Ambulatory versus inpatient rotations in teaching third-year students internal medicine

Abstract

We studied 63 randomly selected third-year students who split their 10-week medicine clerkship between ambulatory and inpatient components. Compared with their inpatient experience, during the ambulatory rotation, the 63 students felt more like doctors, more responsible for patients, and more able to know and help their patients. Students reported that ambulatory attending staff appeared happier and less stressed, and did not embarrass them as frequently. Compared with their 619 "inpatient" classmates, these 63 "ambulatory" students scored as well on the medicine examination, and were as likely to receive honors (44% vs 41%), and to choose internal medicine residencies (35% vs 34%). In conclusion, students experienced better relationships with their patients and teachers during the ambulatory rotation, which was academically comparable to the inpatient experience.KEY WORDS: medical student; medical education; ambulatory rotation; medical clerkship; inpatient rotation. J GEN INTERN MED 1998;13:327-330.S hifting medical student education in internal medicine (IM) from the inpatient to the outpatient setting is an appropriate response to the parallel shift in clinical practice. 1 However, compared with the rich tradition of bedside teaching in hospital-based clerkships, ambulatory care sites are relatively new to the medical education enterprise. Reports of ambulatory clerkships suggest that academically rigorous programs can provide students with an adequate knowledge base while broadening the curriculum to include ambulatory-specific topics. 2-4 However, we lack comprehensive evaluation data. This has raised concerns that ambulatory medical education is being embraced before its educational consequences are fully understood and the curricula are rigorously evaluated. 5 Between 1991 and 1995, New York University (NYU) School of Medicine piloted an ambulatory IM rotation for randomly selected third-year students. These students split their 10-week IM clerkship in half: an established inpatient rotation, and a new ambulatory rotation at the Gouverneur Diagnostic and Treatment Center. We describe this ambulatory IM rotation and evaluate students' perceptions and educational outcomes compared with the inpatient rotation. METHODS Description of the Ambulatory RotationFour randomly selected students (out of 30-40) per quarter were assigned to spend half their IM clerkship at Gouverneur, a municipal, primary care clinic affiliated with NYU School of Medicine. The rotation consisted of six, half-day clinical sessions in the primary care IM clinic. For each patient, the student completed a history and physical examination, developed a differential diagnosis and problem list, and designed a management plan. The student presented each case to a faculty preceptor who reviewed the clinical data and the student's clinical reasoning, and did a focused clinical evaluation. As case loads grew, students saw patients for follow-up visits. These core clinical learning experiences were supplemented with weekly rounds with the chief of...

Disagreement Between Students and Preceptors Regarding the Value of Teaching Behaviors for Ambulatory Care Settings

“…[1][2][3] Designed to ensure that students acquire fundamental skills needed for further specialty training, these clerkships involve a complex interaction between student and teacher that is often described as an apprenticeship. 4 The student is acquiring the skills of a physician by doing the work of patient care.…”

Using the Ambulatory Care Teaching Centre to develop opportunities for integrated learning

“…Tutors enjoy teaching in the ambulatory care setting (Kalet et al, 1998). In our experience tutors interacted well with both students and patients and were reported to be at ease in the new teaching environment.…”

Outpatient training in neurology

“…A study of medical students found that those students who had increased time on ambulatory rotations had a more positive experience, and scored as well on objective measures of learning, as students with mostly inpatient rotations. 20 A survey of medical clerkship directors recommended onethird of medical student time be spent in ambulatory care compared with 50% in the inpatient setting. 21 The relative benefits for residents may be different, however: in one study at an academic medical center residents gave better evaluations to inpatient than outpatient teaching physicians.…”