.03±1.56 . They mentioned that the ratio of ambulatory medical education to bedside one was nearly 2.5 to 1 . Approximately 73% of them pointed that their needs to ambulatory education were fulfilled: low and very low. Whereas 71% of them mentioned that the amount of fulfillment of bed side education were: enough and very enough. Conclusion: This study showed that the contents of medical curriculum are not completely relevant to GP needs, especialy in basic science. The recommendation is that there needs to be a shift in the emphasis from hospital to the community, and particularly to ambulatory centers. Keywords: MEDICAL EDUCATION, PROFESSIONAL NEEDS, CURRICULUM, OPINION.

The Impact of Emergency Medicine Student Clerkships on Ambulatory Medical Education: An Encounter-based Analysis

The Impact of Emergency Medicine Student Clerkships on Ambulatory Medical Education: An Encounter-based Analysis

Ambulatory rounds: a venue for evidence-based medicine.

The format of inpatient morning reports and ward rounds is infrequently applied in ambulatory medical education. Published reports, however, suggest that this format provides for learner-centered, case-based discussions rather than topic-based lectures in the ambulatory setting.(1) We developed an ambulatory morning report with the specific objective of enhancing evidence-based medical inquiry among our pediatrics housestaff. We developed a pediatric encounter form (PEF) by adapting and modifying an instrument described by Paccione et al.(2) The PEF was to be used by residents to document pertinent information and unanswered questions about patients seen during each ambulatory clinic session. Prompts were provided for documenting the patient's primary complaints, the patient's disposition, and questions that the resident needed answered. The PEF was piloted among a group of residents and faculty. The final version incorporated both resident and faculty input. Each resident was asked to complete a PEF for a maximum of two patients per clinic session. We did not direct residents as to what types of questions to formulate. All completed forms were maintained in a central folder. Next, we instituted a one-hour "Ambulatory Rounds" seminar once a week at lunch-time. During these seminars, faculty selected PEF cases from the previous week for discussion. Residents presented the cases and discussed the reasons behind the formulation of their questions. Faculty facilitated and guided residents toward resources for answering their questions. Faculty also helped residents to reformulate their questions to reflect an evidence-based medicine approach. At the end of each seminar, residents elected to research specific questions and present brief reports at the next seminar. To test the hypothesis that residents will formulate a higher proportion of evidence-based medicine (EBM) questions over time, we collected and analyzed 445 questions asked by 12 residents between July 2000 and August 2001. We categorized questions into EBM and non-EBM questions based on faculty assessment. We performed a trend analysis using chi-square to compare questions from July 2000 (as reference value) with the six-month periods of August 2000 to January 2001 and February to August 2001. By the end of the observation period, the proportion of EBM questions had significantly increased from 13% in July 2000 to 28% in the first six-month period and 59% in the second six-month period (p < 0.001). We describe a new application of outpatient morning reports. This format has been very well received. Housestaff gave the ambulatory rounds an average rating of 4.3 (out of 5) on a Likert scale. Our experience suggests that this format not only provides a forum for case-based learning but can be successfully used to enhance the principles of evidence-based medicine among residents.

A collaborative model for supporting community-based interdisciplinary education.

Development and support of community-based, interdisciplinary ambulatory medical education has achieved high priority due to on-site capacity and the unique educational experiences community sites contribute to the educational program. The authors describe the collaborative model their school developed and implemented in 2000 to integrate institution- and community-based interdisciplinary education through a centralized office, the strengths and challenges faced in applying it, the educational outcomes that are being tracked to evaluate its effectiveness, 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 recruitment, 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) monitored the effectiveness of community-based education programs by tracking product yield and cost estimates needed to generate these programs. The model's 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 community-based preceptors were fulfilled in 2000. The current 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, manuscripts, presentations) in research and academic scholarship 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.

Ambulatory medical education: teachers' activities, teaching cost, and residents' satisfaction.

To assess faculty activities and costs in supervising ambulatory patient care at a family practice clinic, and to assess resident satisfaction with access to ambulatory care teaching. This time-and-motion study was conducted in 1993 over two three-week periods (at the end of one academic year and at the beginning of another) in a family practice clinic affiliated with the University of Iowa College of Medicine. Observers recorded time spent by 14 faculty on teaching and non-teaching activities. Thirty-two residents were surveyed about their satisfaction with access to teaching. Over 59 half-days, 2,644 faculty service events were recorded; 47% were teaching events (supervising care delivered by residents) and 53% were non-teaching events (providing care for other clinic patients). Mean teaching time was greater for first-year residents; they consulted faculty more frequently and required more teaching time per consultation. The most common non-teaching activities were telephone calls out, telephone calls in, and inquiries from nurses and office staff. Ten percent of non-teaching activities interrupted teaching, and 17% of the residents reported their teaching had been interrupted. Eighty percent of the residents were satisfied with their access to teaching, but 12% reported they had had to postpone discussing pressing patient problems. Resident dissatisfaction correlated with longer perceived waiting time, interruption of teaching, and faculty inaccessibility. Faculty should plan to spend two to three times longer to teach lower-level residents than upper-level residents. By delegating some non-teaching activities to other personnel, faculty can reduce teaching costs and increase resident satisfaction.

Practical Approaches to a Major Educational Challenge

Medical schools and residency training programs are recognizing the need to expand education in ambulatory medicine. Inpatients wards increasingly provide treatment for only the most critically ill patients and are required only for very specialized procedure-oriented technology. Most diagnostic and management decisions are being made in outpatient settings. This shift in where medical care occurs has led to a reassessment of the educational value of training students and house staff primarily on hospital-based wards. New training initiatives in ambulatory medicine are being developed in medicine, pediatrics, and family medicine, and the principal sites for most of this training are primary care offices, clinics, and health maintenance organizations. Program planners and individual preceptors are confronting numerous obstacles in their efforts to find effective solutions to the dilemmas raised by the need to train large numbers of students in these settings. This article will explore many of these obstacles, including the unique learning requirements of third-year students, the elements of a quality clinical training environment, and the precepting skills needed for this educational task. Finally, we propose for debate a model for ambulatory medical education that focuses on strengthening the ties between academia and the numerous training sites. By taking optimal advantage of academic and community attributes, we are more likely to be assured quality medical education, skilled teaching, and rigorous scholarship in ambulatory medicine.

Practical approaches to a major educational challenge. Training students in the ambulatory setting

Medical schools and residency training programs are recognizing the need to expand education in ambulatory medicine. Inpatients wards increasingly provide treatment for only the most critically ill patients and are required only for very specialized procedure-oriented technology. Most diagnostic and management decisions are being made in outpatient settings. This shift in where medical care occurs has led to a reassessment of the educational value of training students and house staff primarily on hospital-based wards. New train ing initiatives in ambulatory medicine are being developed in medicine, pediatrics, and family medicine, and the principal sites for most of this training are primary care offices, clinics, and health maintenance organizations. Program planners and indiviual preceptors are confronting numerous obstacles in their efforts to find effective solutions to the dilemmas raised by the need to train large numbers of students in these settings. This article will explore many of these obstacles, including the unique learning requirements of third-year students, the elements of a quality clinical training environment, and the precepting skills needed for this educational task. Finally, we propose for debate a model for ambulatory medical education that focuses on strengthening the ties between academia and the numerous training sites. By taking optimal advantage of academic and community attributes, we are more likely to be assured quality medical education, skilled teaching, and rigorous scholarship in ambulatory medicine. Arch Intern Med. 1995;155:897-904

The medical day hospital. A new concept in ambulatory medical education

The medical day hospital. A new concept in ambulatory medical education

Ambulatory medical education

This paper deals with the varied sites and teachers that can and should be used in educating residents and medical students in ambulatory care. A basic premise is that sites other than academic medical centers and teachers other than physician faculty members should be among those used. The paper describes how institutions have used non-traditional sites and teachers. Then, after emphasizing the need to choose settings according to curricular objectives, it discusses teaching sites, both hospital-based (general medical, specialty, and multidisciplinary clinics) and community-based (home care settings, rural clinics, nursing homes, and community clinics). Next it describes the array of current and potential teachers, which includes generalist and specialist physician faculty members, community physicians, residents, and allied personnel such as pharmacists and nurses. The paper also discusses forces resisting and supporting the use of new sites and teachers. It ends with general recommendations.

The costs and financing of ambulatory medical education.

The costs and financing of ambulatory medical education.

An ambulatory medical education program for internal medicine residents

Teaching the fundamentals of ambulatory medicine has many well known difficulties. An education program with specific topics covered and modeled after continuing medical education programs for practicing physicians was instituted for residents in a university hospital clinic and was evaluated. The program was effective in improving the residents' knowledge, in enhancing their attitudes toward the clinic, and in improving their performance of influenza vaccinations. No adverse effects of the program were found. This approach, in which a curriculum is carefully defined and participation of the house staff is required, makes the ambulatory medical education process more accountable for what is taught.