Rationale And Special Features of Ambulatory Care Education

Core competencies for internal medicine can be learned efficiently in the office

The Accreditation Council for Graduate Medical Education (ACGME) recently proposed the following six competencies for internal medicine trainees:

  • Patient Care (that is compassionate, appropriate, effective)
  • Medical Knowledge
  • Practice-based Learning and Improvement
  • Interpersonal and Communication Skills
  • Professionalism
  • Systems-based Practice

Broadly speaking, each of these competencies is equally essential for practice in the hospital and the office. Some aspects of each competency are different in the hospital compared with the office, but significant components of each competency can be learned during training in either location. Physical examination skills as a component of patient care, for example, can be learned anywhere. The same is true for professionalism, most communication skills, and the vast bulk of medical knowledge. Where students receive their training for these core competencies, therefore, should depend partially on where training can be most efficient and effective.

Special features of the office setting make it uniquely attractive for learning the ACGME core competencies. Those features include greater responsibility in patient care, routine teaching at the bedside, one-on-one instruction with an experienced physician, and large numbers of patients. The Ambulatory Component of the Internal Medicine Clerkship seeks to capitalize on these opportunities.

Greater Responsibility in Patient Care. In the current paradigm for office-based instruction, students complete an initial assessment of their patient before presenting to an attending. They are expected to develop a preliminary assessment and plan, educate the patient, negotiate a treatment plan with the patient, and complete all necessary follow-up. In this paradigm, the student is the primary care giver, working under the close supervision of an experienced physician. The student's role in patients care is constantly being adopted to his or her preparedness, skill, and demonstrated competence. This compares to the typical hospital setting where a third-year student is usually not the first person to see a patient and obtains less ownership over his or her patients. Greater responsibility and accountability typically translates into higher motivation to learn and rapid skill acquisition.

Bedside Teaching. In office-based precepting bedside teaching is an inextricable part of routine education and good patient care. The student may accompany the attending as a passive observer. Alternatively, if the student sees the patient first, the attending may later join them to speak directly with the patient, verify the history, confirm physical findings, or observe the student's performance. Attending physicians virtually never allow patients to leave an office having been seen only by a student.

In contrast, bedside teaching may be less routine during inpatient rotations.; During inpatient rotations, furthermore, bedside teaching customarily involves one attending with a group of students and houseofficers Typical practice-based precepting is a more direct interaction between one attending and one student.

Bedside (or tableside) teaching is an excellent technique to help students acquire new skills in interviewing and examination. Attending physician may coach students in practicing specific new skills, or students may observe their effective use by a mature physician. In every meeting between a student, patient, and attending, the attending has a convenient opportunity to demonstrate attitudes that are essential to successful patient care. They include the attitude that diagnostic and treatment strategies must be negotiated with each patient to assure they are in line with the patient's values and health beliefs.

Observation of students is a key component of effective clinical education. As a component of bedside teaching preceptors in this clerkship will routinely observe students performing the skills they are attempting to acquire, particularly interviewing and physical exam. To preserve work flow in the office, observation will usually be brief and focused on skills. For example a preceptor may observe just the first few minutes of an interview before leaving the student on his or her own. Observation is necessary as a basis for assessment, feedback and skill improvement.

One-On-One Instruction with an Experienced Physician. Office-based teaching for third-year medical students is appropriately described as an apprenticeship. One student works with one physician (at a time) who has the opportunity to identify the student's immediate and long-term learning needs, address them, and monitor progress The apprenticeship model has the advantage of supporting learning plans that are tightly matched to the student's particular learning needs. Students receive directed coaching for rapid skill development.

Within the context of this apprenticeship, students learn both the craft and the culture of medical practice. Craft refers to the cognitive, linguistic, interpersonal, and physical skills required for practice. Culture refers to the values, attitudes, and relationships that characterize mature medical communities. Within the context of the apprenticeship, student may observe how values and attitudes are verbalized and translated into patient care by their teachers. They may observe how their teachers interact with colleagues and the broader medical community. Through these role models, the students themselves may be challenged to grow into individuals who are better prepared to meet the needs of their patients.

Large numbers of patients. Over the course of a typical month in ambulatory care internal medicine, a student may be expected to complete an independent assessment on at least 64 patients. If the student's practice site attracts a suitable spectrum of patients, he or she will encounter an enormous variety of diseases, physical findings, and management challenges.