WHITCOMB, MICHAEL E. MD
During the 1980s, several “blue ribbon” panels were convened to examine the state of medical students' education in the United States. Each of the panels, including the AAMC Panel on the General Professional Education of the Physician, recommended that medical schools provide students with more educational experiences in ambulatory care settings. Those recommendations were based largely on the fact that patients with the kinds of common disorders that medical students should be exposed to were no longer receiving their care in hospitals as frequently as in the past. Thus, schools were encouraged to reassign students from traditional hospital inpatient environments to ambulatory sites to ensure that they would have opportunities to encounter those patients.
These recommendations presented a major challenge to medical school deans and faculties. They recognized that the number of patients the fulltime faculty were seeing on an ambulatory care basis, largely in the clinics of the major hospitals affiliated with their medical schools, was inadequate to meet the educational needs of all of the students. Accordingly, they had little choice but to explore the possibility of placing students in the offices of practicing physicians. To do so meant that schools would become dependent on those community practitioners—many of whom had little experience teaching medical students—for providing a major part of the students' clinical education. In addition, almost nothing was known at that time about how to effectively educate students in the offices of practitioners. As a result, medical schools were hesitant to take up the challenge.
In the early 1990s, however, an additional factor—the need for medical schools to ensure their students had experiences in primary care settings early in their medical school experiences—came into play. This imperative was a response to study findings showing that fewer and fewer graduating students were opting for careers in primary care medicine at a time when the country appeared to have a significant shortage of primary care practitioners. Based on the assumption that students would be more likely to choose careers in primary care medicine if they had a better appreciation of primary care practice, medical schools were encouraged to integrate aspects of primary care medicine into the early years of the curriculum. In response, schools began to place students in the offices of primary care practitioners one half day a week, or every other week, throughout most of the first two years of the curriculum, despite a lack of understanding about how to conduct effective educational experiences in doctors' offices.
During the past decade, medical schools have accumulated a great deal of experience with ambulatory-care—based education. The adoption of family medicine as a required clerkship by most schools resulted in a great increase in the amount of ambulatory-care—based education experienced by medical students. In addition, a number of schools, in keeping with the emphasis placed on primary care medicine, established multispecialty primary care clerkships in the third year of the curriculum. Finally, most schools redesigned traditional clerkships in other disciplines to include a block of ambulatory experience. Thus, the total amount of time that students spend in ambulatory care sites has increased dramatically in recent years. Given this, what do we now know about conducting effective educational experiences in ambulatory settings, particularly in the offices of community-based practitioners?
The papers about ambulatory care-based education that appear in this issue of the journal provide important information to address this question. The two literature reviews—one by Orginc, Mutha, and Irby and the other by Bowen and Irby—make it clear that a great deal is now known, at least with regard to experiences in family medicine, internal medicine, and pediatrics. These reviews show that students are generally satisfied by the experiences they have when rotating through doctors' offices, as are the doctors who serve as their preceptors during those rotations. However, while it is clear that students learn aspects of medicine while rotating through ambulatory sites, the scope of their learning is not known, and the literature does not indicate the most effective way to teach in ambulatory settings, or how best to structure the educational experiences. These observations suggest areas for future investigation that should engage the medical education research community.
The four papers by members of the faculty and administration at Dartmouth Medical School illustrate nicely how institutions can approach these issues. Those papers describe the organizational arrangements that Dartmouth made to ensure optimal management of the educational experiences provided to its students while assigned to an integrated primary care clerkship, and describe the results of some of the research conducted to improve the quality of those experiences. The systematic approach undertaken at Dartmouth, if adopted by other schools, would almost certainly lead in the near future to answers to many of the important questions that remain about ambulatory care-based education.
The importance of undertaking such research cannot be overestimated. Given the trends of the past few decades, there can be little doubt that an ever-increasing amount of the care provided to patients will be delivered in various ambulatory settings. It follows, therefore, that more and more of the clinical education of both medical students and residents will have to be conducted in those settings. To ensure that physicians are being adequately prepared for the future practice of medicine, the medical education community must focus its effort on conducting research that will lead to improvements in the design of ambulatory-care—based educational experiences and in the teaching that occurs during those experiences. In addition, it is important to continue to develop methods for monitoring closely the kinds of patients that students and residents are encountering, and the kinds of clinical situations being presented to them. The research agenda is challenging. The papers published in this issue of the journal make it clear that the work has begun.