Rationale and Special Features of Ambulatory Care Education

You are about to spend a month learning internal medicine in the office setting. You may be placed in a subspecialty practice for a portion of your time, but your main assignment will be in general internal medicine/ primary care. A strong system of primary care is an essential platform for a modern health care system. In the U.S., however, the system is struggling to meet the needs of our changing population. Policy makers and professional groups are calling for significant restructuring in primary care finance and delivery. In these circumstances of crisis and evolution, the importance of training in the ambulatory care environment is particularly important for physicians who will inherit and shape our health care system.

To see the full spectrum of patients who visit internists and to learn the full spectrum of skills required for the practice of internal medicine, students must be educated both inside and outside the hospital. Among all encounters between internists and patients, about 10% occur in the hospital and 90% occur in the office or other outpatient location. This simple ecological fact underlies the strongest rationale for ambulatory care education. Students need to be where the patients are.

Typical patients who visit internists outside the hospital are adults who seek diagnosis and treatment for acute symptoms, care of chronic conditions, or health maintenance.

Patients Seeking Diagnosis and Treatment of Acute Symptoms:

The most common symptoms include headache, fatigue, abdominal pain, weight loss, diarrhea, dizziness, dysuria, chest pain, shortness of breath, cough, insomnia, malaise, back pain, and rhinitis. Most patients who present with one of these will be found to have a readily treatable condition. Only a minority will require hospitalization. To learn to diagnose and treat common symptoms, students must work in clinics and private practices.

Patients Seeking Management of Chronic Conditions:

Among the chronic conditions for which patients see internists, some rarely cause hospital admission and will not be seen by students during hospital clerkships. Examples include rheumatoid arthritis, venereal disease, osteoarthritis, dementia, thyroid disease, asthma, hypertension, and allergic rhinitis.

When chronic diseases do precipitate hospital admission, the emphasis of physicians' care is on short-term management. The goals and principles of short term management are often very different from the goals and principles of definitive, long-term management. For example, when a diabetic patient is hospitalized, the reason is usually ketoacidosis, nonketotic hyperosmolar coma, another severe complication, or a comorbid illness. In the hospital, care is then directed toward restoring homeostasis or treating the comorbid condition. Definitive long-term treatment of diabetes is not emphasized. In office-based care, however, long-term care is the physician's principal concern. Students who work in offices, therefore, have an excellent opportunity to learn about glucose monitoring, insulin adjustment, diet, exercise, and special health maintenance protocols for diabetics.

Patients Seeking Disease Prevention:

A principle concern for many patients who visit internists is disease prevention. The spectrum of preventable conditions is broad and includes prevalent chronic diseases such as breast cancer, lung cancer, colon cancer, coronary artery disease, osteoporosis, emphysema, and AIDS. The scientific literature on the effectiveness of putative prevention modalities is abundant and, often, conflicting. To meet patient's expectations for clear, authoritative guidance on disease prevention, physicians must be well-informed, skilled in critical appraisal of the literature, and skilled at negotiating treatment plans with patients who may have distinct preferences and values. Disease prevention is a major intellectual and humanistic challenge for modern internists. It is an area of medicine that is not emphasized or conveniently taught in hospital-based curricula, but which must be a major focus of a practice-based curriculum.

Chronic and acute conditions manifest a spectrum of severity from mild or early to severe or advanced. Only patients with severe forms of an acute illness or uncompensated exacerbations of chronic illness typically enter the hospital. To see the full spectrum of patients including those who are not yet diagnosed, newly diagnosed, or successfully managed, students must learn in clinics and private offices. Not all patients with coronary artery disease have heart failure. Not all patients with HIV disease have disseminated MAI. Not all patients with breast cancer have metastatic disease. The challenge for educators is to create clerkships in which students can develop accurate impressions of the spectrum of illness in these and other common chronic conditions.

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.

To be effective in the ambulatory care internal medicine, generalists and subspecialists need skills that pertain broadly to the organization and delivery of office-based and community-based care. These key skills are best taught where they are applied – in the office. Such skills include:

  • orchestrating a brief office visit,
  • maintaining an office record,
  • working with other members of the office-based health care team,
  • assuring proper follow-up for acute and chronic conditions,
  • managing patient contact between visits,
  • making subspecialty referrals,
  • communicating with other health care providers and community health workers outside the office,
  • and performing quality assurance.

Internists are specially trained to care for patients with advanced, complex chronic illness (e.g. CRF, diabetes, advanced CHF, hypoxemic respiratory failure). Office-based management strategies for these sicker patients typically include frequent visits, between visit phone and e-mail contact, use of non-physician providers and home care agencies, and extensive patient self-monitoring. Medical students need to understand intensive office-based care and develop basic competencies in this area.

Internal medicine is the largest specialty in the United States. Among 820,000 active physicians, 216,000 (26%) are internists. Internists provide the bulk of medical care for adults, and conduct a large proportion of all clinical research in the US. At Yale, like most medical schools, the department of internal medicine comprises the largest number of faculty members. These physicians provide more patient care service, as measured in revenue, than any other department and bring in the most NIH research dollars.

Internal medicine comprises two broad areas: general internal medicine and 12 subspecialties. About 50% of internists are generalists. In recent years, generalists have tended to identify themselves either as ambulatory care physicians who practice primary care internal medicine in the office, or hospitalists who practice acute care internal medicine in the hospital. Some generalists still follow their patients from the office into the hospital, but this has become difficult for several reasons. Reimbursement for hospital visits is low when travel time between office and hospital is considered. Time away from the office to see a hospitalized patient may result in lost work productivity in the office or longer work hours. Short stays and intense activity in the hospital mean that it is advantageous to have the attending physician on-site. Effective acute care is sufficiently challenging to require special expertise.

In contrast to the situation for generalists, subspecialists, with rare exceptions (e.g., some invasive cardiologists), see patients both in the office and in the hospital. They are expected to provide subspecialty care to their patients when they become hospitalized.

Most health policy experts agree that an effective national health system should be based on a network of primary care providers. The essential function of these providers is to evaluate acute symptoms, manage chronic illness, and prevent disease. Under an effective primary care system, patients have rapid access to care before conditions reach advanced stages and overall disease burden is reduced by thorough management and prevention. Countries with advanced primary care systems and nationalized health care (e.g., Germany, the UK, and Italy), also control health care costs more effectively than other nations (e.g., the US). In the US, general internists provide most of the primary care for adults. Family physicians are also a very important source of adult primary care. For a more detailed discussion of the current state of primary care and future prospects, please see "Primary Care Internal Medicine" on the clerkship website.

The Ambulatory Component of the Internal Medicine Clerkship is designed to assure that students graduate from Yale with a thorough understanding of the organization and delivery of ambulatory care internal medicine, particularly primary care internal medicine. Health care delivery is somewhat regionalized within the US and even within each state, so the practical experience we provide to students will represent a sampling of sorts. Nevertheless, a thorough familiarity with ambulatory care internal medicine is a necessary foundation for almost any specialist. Surgeons, psychiatrists, pediatricians, neurologists, and other specialists all collaborate with internists in the care of individual patients and need to understand the capabilities of an internist and the conditions that make consultation most effective and efficient. Students who pursue careers in health policy, health administration, or health services research need a thorough understanding of our current health care system, its limitations and potential.

Student choice for specialty training after medical school is strongly influenced by experiences on clinical clerkships. Quality of teaching, patient care opportunities, practice environment, role models, and mentorship are all important as students seek to understand how their own interests would be served in a specific specialty. Because most internal medicine is practiced in the office setting, the ambulatory component of the internal medicine clerkship seeks to provide students with the experiences they need to understand the current practice and potential opportunities for a career in internal medicine.