AMEE Guide No 26: clinical teaching in ambulatory care settings: making the most of learning opportunities with outpatients

A corporeal conundrum: Challenges posed by remote consultation for postgraduate medical education

BACKGROUND

The COVID-19 pandemic accelerated the use of remote consultation in hospital outpatient clinics. Remote consultation alters the clinical environment and the learning environment in ways that are incompletely understood. This research sought to explore how trainees negotiate training and learning in such an environment when it is novel to them.

METHODS

Purposive sampling was used to recruit eight doctors from the gastroenterology department of an academic teaching hospital. Four consultants and four trainees participated in individual, semi-structured interviews. Interpretative phenomenological analysis of interview transcripts was employed and themes developed from the analysis, to characterise the experience of learning and teaching in remote consultation clinics, as described by participants.

RESULTS

Participants described how they try to create mental representations of each patient they review by remote consultation. Whilst consultants found this task relatively easy, trainee physicians found remote consultation more challenging and highlighted the importance of the physical presence of the patient to help them form a holistic sense of the patient's condition. Doctors in training also struggled to develop a workable mental model of the patient's condition when physical examination was precluded by remote consultation.

CONCLUSIONS

This study highlights the place of the patient's physical presence as an essential educational stimulus to facilitate teaching and learning. Further research is needed to characterise the processes clinicians use to formulate mental models of patients who are physically absent from the consultation room.

Outpatient education, a momentous in clinical education: a qualitative study of medical students', faculty members', and residents' perspectives

BACKGROUND

Even though a lot of scholars have been looking at outpatient education lately because it has become more popular and they want to know about its successes, failures, and problems, we have not been able to find a complete study. Therefore, our study aims to gain a deeper understanding of the various aspects of outpatient education based on the actual experiences of medical students, faculty, and residents.

METHODS

Face-to-face and semi-structured interviews were used to collect data for this qualitative study. Until data saturation was reached, the interviews continued. A total of 21 participants from Shiraz University of Medical Sciences, including medical students, residents, and teachers, were enrolled. The Guba and Lincoln-first written standards for scientific accuracy in qualitative research were used to figure out how reliable the data were.

RESULTS

Fourteen categories were extracted from four main themes. The results show that four categories: "physical space and equipment," "prerequisites related to the curriculum," "teaching skills development," and "near-peer teachers" should be considered for outpatient education preparation. Theme 2, "implementation requirements," included "student dimension," "faculty's commitment to planning," and "program supervision." Theme 3, "challenges of outpatient education," was described by five related categories, including "curriculum implementation challenges," "student challenges," "faculty challenges," "system-related challenges," and "patient-related challenges." Finally, two categories emerged about facilitators of outpatient education: internal and external facilitators.

CONCLUSION

Outpatient clinics represent a crucial aspect of medical practice. To effectively leverage this resource, preliminary planning, considering all the prerequisites, paying attention to the implementation requirements, getting to know the challenges, and trying to solve them, especially with incentives, are essential.

Implementation of a Problem-Based Presentation Format to Improve Residents' Ambulatory Patient Presentations

Background

The format for residents to present hospitalized patients to teaching faculty is well defined; however, guidance for presenting in clinic is not uniform.

Objective

We report the development, implementation, and evaluation of a new standardized format for presenting in clinic: the Problem-Based Presentation (PBP).

Methods

After a needs assessment, we implemented the format at the teaching clinics of our internal medicine residency program. We surveyed participants on innovation outcomes, feasibility, and acceptability (pre-post design; 2019-2020; 5-point scale). Residents' primary outcomes were confidence in presentation content and presentation order, presentation efficiency, and presentation organization. Faculty were asked about the primary outcomes of resident presentation efficiency, presentation organization, and satisfaction with resident presentations.

Results

Participants were 111 residents and 22 faculty (pre-intervention) and 110 residents and 20 faculty (post-intervention). Residents' confidence in knowing what the attending physician wants to hear in an outpatient presentation, confidence in what order to present the information, and how organized they felt when presenting in clinic improved (all P<.001; absolute increase of the top 2 ratings of 25%, 28%, and 31%, respectively). Residents' perceived education in their outpatient clinic also improved (P=.002; absolute increase of the top 2 ratings of 19%). Faculty were more satisfied with the structured presentations (P=.008; absolute increase of the top 2 ratings of 27%).

Conclusions

Implementation of a new format for presenting in clinic was associated with increased resident confidence in presentation content, order of items, overall organization, and a perceived increase in the frequency of teaching points reviewed by attending physicians.

Challenges Facing Undergraduate Medical Education in Ambulatory Care Clinics at Tertiary Care Hospitals

Background: Medical education has been rapidly growing and transforming due to the enormous evolution of medicine. There have been many proficient ways to learn in medicine, but academic lectures, attending wards, and ambulatory care clinics (ACC) remain the three main ways of gaining clinical knowledge and experience for medical students. Over the past decade, there has been a dramatic shift in care by focusing on ambulatory care rather than inpatient settings, which provides a golden opportunity to reinforce medical education. Purpose: Most of the published studies that have focused on the teaching barriers in ACC were descriptive rather than analytic studies. Herein, we aim to detect and determine the barriers to teaching in ACC settings using qualitative analysis. Methods: This is a cross-sectional, observational study, involving medical students in their clerkship years (i.e., fourth and fifth) from two different medical colleges in Riyadh, Saudi Arabia. Faculty who are involved in undergraduate medical education in both colleges were also included. Main Results: A total of 387 medical students studying at the two universities were enrolled in the study. Most of the participants preferred attending outpatient clinics with consultants (44.2%) and the majority preferred attending internal medicine (IM) and IM subspecialties clinics (40.4%). Regarding the challenges, students believe the top three barriers are related to: faculty (39%), environment (34.8%), and patients (14.8%). Faculty on the other hand see that the top three barriers are related to environment (55.6%), patients (24.4%), and faculty (20%). Conclusion: Undergraduate medical education in outpatient settings has many challenges. In our study, the most significant challenges were COVID-19-related restrictions, patient refusal, and insufficient time for teaching. Future studies are needed to investigate these barriers and explore potential solutions that can decrease their burden on undergraduate medical education.

Applying Educational Theory to Optimize Trainee Education in the Ambulatory Virtual Care Environment

Virtual care (VC) encounters have become an essential part of outpatient clinical care. The theory of situated learning and legitimate peripheral participation posits that medical trainees learn best when they participate in authentic patient care experiences and engage effectively with their preceptors, members of the health care team, and the clinical learning environment. This theory can provide a framework from which to approach teaching in the VC setting, whereby preceptors may capitalize on the unique learning and assessment opportunities provided during VC encounters and optimize educational experiences for trainees as well as clinical outcomes for patients. In this monograph, we propose an approach grounded in situated learning and legitimate peripheral participation for teaching in the VC environment, particularly during real-time video visits.

Understanding the clinical reasoning processes involved in the management of multimorbidity in an ambulatory setting: study protocol of a stimulated recall research

BACKGROUND

Primary care physicians are at the very heart of managing patients suffering from multimorbidity. However, several studies have highlighted that some physicians feel ill-equipped to manage these kinds of complex clinical situations. Few studies are available on the clinical reasoning processes at play during the long-term management and follow-up of patients suffering from multimorbidity. This study aims to contribute to a better understanding on how the clinical reasoning of primary care physicians is affected during follow-up consultations with these patients.

METHODS

A qualitative research project based on semi-structured interviews with primary care physicians in an ambulatory setting will be carried out, using the video stimulated recall interview method. Participants will be filmed in their work environment during a standard consultation with a patient suffering from multimorbidity using a "button camera" (small camera) which will be pinned to their white coat. The recording will be used in a following semi-structured interview with physicians and the research team to instigate a stimulated recall. Stimulated recall is a research method that allows the investigation of cognitive processes by inviting participants to recall their concurrent thinking during an event when prompted by a video sequence recall. During this interview, participants will be prompted by different video sequence and asked to discuss them; the aim will be to encourage them to make their clinical reasoning processes explicit. Fifteen to twenty interviews are planned to reach data saturation. The interviews will be transcribed verbatim and data will be analysed according to a standard content analysis, using deductive and inductive approaches.

CONCLUSION

Study results will contribute to the scientific community's overall understanding of clinical reasoning. This will subsequently allow future generation of primary care physicians to have access to more adequate trainings to manage patients suffering from multimorbidity in their practice. As a result, this will improve the quality of the patient's care and treatments.

Interprofessional versus uniprofessional dyad learning for medical students in a clinical setting

OBJECTIVES

The aim of the present study was to explore and compare medical students' perceived learning outcomes when treating patients under supervision in two different learning settings: a uniprofessional or an interprofessional dyad.

METHODS

The design of the study is a qualitative interview study. Data were collected from October 2016 to June 2017 via semi-structured group interviews performed at the end of the clinical placement in an orthopaedic outpatient clinic for medical students in the last semester of the curriculum. In the placement, the students worked by turns in either a uniprofessional dyad with two medical students or an interprofessional dyad with a nursing student. The data from the interviews were analysed using Systematic Text Analysis.

RESULTS

Overall, 21 students were interviewed. The students appreciated the authenticity of dealing with real patient problems. Both dyads provided the possibility of working as a professional, but the interprofessional dyad had a more authentic setting. In both dyads, the students' interdependence and mutual support promoted the acquisition of knowledge and skills. Working in the interprofessional dyad facilitated relationships between the professions, and the medical students became aware of some of their own profession's strengths and weaknesses. The interprofessional collaboration contributed to different perspectives on the patients' course of treatment and led to a more holistic understanding of the treatment.

CONCLUSIONS

Interprofessional dyads have the potential to improve learning outcomes in the clinical training of medical students. Further studies are needed to explore the benefits across medical specialities and settings.

Barriers to outpatient education for medical students: a narrative review

OBJECTIVES

This study surveys medical education literature published over the last 25 years (1993-2018) to identify the factors scholars consider deleterious to outpatient teaching for medical students.

METHODS

This study conducts a review of medical education literature published between 1993 and 2018 using Medline, Lilacs, Ibecs, Cochrane Library, and Scielo databases. The following search terms were utilized: "Education, Medical, Undergraduate" AND "Ambulatory Care" AND "Teaching/methods" OR "Clinical Clerkship" OR "Preceptorship." This study focuses on papers describing deleterious factors for outpatient teaching with medical students and analyzes their results, discussions, and conclusions sections.

RESULTS

Of the 363 articles obtained, this study selected 33 for analysis. These papers identify numerous factors as barriers to outpatient education. For didactic purposes, these factors are categorized into four barrier groups: environment-institution, academic staff, students, and patients. Academic staff-related teaching barrier was the most frequently mentioned obstacle. Intense care schedule with little teaching time was considered the most common and relevant barrier to outpatient medical education, followed by inappropriate teaching environment and inadequate supervision model.

CONCLUSIONS

There is a lack of recent literature on studies focusing on barriers to effective outpatient medical education. Factors identified as harmful to outpatient education have been pointed out by course directors, academic staff, and students in the literature. However, many of these factors remain overlooked by educators, who can use these factors to modify their academic activities for more effective results.

Deliberate teaching tools for clinical teaching encounters: A critical scoping review and thematic analysis to establish definitional clarity

PURPOSE AND METHOD

We conducted a scoping review of tools designed to add structure to clinical teaching, with a thematic analysis to establish definitional clarity.

RESULTS

Six thousand and forty nine citations were screened, 434 reviewed for eligibility, and 230 identified as meeting study inclusion criteria. Eighty-nine names and 51 definitions were identified. Based on a post facto thematic analysis, we propose that these tools be named "deliberate teaching tools" (DTTs) and defined as "frameworks that enable clinicians to have a purposeful and considered approach to teaching encounters by incorporating elements identified with good teaching practice." We identified 46 DTTs in the literature, with 38 (82.6%) originally described for the medical setting. Forty justification articles consisted of 16 feedback surveys, 13 controlled trials, seven pre-post intervention studies with no control group, and four observation studies. Current evidence of efficacy is not entirely conclusive, and many studies contain methodology flaws. Forty-nine clarification articles comprised 12 systematic reviews and 37 narrative reviews. The most number of DTTs described by any review was four. A common design theme was identified in approximately three-quarters of DTTs.

CONCLUSIONS

Applicability of DTTs to specific alternate settings should be considered in context, and appropriately designed justification studies are warranted to demonstrate efficacy.

Listen to the outpatient: qualitative explanatory study on medical students' recognition of outpatients' narratives in combined ambulatory clerkship and peer role-play

BACKGROUND

Understanding patients' narratives has been associated with methods of improving care that go beyond what may be regarded as a "narrow" view of scientific medicine. Medical interview training in which medical students develop understanding of the importance of patients' narratives is receiving increased attention. However, students generally receive education on patients' narratives that does not distinguish inpatients and outpatients. No studies exploring the characteristics of outpatients' narratives have been reported. We developed an educational program combining ambulatory clerkship and peer role-play using actual narratives from outpatients that students had encountered during their clerkship. These narratives were used as peer role-play scenarios in which the students acted as outpatients. This study explored what and how medical students learned about the characteristics of outpatients' narratives through this original educational program.

METHODS

Participants were 70 fifth-year medical students from Nagoya University, Japan. We conducted 13 focus groups, based on a convenience sample of 11 groups in 2012, one group in 2013, and one group in 2017 (from 17 clinical groups in each year). Focus group transcripts were analyzed using the "Steps for Coding and Theorization" qualitative data analysis method. We assessed medical anthropological findings regarding narratives in a conceptual framework.

RESULTS

Patients' narratives as perceived by medical students were divided into four quadrants by two axes: medical versus lived content, and objective versus subjective structure. Students recognized that outpatients' narratives mainly used a subjective structure, but were mixed and crossed each quadrant. This was described as "irreproducibility." Students also recognized that narratives of simulated patients and inpatients were mainly limited to a medical-lived content with an objective structure. These differences in narrative characteristics were recognized through students' previous interactions with simulated patients and inpatients.

CONCLUSIONS

Despite some limitations, medical students learn about patients' narratives in our original educational program in a way that would be difficult to achieve through training using simulated patients or inpatients.

Feeling inadequate: Residents' stress and learning at primary care clinics in the United States

BACKGROUND

Educators hope that residents' experiences in primary care continuity clinics will influence more trainees to enter primary care careers. Unfortunately, evidence shows that outpatient primary care training in the United States is stressful and fails to promote primary care careers. We conducted qualitative interviews with residents to understand the source of stress and to explain this failure.

METHODS

In-person individual interviews were conducted with 37 primary care residents training at outpatient clinics in the US. Analysis used the constant comparative method and included open and focused coding, allowing themes to emerge inductively from the data.

RESULTS

73% of residents interviewed reported negative emotions about clinic. Beyond stress, residents reported feeling inadequate as primary care physicians at clinic. Four factors contributed: mental distractions, unfamiliarity with primary care medicine, management of outpatients, and relationships with patients. Residents' comparisons of hospital-based and outpatient experiences favored the former in relation to the four factors.

CONCLUSIONS

Residents feel unprepared for primary care and inadequate as primary care physicians, and these feelings discourage them from practicing primary care. This phenomenon must be studied within the entire context of residency, as residents' attitudes about their outpatient experiences were shaped in relation to their inpatient experiences.

Integrating teaching into routine outpatient care: The design and evaluation of an ambulatory training concept (HeiSA)

Background: Direct patient contact is crucial in learning important interactional and examination skills. However, medical students have limited opportunity to self-responsibly practise these skills in authentic clinical settings and typically receive insufficient feedback on their performance. We developed a novel single-session ambulatory teaching concept (Heidelberg Student Ambulatory training, "HeiSA") to prepare students more adequately for clinical-practical responsibilities. Methods: To identify challenges and target group needs, we reviewed current literature and consulted an expert group of faculty lecturers and training researchers. The resulting course concept was put into practice at the University Hospital's general-internistic outpatient department and evaluated in a pilot phase (winter term 2010, ten participants) and a main project phase (summer and winter terms 2011, 14 and 21 participants, respectively). Third and fourth-year students autonomously take a new patient's medical history and conduct a complete physical examination in one hour under supervision, followed by extensive preceptor feedback. To assess learning achievements, participants and a control group self-rated their communication and examination skills before and (participants only) after the session on six-point Likert scales (1=completely able, 6=completely unable). The preceptor also evaluated the participants' performance. Finally, all stakeholders re-evaluated the course concept. Results: HeiSA is a feasible training concept and accepted by staff members and students. It provides opportunities to practise clinical skills in a relevant, authentic learning environment with extensive feedback. Participants report improved anamnesis (0.27±0.51, p=.003) and physical examination (0.25±0.41, p=.008) skills. The preceptor evaluated students' performance to be generally high, with ratings ranging from 1.40±0.55 (item: the student does not interrupt the patient) to 2.51±0.89 (item: psychosocial anamnesis). Conclusions: HeiSA is a viable course concept for teaching anamnesis and physical examination skills. It integrates student teaching into routine care and can potentially be adapted to other outpatient departments.

Medical students, early general practice placements and positive supervisor experiences

Introduction Community-based longitudinal clinical placements for medical students are becoming more common globally. The perspective of supervising clinicians about their experiences and processes involved in maximising these training experiences has received less attention than that of students. Aims This paper explores the general practitioner (GP) supervisor perspective of positive training experiences with medical students undertaking urban community-based, longitudinal clinical placements in the early years of medical training. Methods Year 2 medical students spent a half-day per week in general practice for either 13 or 26 weeks. Transcribed semi-structured interviews from a convenience sample of participating GPs were thematically analysed by two researchers, using a general inductive approach. Results Identified themes related to the attributes of participating persons and organisations: GPs, students, patients, practices and their supporting institution; GPs' perceptions of student development; and triggers enhancing the experience. A model was developed to reflect these themes. Conclusions Training experiences were enhanced for GPs supervising medical students in early longitudinal clinical placements by the synergy of motivated students and keen teachers with support from patients, practice staff and academic institutions. We developed an explanatory model to better understand the mechanism of positive experiences. Understanding the interaction of factors enhancing teaching satisfaction is important for clinical disciplines wishing to maintain sustainable, high quality teaching.

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

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

DISCUSSION

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.

The paediatric change laboratory: optimising postgraduate learning in the outpatient clinic

BACKGROUND

This study aimed to analyse and redesign the outpatient clinic in a paediatric department. The study was a joint collaboration with the doctors of the department (paediatric residents and specialists) using the Change Laboratory intervention method as a means to model and implement change in the outpatient clinic. This study was motivated by a perceived failure to integrate the activities of the outpatient clinic, patient care and training of residents. The ultimate goal of the intervention was to create improved care for patients through resident learning and development.

METHODS

We combined the Change Laboratory intervention with an already established innovative process for residents, 3-h meetings. The Change Laboratory intervention method consists of a well-defined theory (Cultural-historical activity theory) and concrete actions where participants construct a new theoretical model of the activity, which in this case was paediatric doctors' workplace learning modelled in order to improve medical social practice. The notion of expansive learning was used during the intervention in conjunction with thematic analysis of data in order to fuel the process of analysis and intervention.

RESULTS

The activity system of the outpatient clinic can meaningfully be analysed in terms of the objects of patient care and training residents. The Change Laboratory sessions resulted in a joint action plan for the outpatient clinic structured around three themes: (1) Before: Preparation, expectations, and introduction; (2) During: Structural context and resources; (3) After: Follow-up and feedback. The participants found the Change Laboratory method to be a successful way of sharing reflections on how to optimise the organisation of work and training with patient care in mind.

CONCLUSIONS

The Change Laboratory approach outlined in this study succeeded to change practices and to help medical doctors redesigning their work. Participating doctors must be motivated to uncover inherent contradictions in their medical activity systems of which care and learning are both part. Facilitators must be willing to spend time analysing both historical paediatric practice, current data on practice, and steer clear of organisational issues that might hamper a transformative learning environment. To ensure long-term success, economical and organisational resources, participant buy-in and department leadership support play a major role.

Reflection and feedback in ambulatory education

BACKGROUND

It has been argued that the best method of acquiring clinical reasoning is through seeing new out-patients. The purpose of this interventional study was to establish a clinical clerkship course for Japanese medical students in an out-patient care setting, with multiple opportunities for reflective practice and improving the clinical reasoning abilities of the students. The effectiveness of the course was also examined.

METHODS

Students performed examinations of new patients and made diagnostic decisions in 20 minutes. They presented their case using the SNAPPS (Summarize the case, Narrow the differential, Analyze the differential, Probe the preceptor, Plan management, and Select an issue for self directed learning) method, and this was followed by feedback from faculty members using the 1-minute preceptor method and a mini clinical evaluation exercise (mini-CEX). Students' clinical reasoning abilities were assessed by the objective structured clinical examination (OSCE) and the script concordance test (SCT). Students' written comments and responses to an interview about the course were also analysed. Cross-sectional data were examined by comparing individual OSCE and SCT scores, and the multiple-choice question examination (MCQ) completed by students who did and did not participate in this project.

RESULTS

Students in the programme had higher scores on the mini-CEX in all areas. The SCT and OSCE scores were also significantly higher than the scores for the control group. Students' comments about the course, which provided an opportunity for daily reflection, were positive.

DISCUSSION

Students rapidly acquired clinical reasoning skills through reflective practice. Students also demonstrated motivation to learn through the examination of new patients. The clinical clerkship programme with multiple opportunities for reflective practice in an out-patient care setting substantially improved the clinical reasoning abilities of medical students.

How we established a new undergraduate firm on a Medical Admissions Unit

Medical Admission Units (MAUs) were introduced in the UK in the 1980s primarily driven by a governance and service improvement agenda. In the UK this has led to the development of Acute Medicine as a specialty in its own right, together with a strong role of this specialty in postgraduate teaching. In contrast, the role of MAUs, if any, in undergraduate medical education is currently unclear. Prompted by an expansion of our undergraduate student numbers, our aim was to establish a Year 3 undergraduate firm on a 33-bedded MAU in a large academic teaching hospital in the National Health Service (NHS). Despite initial scepticism from clinicians, managers, and educators, the new firm placement on MAU became an instant success and continues to attract excellent feedback from our Year 3 undergraduate students. Students enjoy the bedside teaching with a high percentage of consultant-delivered teaching and also liked the involvement of Foundation Doctors. Here, we report our experience on how to make such a firm work, based on student feedback and the tutors' experience. We provide an overview and a step-by-step guide of how to construct a successful new undergraduate firm on a busy MAU. We also discuss opportunities and challenges and discuss the relevant literature. We conclude that undergraduate teaching is feasible and rewarding in an extremely busy MAU setting. We note that identifying enthusiastic educators within the MAU team, utilisation of peripheral learning opportunities, structured timetables and induction, and a robust framework for quality assurance are all crucial to success.

Minimal supervision out-patient clinical teaching

BACKGROUND

Minimal faculty member supervision of students refers to a method of instruction in which the patient-student encounter is not directly supervised by a faculty member, and presents a feasible solution in clinical teaching. It is unclear, however, how such practices are perceived by patients and how they affect student learning.

CONTEXT

We aimed to assess patient and medical student perceptions of clinical teaching with minimal faculty member supervision. Questionnaires focusing on the perception of students' performance were administered to patients pre- and post-consultation. Students' self-perceptions on their performance were obtained using a questionnaire at the end of the consultation.

INNOVATION

Before encounters with students, 22 per cent of the 95 patients were not sure if they would feel comfortable or trust the students; after the consultation, almost all felt comfortable (97%) and relied on the students (99%). The 81 students surveyed agreed that instruction with minimal faculty member supervision encouraged their participation and engagement (86%). They expressed interest in knowing patients' opinions about their performance (94%), and they felt comfortable about being assessed by the patients (86%).

IMPLICATIONS

The minimal faculty member supervision model was well accepted by patients. Responses from the final-year students support the use of assessments that incorporate feedback from patients in their overall clinical evaluations.

Enhancing clinical skill development through an Ambulatory Medicine Teaching Programme: an evaluation study

BACKGROUND

Teaching of clinical skills traditionally takes place in hospital wards and outpatient settings. However high acuity and short hospital stays means there are fewer suitable inpatients available for teaching; and time pressures limit students' involvement in other settings. The Ambulatory Medicine Programme was established to develop undergraduate medical students' clinical skills by providing increased exposure to patients with a wide range of chronic medical conditions, in a dedicated learning environment.

METHOD

A mixed qualitative/quantitative approach was used to evaluate the Programme. This research focuses on staff and student perspectives of teaching and learning in Ambulatory Medicine compared with inpatient and outpatient settings; identifies which teaching methods are considered most effective; and determines the transferability of learning. Patients' perspectives of being involved in student teaching are also reported.

RESULTS

Results show that the programme has made a positive impact on students' development of clinical skills, which are transferable to the clinical setting. Patients enjoy being involved and find it personally satisfying.

CONCLUSIONS

The Ambulatory Medicine Programme is an effective way of developing medical students' clinical skills by providing focussed teaching with real patients in a dedicated learning environment.

Training tomorrow's doctors in the preoperative clinic

BACKGROUND

  The reduction in the length of hospital stay for surgical patients at a time of expanding medical student numbers has created challenges in the provision of adequate exposure to surgical patients. This has required the use of surgical learning opportunities in the ambulatory setting, including the preoperative assessment clinic. At Keele University, fourth-year medical students follow patient journeys through the preoperative assessment process, gaining experience of history taking, examination, prescribing and practical skills. This is followed by group discussion with a clinical teaching fellow, focusing on management and clinical reasoning. We audited the experience our students gained in the preoperative assessment clinic against the relevant Tomorrow's Doctors outcomes.

METHODS

  An audit tool was created by reviewing the patient journey to identify potential learning opportunities. These were then mapped to the relevant Tomorrow's Doctors outcomes. Audit pro formas were completed for each student at the end of the clinic by the clinical educator, with a total of 42 sessions audited.

RESULTS

  Our findings show that it is possible for students to gain experience in all nine of the identified Tomorrow's Doctors outcomes in the preoperative assessment clinic. Practical procedure experience was gained by 92 per cent of students, and 70 per cent demonstrated clinical judgment and decision skills.

DISCUSSION

  This study shows that students can gain experience in multiple Tomorrow's Doctors outcomes in the preoperative assessment clinic. In particular, it is a useful environment to learn and teach practical procedures, clinical reasoning and decision-making skills.

Preoperative assessment clinic: a missed learning opportunity?

BACKGROUND

Day-case surgery, theatre direct admissions and elective surgery have revolutionised the surgical patient's pathway, and have minimised the length of their hospital stay. However, with large numbers of medical students placed mostly at teaching hospitals, this has also significantly reduced students' exposure to clinical signs in surgery. This study aimed to assess whether the preoperative assessment clinic would be an appropriate teaching arena to offer medical students exposure to clinical signs.

METHODS

Junior doctors assigned to the preoperative assessment clinic were asked to fill out a specially designed questionnaire for each patient they reviewed. This included the planned operation, presenting complaint, and identification and categorisation of objective clinical signs on examination. The assessor was asked whether the patient was suitable for, and amenable to, having medical students observe. The presenting complaints and clinical signs were referenced to the curriculum for Oxford University's second Bachelor of Medicine examinations (finals).

RESULTS

Of the 100 patients seen in 40 clinics, only four refused to be seen by a medical student. Of the remaining patients, 89 (92%) had presenting complaints listed on the core curriculum for Oxford University. Seventy-six (79%) patients had objective clinical signs on examination. Only three patients (3%) had neither clinical signs nor core relevant presenting complaints.

CONCLUSIONS

The results clearly demonstrate that preoperative assessment is an arena that would give medical students two important opportunities: to examine objective clinical signs and to take histories of presenting complaints from the core curriculum. This learning opportunity would otherwise be missed.

The use of standardized patients to teach medical students clinical skills in ambulatory care settings

BACKGROUND

Ambulatory medicine is being increasingly emphasized in undergraduate medical education. Because of the limited availability of real patients, we introduced a standardized patient (SP) encounter program in an ambulatory care setting.

AIMS

This study was undertaken to assess the usefulness of SPs for teaching undergraduate students clinical skills in ambulatory settings.

METHOD

Third-year medical students met two different SPs, who presented common authentic problems, during internal medicine clerkship. Each SP encounter of 30 min was followed by SP and a tutor's feedback, using a video recording of the SP encounter. We surveyed students for program evaluation purposes at the end of their three-year internal medicine clerkships (from 2006 to 2008).

RESULTS

Most students found that the consecutive SP sessions were instructive and helpful. Video recordings of clinical encounters allowed students to reflect on their behavior and receive feedback from tutors. However, students identified several weaknesses of these SP encounters. For example, pre-exposure to the SP scenario reduced tension of the experience and inconsistent feedback from tutors caused confusion.

CONCLUSIONS

SP encounters in an ambulatory care setting, followed by tutor's feedback based on a video recording, can be used for teaching basic clinical ambulatory care skills.

Learning in the clinical environment

Clinical learning is central to medical education. Learning theories suggest that it is most effective when students are actively engaged with patient care and receiving timely feedback. Changes in health care delivery mean that learning must take place in a variety of clinical settings. The 'One Minute Preceptor' approach allows teaching to take place in the course of routine delivery of care.

Harnessing the IT Factor in Medical Education

Escalating healthcare costs in Singapore have produced a significant movement of patients into ambulatory care, and the consequent dearth of clinical teaching materials. This deficiency has likewise prompted the creation of ambulatory teaching clinics and the use of standardised patients and simulators. In the last few decades, educators have utilised digital technology, for instance, digitally recorded heart and breath sounds, and digitised video vignettes, in medical education. We describe several pedagogical initiatives that we have undertaken at our university school of medicine. Key words: Clinical material, Digital image, Multimedia

Students' perceptions of early patient encounters in a PBL curriculum: a first evaluation of the Maastricht experience

INTRODUCTION

Real patient encounters before the clinical phase of undergraduate medical education are recommended to stimulate integration of theory and practice. Such encounters are not easy to integrate into the three phases of the problem-based learning cycle, i.e. preparation, self-study and reporting. The authors studied students' perceptions of problem-based learning with real patient encounters as the starting point for learning.

METHOD

Students' perceptions of the programme with real patients were evaluated by means of a questionnaire. Mean item scores on a five-point Likert scale and 95% confidence intervals were calculated.

RESULTS

Students showed satisfaction with the patient encounters and said they learned a lot from them. Reporting was also highly rated, particularly the integration of theory and practice. Preparation and self-study received lower scores.

DISCUSSION

The findings support the view that real patient encounters can act as a powerful driving force for learning and enhance integration of theory and practice. Student learning might benefit from: better information to students and teachers regarding educational objectives, teacher training and careful selection of patients. In order to gain more insight into learning from patient encounters, further studies should address students' and teachers' views and behaviours in respect of this type of learning.