Teaching clinical medicine in the ambulatory setting: An idea whose time may have finally come
ABSTRACT A resurgence of general interest in teaching clinical medicine in ambulatory-care settings has occurred for several reasons, including changes in the case mix in teaching hospitals, the new responsibilities of house officers and attending physicians brought about by the current payment systems for health care, the increased expectations of patients that medical care will be "personal," the progressive limitations imposed on the education of medical students by the shorter lengths of stay sought by hospitals under the diagnosis-related-groups system of payment, and the growing need for well-trained primary care physicians that has resulted from the increase in medical care organizations. In this paper, I review earlier attempts to emphasize ambulatory care, to identify the pitfalls that new efforts in this direction should avoid. I also compare inpatient and ambulatory-care teaching to provide a basis for understanding the educational goals that can be achieved more easily in each setting. In addition, I suggest major changes in the flow and use of clinical-practice funds and hospital payments so that they can become possible sources of the financing and organization of an expanded effort to teach clinical medicine in ambulatory-care settings.
- SourceAvailable from: James O Woolliscroft
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- "1975; Mendenhall eta/. 1979); changes in the financing of medical care (Perkoff 1986; Schroeder et a / . 1986); and changes in the utilization of hospital and ambulatory services (Perkoff 1976). "
ABSTRACT: In an academic medical centre between 1980 and 1985, the attitudes, preferences and career goals of house officers in a primary medical care residency training programme were assessed at entry and at the end of each house officer year. Primary care trainees who went on to practise in a general medicine setting were compared to primary care trainees who subsequently received subspecialty training and also to traditional internal medicine trainees. House officers in the primary care programme generally maintained attitudes and preferences central to the practice of primary care, and scored significantly higher than traditional track house officers on attitudes and preferences compatible with the practice of medicine in a primary care setting. However, primary care house officers who later went into subspecialty training received scores similar to those of traditional track house officers on practice preferences relating to specialty care. There were no significant differences between primary care and traditional track house officers on standard measures of knowledge and clinical skill.Medical Education 10/1987; 21(5):441-9. DOI:10.1111/j.1365-2923.1987.tb00393.x · 3.62 Impact Factor
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ABSTRACT: Family medicine predoctoral programs frequently have medical students record patient diagnoses in logbooks. Little is known about the accuracy of such logbooks. No studies have compared patient records dictated by students with cases recorded in logbooks. Over 2 years, all patient encounters dictated by 79 medical students during their 8-week family medicine rotations were recorded and compared with information in the students' logbooks. Students dictated 2,520 patient encounters but only recorded 2,085 (82.7%) of them in their logbooks. Still, this rate of inclusion is higher than other studies where students did not dictate patient encounters. On the average, each student saw and dictated 32 patient encounters but omitted five to six from their logs. There were no significant differences between the 10 honors and 69 non-honors students in the proportion of patients omitted from logbooks. Medical students underreport patient encounters in clerkship logbooks. Keeping a record of the patients dictated by medical students was helpful in determining the accuracy of students' logbooks.Family medicine 30(7):487-9. · 0.85 Impact Factor
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ABSTRACT: To evaluate the casemix seen during an internal medicine clerkship and to assess the educational value of the problems seen. A modified Delphi-group opinion technique was used to develop a clerk log that included priority problems for internal medicine. Over a 12-month period, clerks recorded their exposure to the problems seen during their eight-week rotations. General internists rated the importance of each of the problems on a three-point scale. The inpatient internal medicine services in six university teaching hospitals. All clinical clerks in a single undergraduate year recorded their experiences. All university-based general internists participated in rating problem importance. The final approved log contained 72 problems, 64 of which received importance ratings greater than or equal to 2 on the three-point scale. The frequency of clerk exposure per problem was high and the correlation between frequency of exposure and importance was good. Ten important problems had relatively low exposure and four problems of lower importance had high exposure. The clinical clerks were exposed to a broad spectrum of diseases, but some key problems were not well represented on the wards. Alternative strategies, including increased ambulatory care exposure, will be required to complete the exposure and to assure that the quality of patient exposure matches the quantity.Journal of General Internal Medicine 01/1991; 6(5):455-9. DOI:10.1007/BF02598171 · 3.42 Impact Factor