Academic medicine : journal of the Association of American Medical Colleges
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Review
Assessing quality and costs of education in the ambulatory setting: a review of the literature.
Time-pressured interactions with little direct observation or feedback characterize teaching in ambulatory settings. The authors report findings from the literature on teaching and learning in the ambulatory setting and propose opportunities for further research that addresses these barriers. ⋯ This review identifies many gaps in our knowledge of effective clinical teaching practices, and of learning environments in which that teaching takes place. The predominance of single-institution studies limits generalizability of current findings. A prioritized research agenda should be established and funded, focusing on improving the efficiency and effectiveness of teaching and learning in ambulatory settings.
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Comparative Study
The training and career paths of fellows in the National Research Service Award (NRSA) Program for Research in Primary Medical Care.
To describe the training and career paths of fellows in the National Research Service Award (NRSA) Program for Research in Primary Medical Care. ⋯ Only a minority of those completing NRSA programs held positions as faculty researchers. The preponderance of general internists among researchers may indicate problems in the capacity of general pediatrics and family medicine to support primary care research. The amounts of direct research time during these fellowships may need to be increased to enhance the likelihood of subsequent research success.
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Adolescents in the United States have high morbidity rates, which are attributable to injuries, behavioral disorders, sexually transmitted diseases, and unplanned pregnancies. This has led to a call to action for health care educators to better prepare future practitioners to meet adolescent health care needs. Although pediatrics residency programs have required one-month curricula dedicated to adolescent medicine, many internal medicine (IM) residency programs do not have such requirements despite an American College of Physicians position paper recognizing the importance of internists' providing health care to adolescents. Thus, an introductory curriculum in adolescent medicine was developed for a community hospital IM residency program. The curriculum was designed to train IM residents to effectively interview, provide preventive care for, and evaluate common medical problems of older adolescents (ages 16-21) in an outpatient setting. ⋯ Twenty-one of 40 residents participated in the pilot unit. Evaluations were overall very positive. Quiz scores confirmed that the residents achieved the desired learning objectives. Given these results from the pilot unit, the remaining two units of the curriculum have been integrated into the residency curriculum. Additional faculty members have been selected to deliver future sessions and support this important educational activity. The adolescent medicine curriculum can be used as an model by other IM residency programs for teaching adolescent health care, with an emphasis on both the knowledge base of adolescent issues and awareness of the unique skills necessary for the establishment of a physician-patient relationship between internists and older adolescents.
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Teaching and learning in the ambulatory setting have been described as inefficient, variable, and unpredictable. A model of ambulatory teaching that was piloted in three settings (1973-1981 in a university-affiliated outpatient clinic in Portland, Oregon, 1996-2000 in a community outpatient clinic, and 2000-2001 in an outpatient clinic serving Dartmouth Medical School's teaching hospital) that combines a system of education and a system of patient care is presented. Fully integrating learners into the office practice using creative scheduling, pre-rotation learning, and learner competence certification enabled the learners to provide care in roles traditionally fulfilled by physicians and nurses. ⋯ The time spent alone with patients, in direct observation by preceptors, and for scheduled case discussion was appreciated by learners. Increased satisfaction was enjoyed by learners, teachers, clinic staff, and patients. Barriers to implementation include too few examining rooms, inability to manipulate patient appointment schedules, and learners' not being present in a teaching clinic all the time.
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Residents must learn to assess the medical literature and apply it clinically. We designed and implemented a curriculum to support resident acquisition and use of skills required for critical review and clinical application of evidence from the pediatrics literature. The experience provided an opportunity for residents to observe, demonstrate under supervision, and practice evidence-based skills using the "see one, do one, practice many" approach. ⋯ Skills are best acquired in an environment which promotes active learning supervised by experts and provides frequent opportunities to practice the skills. Residents have responded positively to our curriculum and have presented high-quality conferences. Evaluation data being collected now (resident self-assessments and evaluations of the experience, faculty assessments of presentations, pre- and post-second year written assessments of knowledge) will inform us if the desired outcomes are being attained. Over the first two years of implementation of this curriculum, we have observed that it takes no more faculty time to supervise resident preparation and presentation than it would for the faculty to prepare and present material concerning similar curriculum objectives in a lecture or conference format. Additional benefits for residents include creating materials for presentation with experienced faculty, making presentations for peer groups, and assuming the role of teacher.