An efficient and effective teaching model for ambulatory education

Educating for success: ambulatory anesthesia training

PURPOSE OF REVIEW

This article explores the unique intersection of the challenges confronting ambulatory anesthesiology education and charts a trajectory forward. The proportion of ambulatory, nonoperating room (NORA), and office-based surgical cases continues to rise; however, the requirements for trainees in these settings have remained static. The rapid evolution of the field combined with a limited workforce also makes continuing education essential, and we discuss the current and future states of ambulatory anesthesia education.

RECENT FINDINGS

Although numerous resources are available across an array of platforms to foster both trainee education and continuing education for practicing anesthesiologists, there is a paucity of current literature evaluating the impact of new curricula developed specifically for ambulatory, NORA, or office-based anesthesiology (OBA).

SUMMARY

We begin with an appraisal of the current state of ambulatory anesthesiology training and evaluate the gap between current graduate medical education and trends in ambulatory surgery. We then develop a vision for an ideal state of future ambulatory education for residents as well as anesthesiologists in practice and highlight the priorities necessary to reach this vision.

A Qualitative Study of the Barriers and Benefits to Resident Education in Ambulatory Surgical Centers

OBJECTIVE

As Ambulatory Surgical Centers (ASCs) become more common in academic medical centers, large hospital systems must determine how to shift resident education from inpatient to outpatient surgical centers. This study aims to define stakeholders' views regarding the integration of surgical residents into ASCs.

DESIGN

Long-form interviews lasting 30 to 60 minutes were conducted. Interviews were hand-transcribed and analyzed by qualitative analysis to determine benefits of learning in ASCs for residents, challenges that arise from integrating residents, and recommendations to improve resident incorporation.

SETTING

Interviews were conducted using a video conferencing platform.

PARTICIPANTS

Residency program directors, attending surgeons, graduate medical learners, and a nursing manager were interviewed. Twenty-one total interviews were conducted, representing ten different departments.

RESULTS

Stakeholders agreed that residents benefit from being placed in ASCs because the fast, surgical pace allows the residents to engage in more cases. However, different stakeholders highlighted different challenges, all centered around the notion of inter-stakeholder conflict due to conflicting priorities among residents, attending physicians, and administration. Likewise, recommendations differed by stakeholder group-faculty members sought more defined learning objectives and enhanced communication, whereas residents desired that ambulatory surgical time be more structured.

CONCLUSIONS

Despite the pressures of rapid case turnover, stakeholders agreed that there are many benefits to resident education in ASCs. Findings related to challenges and recommendations support the need to strengthen communication between stakeholder groups and better plan for resident integration into ASCs.

Parallel consulting method: student and tutor evaluation in general practice

The parallel consulting method (PCM) is widely used by general practitioners (GPs) for teaching medical students. Studies have described individual aspects of bedside teaching in community settings, including the logistics of using the PCM, but there has been no evaluation of it as a teaching method. This study aimed to evaluate the PCM and whether it helped students develop consultation, clinical and clinical reasoning skills. The study was based at the Oxford University Primary Care Department. Penultimate clinical year students (n = 63) were recruited to take part in this mixed methods study. Students completed a questionnaire with closed and open-ended questions rating the PCM. A focus group explored questionnaire themes. GP tutors completed a questionnaire about the PCM and the logistics of delivering it. Three tutors took part in semi-structured interviews. The PCM helped develop students' consulting, and clinical reasoning skills. Teaching was improved when tutors were unrushed and had increased time to provide feedback and teaching. Delivery logistics of the PCM impacted on whether tutors were rushed and found it difficult to teach. Most benefit was derived when students were well briefed with sufficient debriefing time following a consultation. The following steps are recommended for effective delivery of the PCM teaching model: ensure tutors are appropriately trained; comprehensively brief the student about how to gain the most out of the learning experience; plan the logistics; ensure appropriate review and debriefing following consultation; review clinical cases after the session teaching on any outstanding aspects.

Outpatient learning perspectives at a UK hospital

BACKGROUND

Undergraduate students spend much of their training in the clinical workplace, increasingly in hospital outpatient settings; however, they report that this does not always yield the educational value that they expect. This study investigates ways in which outpatient learning can be enhanced from the perspectives of students and teachers, exploring which approaches may be most appropriate in different circumstances.

METHODS

We conducted 14 semi-structured interviews with medical students from one UK medical school and consultants (specialists) at a single teaching hospital. We explored their experiences and perceptions of clinical teaching and learning in this outpatient setting. Transcripts were analysed through a consensual qualitative research approach. An evaluation of established frameworks for outpatient teaching was conducted and strategies were matched to stakeholder needs.

FINDINGS

A total of 24 core ideas were identified, which were categorised into: individual factors (student, doctor and patient), interpersonal factors, team factors and organisational factors. Teaching strategies that address stakeholder needs included: student-led clinics, case-based discussions, one-minute preceptor, the SNAPPS tool (summarize, narrow differential, analyse, probe preceptor, plan and select issues for self-learning), advanced organisers and supplementing.

DISCUSSION

There is a complex interplay between personal, interpersonal, team and organisational factors that contribute to the effectiveness of the outpatient setting as a learning environment. Strategies at the personal and interpersonal levels are unlikely to be successful or sustained without organisational resourcing and support. Further research is needed to implement and evaluate these suggested strategies.

Development and Implementation of a Novel Learner-driven Precepting Model for Pulmonary Fellowship

Background: Ambulatory education is currently underemphasized in pulmonary and critical care medicine (PCCM) fellowship training. Existing clinic precepting models, originally developed for students and residents, do not meet the unique needs of fellow-level trainees.

Objective: We aimed to develop and implement a novel fellow-led precepting model to improve ambulatory education for PCCM trainees.

Methods: We performed a mixed-methods needs assessment, including surveys, focus groups, and direct observations, to explore perceptions of ambulatory training, define current precepting practices, and identify target areas for improvement. On the basis of these findings, we developed, implemented, and evaluated a novel model for PCCM outpatient precepting.

Results: A targeted needs assessment identified that current precepting practices did not meet fellows’ needs for graduated autonomy, development of assessment and management skills, and self-directed learning. We developed and implemented a novel, learner-driven precepting model (Set the Stage, Tell the Story, Educational Goals, Preliminary Plan, Uncertainties, Plan Recap [STEP-UP]), designed to prioritize clinical reasoning skills and self-identification of learning goals. Implementation of the STEP-UP model improved perceptions of overall outpatient training and precepting. However, we faced several barriers to uptake of the new model, including increased cognitive burden of integrating a new process.

Conclusion: A robust assessment of ambulatory education at a single PCCM fellowship program identified a need to align precepting processes with the unique goals of advanced trainees. We developed a learner-driven precepting model focused on development of clinical reasoning skills and self-directed educational objectives. Additional study is warranted to refine, adapt, and test the model in different setting.

Placing education at the centre of the outpatient clinic improves learning and experiences for everyone using the multilevel attainment of learning, teaching and support (MALTS) approach

A large proportion of consultant time is spent in outpatient practice. This setting provides an excellent learning environment for different levels of a trainee if well organised. This article describes an evidence-based teaching approach and its evaluation by trainees, patients and carers in a typical district general hospital setting which it is hoped others might find helpful.

Competence-based teaching and learning in the outpatient clinic: development of a clinical elective in ambulatory medicine

Aim: Although physicians have the most contact with patients in the outpatient setting, topics relating to ambulatory medicine have been less present in medical education. To teach professional skills, practical learning opportunities must be created in which students can practice medical skills under authentic working conditions in the outpatient setting. The clinical elective in ambulatory medicine has been developed, evaluated and revised at the Mannheim Medical School as a practical, competency-based learning experience in outpatient clinics (liver clinic, psychiatric outpatient clinic, uro-oncological consultations, etc.). Methods: The elective was designed using the plan-do-check-act (PDCA) cycle in the form of a longitudinal practical course during the fourth year of study. By selecting one of four concentrations in ambulatory care, students have the opportunity to focus on and pursue an individual interest. Students are given assignments during three separate sessions at an outpatient clinic and complete a log book which contains the learning objectives, assignments and grading criteria. Once the elective had been completed, the students (n=165) and mentors (n=7) had the option to participate in a survey to evaluate knowledge gain and satisfaction with the elective. Results: The students rated their personal growth in knowledge about common diseases and patient-centered communication positively, while rating their knowledge gain in ambulatory patient management somewhat lower. The first offering of the elective was evaluated as satisfactory by students and mentors. In 85.8% of the cases, students reported that they would recommend the selected outpatient clinic for this course. Suggestions for improvement, such as those concerning the log book and scheduling system, were considered during the first revision. Conclusion: This elective provides an opportunity to become familiar with ambulatory medicine in a practical and competency-based manner during medical studies. Skills in ambulatory medicine are already taught and applied in the fourth year of study in a practical setting and also deepened further through interconnections with other courses and chosen concentrations. Moreover, this elective format may be used by other medical schools depending on which aspects of ambulatory medicine are focused on.

Exemplary Learning Environments for the Health Professions: A Vision

In this article, the authors propose a vision for exemplary learning environments in which everyone involved in health professions education and health care collaborates toward optimal health for individuals, populations, and communities. Learning environments in the health professions can be conceptualized as complex adaptive systems, defined as a collection of individual agents whose actions are interconnected and follow a set of shared "simple rules." Using principles from complex adaptive systems as a guiding framework for the proposed vision, the authors postulate that exemplary learning environments will follow four such simple rules: Health care and health professions education share a goal of improving health for individuals, populations, and communities; in exemplary learning environments, learning is work and work is learning; exemplary learning environments recognize that collaboration with integration of diverse perspectives is essential for success; and the organizations and agents in the learning environments learn about themselves and the greater system they are part of in order to achieve continuous improvement and innovation. For each of the simple rules, the authors describe the details of the vision and how the current state diverges from this vision. They provide actionable ideas about how to reach the vision using specific examples from the literature. In addition, they identify potential targets for assessment to monitor the success of learning environments, including outcome measures at the individual, team, institutional, and societal levels. Such measurements can ensure optimal alignment between health professions education and health care and inform ongoing improvement of learning environments.

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.

Incorporating students into clinic may be associated with both improved clinical productivity and educational value

Background

In this study, we aimed to evaluate ambulatory clinic responsibilities that neurology clerkship students perceive as having the highest educational value and to evaluate the association between a student's presence and level of responsibility and a preceptor's clinical and financial productivity during a clinic session.

Methods

Physician preceptors (n = 43) and medical students (n = 67) in the Johns Hopkins Neurology clerkship from 2014 to 2015 were included. Students rated their experience and responsibilities in 291 neurology clinic sessions. Productivity metrics (e.g., relative value units [RVU]/clinic) were collected for each preceptor in the presence and absence of students.

Results

A student's rating of a clinic as an effective learning experience increased with each additional patient the student interviewed (odds ratio [OR] 1.89, p < 0.001), presented (OR 1.86, p < 0.001), or documented (OR 2.00, p < 0.001). The mean RVU/session for preceptors also increased based on the number of patients interviewed (β = 2.64, p = 0.026), presented (β = 2.42, p = 0.047), and documented (β = 2.70, p = 0.036) by students. On average, preceptor RVU/session increased by 42% (mean 5.6 ± 1.2, p < 0.0001) when a student was present in clinic compared to sessions without students. In addition, preceptor invoices increased by 35% (mean 2.7 ± 0.6, p < 0.0001) and charges by 39% (mean $929 ± $210, p < 0.0001) when a student was present in clinic.

Conclusions

This observational study suggests a mutual benefit to preceptor clinical productivity and student-perceived educational value when students have active responsibilities in neurology clinics. Despite concerns that students slow down preceptors in clinic, these results suggest that preceptors may have an overall boost in productivity, potentially by performing billable work while students independently see patients.

Recruiting and Retaining Community-Based Preceptors: A Multicenter Qualitative Action Study of Pediatric Preceptors

PURPOSE

The recruitment and retention of community preceptors to teach medical students is difficult. The authors sought to characterize the underlying motivational factors for becoming a preceptor and to identify strategies for recruiting and retaining community-based pediatric preceptors.

METHOD

This multicenter qualitative action study included semistructured interviews with community-based pediatric preceptors affiliated with 12 institutions from August to December 2015. Only active preceptors were included, and participating institutions were diverse with respect to geographic location and class size. Interviews were conducted over the telephone and transcribed verbatim. Six investigators used deidentified transcripts to develop a codebook. Through a constant comparative method, codes were revised as data were analyzed and disagreements were resolved through discussion. All investigators organized the themes into dimensions.

RESULTS

Fifty-one preceptors were interviewed. Forty-one themes coalesced into four dimensions: (1) least liked aspects of teaching, (2) preparation to teach, (3) inspiration to teach, and (4) ways to improve recruitment and retention. Time constraints and patient care demands were the most commonly cited deterrents to teaching. Successful preceptors balanced their clinical demands with their desire to teach using creative scheduling. External rewards (e.g., recognition, continuing medical education credit) served as incentives. Internal motivation inspired participants to share their enthusiasm for pediatrics and to develop longitudinal relationships with their learners.

CONCLUSIONS

Changes in health care delivery have imposed more time constraints on community-based preceptors. However, this study identified underlying factors motivating physicians to volunteer as preceptors. Strategies to recruit new and retain current preceptors must be collaborative.

Longitudinal integrated clerkships. MEDICAL TEACHER 2017;39:7-13. [PMID: 27832713 DOI: 10.1080/0142159x.2017.1245855]

There is increased interest in longitudinal integrated clerkships (LICs) due to mounting evidence of positive outcomes for students, patients and supervising clinicians. Emphasizing continuity as the organizing principle of an LIC, this article reviews evidence and presents perspectives of LIC participants concerning continuity of care, supervision and curriculum, and continuity with peers and systems of care. It also offers advice on implementing or evaluating existing LIC programs.

The Community Preceptor Crisis: Recruiting and Retaining Community-Based Faculty to Teach Medical Students-A Shared Perspective From the Alliance for Clinical Education

ISSUE

Community-based instruction is invaluable to medical students, as it provides "real-world" opportunities for observing and following patients over time while refining history taking, physical examination, differential diagnosis, and patient management skills. Community-based ambulatory settings can be more conducive to practicing these skills than highly specialized, academically based practice sites. The Association of American Medical Colleges and other national medical education organizations have expressed concern about recruitment and retention of preceptors to provide high-quality educational experiences in community-based practice sites. These concerns stem from constraints imposed by documentation in electronic health records; perceptions that student mentoring is burdensome resulting in decreased clinical productivity; and competition between allopathic, osteopathic, and international medical schools for finite resources for medical student experiences.

EVIDENCE

In this Alliance for Clinical Education position statement, we provide a consensus summary of representatives from national medical education organizations in 8 specialties that offer clinical clerkships. We describe the current challenges in providing medical students with adequate community-based instruction and propose potential solutions.

IMPLICATIONS

Our recommendations are designed to assist clerkship directors and medical school leaders overcome current challenges and ensure high-quality, community-based clinical learning opportunities for all students. They include suggesting ways to orient community clinic sites for students, explaining how students can add value to the preceptor's practice, focusing on educator skills development, recognizing preceptors who excel in their role as educators, and suggesting forms of compensation.

Instructional Design for Assessment of Dental Esthetic Treatment Needs in a Indian Undergraduate School: A Randomised Controlled Trial

In the recent years esthetic dentistry has been the area of focus amongst the public. Esthetics is an important dimension in dental practice and the upcoming dentists need to be enabled to demonstrate their competencies for an efficient clinical outcome. The purpose of this study was to institute a cultural change within traditional didactic dental education towards student centred learning to cope up with the accelerating pace of medical technological change and achieving positive impact on patient care and patient satisfaction. Intervention that was considered for the project included David Merrill's first principles of instruction. A randomized controlled trial was conducted with all the students from four cohorts of final year dental undergraduate students, divided into an intervention group (n = 40) and a control group (n = 40). A professional assessment questionnaire is used to evaluate the relationship between the students and professional's assessment of esthetic treatment needs. The results of the study indicated that the ranking of the most and least noticeable dental features differed significantly (p = 0.0061) between the intervention and non intervention group and the indicates the intervention group to be in better agreement with professional assessment than the non intervention group of students with z value of 2.7435. The relative agreement between intervention group of undergraduate students and the professional assessment of esthetic treatment need shows the importance of intervention of Merrill's first principles of instruction in learning, emphasising the significance of PBL and therefore indicating a positive impact on successful esthetic treatment for patients.

Using a framework to implement large-scale innovation in medical education with the intent of achieving sustainability

BACKGROUND

Particularly when undertaken on a large scale, implementing innovation in higher education poses many challenges. Sustaining the innovation requires early adoption of a coherent implementation strategy. Using an example from clinical education, this article describes a process used to implement a large-scale innovation with the intent of achieving sustainability. Desire to improve the effectiveness of undergraduate medical education has led to growing support for a longitudinal integrated clerkship (LIC) model. This involves a move away from the traditional clerkship of 'block rotations' with frequent changes in disciplines, to a focus upon clerkships with longer duration and opportunity for students to build sustained relationships with supervisors, mentors, colleagues and patients. A growing number of medical schools have adopted the LIC model for a small percentage of their students. At a time when increasing medical school numbers and class sizes are leading to competition for clinical supervisors it is however a daunting challenge to provide a longitudinal clerkship for an entire medical school class. This challenge is presented to illustrate the strategy used to implement sustainable large scale innovation.

WHAT WAS DONE

A strategy to implement and build a sustainable longitudinal integrated community-based clerkship experience for all students was derived from a framework arising from Roberto and Levesque's research in business. The framework's four core processes: chartering, learning, mobilising and realigning, provided guidance in preparing and rolling out the 'whole of class' innovation.

DISCUSSION

Roberto and Levesque's framework proved useful for identifying the foundations of the implementation strategy, with special emphasis on the relationship building required to implement such an ambitious initiative. Although this was innovation in a new School it required change within the school, wider university and health community. Challenges encountered included some resistance to moving away from traditional hospital-centred education, initial student concern, resource limitations, workforce shortage and potential burnout of the innovators. Large-scale innovations in medical education may productively draw upon research from other disciplines for guidance on how to lay the foundations for successfully achieving sustainability.

Applying JIT principles to resident education to reduce patient delays: a pilot study in an academic medical center pain clinic

OBJECTIVES

This study investigated the effect on patient waiting times, patient/doctor contact times, flow times, and session completion times of having medical trainees and attending physicians review cases before the clinic session. The major hypothesis was that review of cases prior to clinic hours would reduce waiting times, flow times, and use of overtime, without reducing patient/doctor contact time.

DESIGN

Prospective quality improvement.

SETTING

Specialty pain clinic within Johns Hopkins Outpatient Center, Baltimore, MD, United States.

PARTICIPANTS

Two attending physicians participated in the intervention. Processing times for 504 patient visits are involved over a total of 4 months.

INTERVENTION

Trainees were assigned to cases the day before the patient visit. Trainees reviewed each case and discussed it with attending physicians before each clinic session.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary measures were activity times before and after the intervention. These were compared and also used as inputs to a discrete event simulation to eliminate differences in the arrival process as a confounding factor.

RESULTS

The average time that attending physicians spent teaching trainees while the patient waited was reduced, but patient/doctor contact time was not significantly affected. These changes reduced patient waiting times, flow times, and clinic session times.

CONCLUSIONS

Moving some educational activities ahead of clinic time improves patient flows through the clinic and decreases congestion without reducing the times that trainees or patients interact with physicians.

Effect of a multidisciplinary-assisted resident diabetes clinic on resident knowledge and patient outcomes

BACKGROUND

Despite the rising prevalence of diabetes, there is a paucity of diabetes curricula in residency training. The multidisciplinary diabetes team approach is underused in residency education.

OBJECTIVE

To assess the feasibility of an innovative multidisciplinary resident diabetes clinic (MRDC) in enhancing (1) resident diabetes knowledge via a Diabetes Awareness Questionnaire, and (2) subsequent process and patient outcomes in patients with diabetes via a Diabetes Practice Behavior Checklist.

METHODS

From October 2008 to February 2010, 14 internal medicine residents managed patients with uncontrolled diabetes in a weekly half-day MRDC for 1 month (total 4-5 half-day sessions/resident), with a collaborative team of internists, diabetes educators, an endocrinologist, and a pharmacist. The curriculum included didactic sessions, required readings, and patient-specific case discussions. A 20-question Diabetes Awareness Questionnaire was administered to each resident prerotation and postrotation. Records of 47 patients with diabetes in the residents' own continuity clinics (not the MRDC) were audited 6 months before and after the MRDC for Diabetes Practice Behavior Checklist measures (glycated hemoglobin, blood pressure, low-density lipoprotein cholesterol, retinal referral, foot exam, microalbumin screen). Pre-MRDC and post-MRDC data were compared via paired t test.

RESULTS

The MRDC residents exhibited a modest increase in mean (SD) scores on the Diabetes Awareness Questionnaire (before, 8.2 [2.8]; after, 10.9 [2.8]; P  =  .02) and a modest mean (SD) performance increase in overall process outcomes from the Diabetes Practice Behavior Checklist (before, 74% [18%]; after, 84% [18%]; P  =  .004). No improvements occurred in patient outcomes.

CONCLUSIONS

Multidisciplinary diabetes teaching may be useful in fostering certain resident knowledge and performance measures but may not alter clinical outcomes. Further large-scale, longitudinal studies are needed to understand the effect of our curriculum on residents' diabetes knowledge and future practice behavior.

Patient perceptions of innovative longitudinal integrated clerkships based in regional, rural and remote primary care: a qualitative study

Background

Medical students at the University of Wollongong experience continuity of patient care and clinical supervision during an innovative year-long integrated (community and hospital) clinical clerkship. In this model of clinical education, students are based in a general practice ‘teaching microsystem’ and participate in patient care as part of this community of practice (CoP). This study evaluates patients’ perceptions of the clerkship initiative, and their perspectives on this approach to training ‘much-needed’ doctors in their community.

Methods

Semi-structured, face-to-face, interviews with patients provided data on the clerkship model in three contexts: regional, rural and remote health care settings in Australia. Two researchers independently thematically analysed transcribed data and organised emergent categories into themes.

Results

The twelve categories that emerged from the analysis of transcribed data were clustered into four themes: learning as doing; learning as shared experience; learning as belonging to a community; and learning as ‘becoming’. Patients viewed the clerkship learning environment as patient- and student-centred, emphasising that the patient-student-doctor relationship triad was important in facilitating active participation by patients as well as students. Patients believed that students became central, rather than peripheral, members of the CoP during an extended placement, value-adding and improving access to patient care.

Conclusions

Regional, rural and remote patients valued the long-term engagement of senior medical students in their health care team(s). A supportive CoP such as the general practice ‘teaching microsystem’ allowed student and patient to experience increasing participation and identity transformation over time. The extended student-patient-doctor relationship was seen as influential in this progression. Patients revealed unique insights into the longitudinal clerkship model, and believed they have an important contribution to make to medical education and new strategies addressing mal-distribution in the medical workforce.

["Working like a doctor": medical students' expectations of their final year elective in Family Medicine]

BACKGROUND

Successful curricular development requires that consideration be given to the opinions of faculty members, teachers and students. The aim of the present study was to explore students' expectations of the final year Family Medicine elective.

METHODS

Three focus group discussions took place with a total of 15 participants who were either in their fifth year (n=11) or had already passed Family Medicine in their final year (third focus group). The discussions were transcribed verbatim and analysed independently by two of the authors using qualitative content analysis. Final codes were developed and clustered under category names.

RESULTS

As students found that Medical School was too theoretical, they aimed at learning through practice in order to be able to make decisions and act independently. Their ideal teacher would respect them as colleagues. Typical Family Medicine skills were mentioned less often by the "pre-" in contrast to the "post-" practical year students than the learning of technical aspects (ECG, ultrasound). The students discussed three different models of instruction and learning (student and patient alone, student or doctor observes consultation).

CONCLUSIONS

Considering that the final year elective in Family Medicine will take place away from Medical School different teaching models should be evaluated for their effectiveness as well as their learner-centeredness.

Integrating teaching into the busy resident schedule: a learner-centered approach to raise efficiency (L-CARE) in clinical teaching

BACKGROUND

Clinical teachers are sometimes challenged by residents who seem too busy to concentrate on their learning. In such situations, teachers must be aware to diagnose underlying problems in learners and to effectively help them maximize learning while minimizing time and energy requirements.

OBJECTIVE

To develop a learner-centered model to improve efficiency of clinical teaching.

METHODS

We reviewed the literature on educational diagnosis, self-directed learning, and effective/efficient teaching to put together a new model.

RESULTS

The Learner-Centered Approach to Raise Efficiency (L-CARE) in Clinical Teaching is inspired from the well-known patient-centered clinical method. Using the L-CARE in clinical teaching involves: (1) addressing the learners' feelings regarding their environment as well as patient care and study issues, which provides a good learning climate facilitating educational diagnosis and management of issues that could impair learning; (2) establishing a learning contract (expectations); (3) sharing resources and strategies (ideas) that should be effective without wasting time or energy; (4) self-assessment and constructive feedback (impact). These steps are grounded in self-directed learning theory to improve motivation and ensure that learners concentrate on their own needs to promote learning efficiency.

CONCLUSION

The L-CARE model integrates educational diagnosis principles, self-directed learning theory, and efficient teaching strategies to improve efficiency of clinical teaching.

Chronic condition self-management support: proposed competencies for medical students

OBJECTIVE

Governments and the medical profession are concerned that there continues to be less than optimal health outcomes despite escalating expenditure on health services from the effect of the ageing population with chronic illnesses. In this context, doctors will need to have knowledge and skills in effective chronic condition management (CCM) and chronic condition self-management (CCSM).

METHOD

A national workshop of representatives of eight medical schools from the CCSM special interest group (SIG) of the Australian and New Zealand Association on Medical Education met in September 2004, to consider curriculum content in CCM and CCSM.

RESULTS

The workshop recommended that the Committee of Deans of Australian Medical Schools and the Commonwealth Department of Health and Ageing consider the identification and possible development of a specific curriculum for CCM and CCSM within the curricula of Australian Medical Schools.

DISCUSSION

Consideration needs to be given to the changing nature of medical practice and that as part of this; doctors of the future will need skills in team participation, continuity of care, self-management support and patient-centered collaborative care planning. Doctors will also need skills to assist patients to better adhere to medical management, lifestyle behaviour change and risk factor reduction, if optimal health outcomes are to be achieved and costs are to be contained.

Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning

OBJECTIVE

To develop a model linking the processes and outcomes of workplace learning.

METHODS

We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students.

RESULTS

To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning.

CONCLUSIONS

The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.

Teaching focused histories and physical exams in ambulatory care: a multi-institutional randomized trial

PURPOSE

We needed specific strategies for students in diverse outpatient settings to more uniformly learn focused history and physical exam skills.

METHODS

We conducted a randomized control trial to test the use of focused history and physical exam scripts in enhancing 3rd-year medical students' clinical skills at two medical schools. The article based scripts outlined focused outpatient encounters. The outcome measure was blinded analysis of progress notes using a standardized scale. Descriptive statistics were used to assess differences among student in each school, and study groups were compared using a t test.

RESULTS

Five of 11 variables were statistically higher in the scripts group. These included history taking, physical examination, and overall score.

CONCLUSION

Focus Scripts facilitated a specific task of learning to document focused evaluations in acute and chronic office visits.

Views, behaviours and perceived staff development needs of doctors and surgeons regarding learners in outpatient clinics

INTRODUCTION

The need to use outpatient clinics as a major learning environment in hospitals for students and doctors-in-training is clear. However, consultant supervisors perceive major barriers to this and continue to rely heavily on traditional inpatient learning. This quantitative study examines what approaches consultant supervisors employ in outpatient learning, together with what they perceive themselves to use and what they would value in further training.

METHODS

We observed learning episodes for students and doctors-in-training in medical and surgical clinics. A questionnaire on outpatient teaching was also sent to consultant doctors and surgeons. This was based on these observations and focus groups with students and doctors-in-training.

RESULTS

There was an overall survey response rate of 62% (194/311). The dominant forms of learning we observed were 'arms-length' supervision for doctors-in-training and 'modelling' for students. Only 7% of learning episodes involved a doctor-in-training doing something under direct supervision. In contrast to the observation results, consultants considered that students and doctors-in-training received a lot of direct supervision and interaction. For example, 45% considered that doctors-in-training 'may see patients with me in a joint consultation'. Only 30% of respondents would be interested in staff development in learning in outpatient clinics.

CONCLUSIONS

Although consultants reported that they frequently used an active approach to learning in outpatient clinics, modelling was used predominantly for students and arms-length supervision was used for doctors-in-training.

In-training assessment: qualitative study of effects on supervision and feedback in an undergraduate clinical rotation

BACKGROUND

Supervision and feedback are essential factors that contribute to the learning environment in the context of workplace learning and their frequency and quality can be improved. Assessment is a powerful tool with which to influence students' learning and supervisors' teaching and thus the learning environment.

OBJECTIVE

To investigate an in-training assessment (ITA) programme in action and to explore its effects on supervision and feedback.

DESIGN

A qualitative study using individual, semistructured interviews.

SUBJECTS AND SETTING

Eight students and 17 assessors (9 members of staff and 8 residents) in the internal medicine undergraduate clerkship at Vrije Universiteit Medical Centre, Amsterdam, the Netherlands.

RESULTS

The ITA programme in action differed from the intended programme. Assessors provided hardly any follow-up on supervision and feedback given during assessments. Although students wanted more supervision and feedback, they rarely asked for it. Students and assessors failed to integrate the whole range of competencies included in the ITA programme into their respective learning and supervision and feedback. When giving feedback, assessors rarely gave borderline or fail judgements.

DISCUSSION AND CONCLUSION

If an ITA programme in action is to be congruent with the intended programme, the implementation of the programme must be monitored. It is also necessary to provide full information about the programme and to ensure this information is given repeatedly. Introducing an ITA programme that includes the assessment of several competencies does not automatically lead to more attention being paid to these competencies in terms of supervision and feedback. Measures that facilitate change in the learning environment seem to be a prerequisite for enabling the assessment programme to steer the learning environment.

Feasibility and reliability of an in-training assessment programme in an undergraduate clerkship

INTRODUCTION

Structured assessment, embedded in a training programme, with systematic observation, feedback and appropriate documentation may improve the reliability of clinical assessment. This type of assessment format is referred to as in-training assessment (ITA). The feasibility and reliability of an ITA programme in an internal medicine clerkship were evaluated. The programme comprised 4 ward-based test formats and 1 outpatient clinic-based test format. Of the 4 ward-based test formats, 3 were single-sample tests, consisting of 1 student-patient encounter, 1 critical appraisal session and 1 case presentation. The other ward-based test and the outpatient-based test were multiple sample tests, consisting of 12 ward-based case write-ups and 4 long cases in the outpatient clinic. In all the ITA programme consisted of 19 assessments.

METHODS

During 41 months, data were collected from 119 clerks. Feasibility was defined as over two thirds of the students obtaining 19 assessments. Reliability was estimated by performing generalisability analyses with 19 assessments as items and 5 test formats as items.

RESULTS

A total of 73 students (69%) completed 19 assessments. Reliability expressed by the generalisability coefficients was 0.81 for 19 assessments and 0.55 for 5 test formats.

CONCLUSIONS

The ITA programme proved to be feasible. Feasibility may be improved by scheduling protected time for assessment for both students and staff. Reliability may be improved by more frequent use of some of the test formats.

Nurturing educational research at Dartmouth Medical School: the synergy among innovative ideas, support faculty, and administrative structures

In recent years, Dartmouth Medical School has increased its commitment to educational research within the school, and in collaboration with other schools across the country. Passionate faculty members with ideas and expertise in particular curricular areas are one critical component needed for a successful educational research program. Other components include an atmosphere that fosters research collaborations and mentoring, and various types of institutional support structures. This same model has effectively supported basic science and clinical research for decades. Because of the complexities involved in studying medical education, Dartmouth Medical School has invested in support structures for educational grant and manuscript development, financial support for pilot projects and partial salary support for investigators and key staff members, and other support targeted toward specific research projects. Ultimately, the goal is to use the results of the school's educational research projects to improve the curriculum through cycles of hypothesis development and testing, providing evidence for subsequent curricular change. When some research findings are relevant and applicable for use in other medical schools, that is an additional benefit of the educational research process. In this report, the authors describe the development of Dartmouth Medical School's infrastructure for supporting educational research, which has helped to accelerate the educational research productivity teaching faculty now enjoy. The authors also address some of the challenges that they anticipate in the near future.

Medical Students' and Residents' preferred site characteristics and preceptor behaviours for learning in the ambulatory setting: a cross-sectional survey

BACKGROUND

Medical training is increasingly occurring in the ambulatory setting for final year medical students and residents. This study looks to identify if gender, school, level of training, or specialty affects learner's (final year medical students and residents) preferred site characteristics and preceptor behaviours for learning in the ambulatory setting.

METHODS

All final year medical students and residents at the five medical schools in Ontario (N = 3471) were surveyed about the site characteristics and preceptor behaviours most enhancing their learning in the ambulatory setting. Preferred site characteristics and preceptor behaviours were rank ordered. Factor analysis grouped the site characteristics and preceptor behaviours into themes which were then correlated with gender, school, level of training, and specialty.

RESULTS

Having an adequate number and variety of patients while being supervised by enthusiastic preceptors who give feedback and are willing to discuss their reasoning processes and delegate responsibility are site characteristics and preceptor behaviours valued by almost all learners. Some teaching strategies recently suggested to improve efficiency in the ambulatory teaching setting, such as structuring the interview for the student and teaching and reviewing the case in front of the patient, were found not to be valued by learners. There was a striking degree of similarity in what was valued by all learners but there were also some educationally significant differences, particularly between learners at different levels and in different specialties. Key findings between the different levels include preceptor interaction being most important for medical students as opposed to residents who most value issues pertaining to patient logistics. Learning resources are less valued early and late in training. Teaching and having the case reviewed in front of the patient becomes increasingly less valued as learners advance in their training. As one approaches the end of ones' training office management instruction becomes increasingly valued. Differences between specialties pertain most to the type of practice residents will ultimately end up in (ie: office based specialties particularly valuing instruction in office management and health care system interaction).

CONCLUSIONS

Preceptors need to be aware of, and make efforts to provide, teaching strategies such as feedback and discussing clinical reasoning, that learners have identified as being helpful for learning. If strategies identified as not being valued for learning, such as teaching in front of the patient, must continue it will be important to explore the barriers they present to learning. Although what all learners want from their preceptors and clinic settings to enhance their learning is remarkably similar, being aware of the educationally significant differences, particularly for learners at different levels and in different specialties, will enhance teaching in the ambulatory setting.

The internal medicine clinical clerkship: opportunities for improvement

We have witnessed a recent explosion of new knowledge in medical education. The use of creative teaching methodologies, curriculum development and the recognition of medical education as a field ripe for research and investigation have occurred at many medical schools in Europe and North America. However, most of this innovation has occurred in the pre-clinical years and very little has been transferred to the clinical setting. The use of comprehensive curricula with goals and objectives, problem-based learning (PBL), a renewed emphasis on physical diagnosis, evidence-based medicine (EBM), patient-centered interviewing, ambulatory education, computer-based learning and new methods of assessment all need to be introduced into the clinical clerkships while ensuring that the majority of learning still takes place through the student-patient interaction at the bedside. By virtue of its traditional excellence in medical education, internal medicine has the opportunity to take the lead in revitalizing clinical education by building on our successful past and leading the other disciplines into the future.

How do precepting physicians select patients for teaching medical students in the ambulatory primary care setting?

OBJECTIVE

To study how clinical preceptors select patients for medical student teaching in ambulatory care and to explore key factors they consider in the selection process.

DESIGN

Qualitative analysis of transcribed interviews.

SETTING

Harvard Medical School, Boston, Mass.

PARTICIPANTS

Nineteen physicians (14 general internists and 5 general pediatricians) who serve as clinical preceptors.

MEASUREMENTS

Responses to in-depth open-ended interview regarding selection of patients for participation in medical student teaching.

MAIN RESULTS

Preceptors consider the competing needs of the patient, the student, and the practice the most important factors in selecting patients for medical student teaching. Three dominant themes emerged: time and efficiency, educational value, and the influence of teaching on the doctor-patient relationship. These physicians consciously attempt to select patients whose participation in medical student teaching maximizes the efficiency of the clinical practice and optimizes the students' educational experiences, while minimizing any potential for harming the relationship between preceptor and patient.

CONCLUSIONS

These findings may help validate the frustration preceptors frequently feel in their efforts to teach in the outpatient setting. Becoming more cognizant of the competing interests-the needs of the patient, the student, and the practice-may help physicians to select patients to enhance the educational experience without compromising efficiency or the doctor-patient relationship. For educators, this study suggests an opportunity for faculty development programs to assist the clinical preceptor both in selecting patients for medical student teaching and in finding ways to maximize the efficiency and educational quality of the outpatient teaching environment.

Reforming medical education to enhance the management of chronic disease

Medical education must adapt to change if it is to remain relevant to the needs of doctors, patients and society. Ideally, it should anticipate and lead change. Undergraduate education remains rooted in urban medical schools where the focus is on acute disease, while most graduates spend their working lives in the community, dealing mainly with chronic health problems. Medical graduates need to acquire specific knowledge, skills and attitudes if they are to effectively manage people with chronic disease. Strategies that create a better balance between education in acute and chronic disease are being developed. These include a transfer of clinical teaching to community and nursing home settings and the development of interdisciplinary teaching.