Ambulatory Component of the Internal Medicine Clerkship

Introduction

In January of 1993, the Department of Medicine revised the third year clerkship to include an ambulatory component. The clerkship now comprises three one-month block rotations, two in-patient and one ambulatory. In the section below, we review the rationale and special features of ambulatory care education in internal medicine.

Rationale And Special Features Of Ambulatory Care Education

General Comments

To see the full spectrum of patients who visit internists and to learn the full spectrum of skills required for the practice of internal medicine, students must be educated both inside and outside the hospital. Patients who traverse the filter of primary care providers, subspecialists, and emergency rooms to be hospitalized are distinct from typical medical patients. The new curriculum for the medicine clerkship is built upon explicit recognition of these distinctions and of the special skills and knowledge required for outpatient care. As background to a description of the new curriculum, what follows is a summary of salient distinctions in the care of outpatients and inpatients.

Typical patients who visit internists outside the hospital are functioning adults who seek diagnosis and treatment for symptoms, care of chronic conditions, or health maintenance. The most common symptoms include headache, fatigue, abdominal pain, weight loss, diarrhea, dizziness, dysuria, chest pain, shortness of breath, cough, insomnia, malaise, back pain, and rhinitis. Most patients who present with one of these will be found to have a readily treatable condition. Only a minority will require hospitalization. To learn to diagnose and treat common symptoms, students must work in clinics and private practices.

Among the chronic conditions for which patients see internists, some rarely cause hospital admission and will not be seen by students during hospital clerkships. Examples include rheumatoid arthritis, venereal disease, osteoarthritis, dementia, thyroid disease, asthma, hypertension, and allergic rhinitis.

When chronic diseases do precipitate hospital admission, the emphasis of physicians' care is on short-term management. The goals and principles of short term management are often very different from the goals and principles of definitive, long-term management. Diabetes is one example. When a diabetic patient is hospitalized, the reason is usually ketoacidosis, nonketotic hyperosmolar coma, another severe complications of diabetes, or a comorbid illness. In the hospital, care is then directed toward restoring homeostasis or treating the comorbid condition. Definitive long-term treatment of diabetes is not emphasized. In office-based care, however, long-term care is the physician's principal concern. Students who work in offices, therefore, have an excellent opportunity to learn about glucose monitoring, insulin adjustment, diet, exercise, and special health maintenance protocols for diabetics.

Chronic and acute conditions manifest a spectrum of severity from mild or early to severe or advanced. Only patients with severe forms of an acute illness or uncompensated exacerbations of chronic illness typically enter the hospital. To see the full spectrum of patients including those who are not yet diagnosed, newly diagnosed, or successfully managed, students must learn in clinics and private office. Not all patients with coronary artery disease have heart failure. Not all patients with HIV disease have disseminated MAI. Not all patients with breast cancer have metastatic disease. The challenge for educators is to create clerkships in which students can develop accurate impressions of the spectrum of illness in these and other common chronic conditions.

Successfully managed patients in office-based practice include those with advanced, complex illness (e.g. CRF, diabetes, advanced CHF, hypoxemic respiratory failure). Internists are specially trained to care for these patients and pride themselves on being able to do it. Office-based management strategies for these sicker patients typically include frequent visits, between visit phone and e-mail contact, use of non-physician providers and home care agencies, and extensive patient self-monitoring. Medical students need to understand intensive office-based care and develop basic competencies in this area.

A principle concern for many patients who visit internists is disease prevention. The spectrum of preventable conditions is broad and includes prevalent chronic diseases such as breast cancer, lung cancer, coronary artery disease, osteoporosis, emphysema, and AIDS. The scientific literature on the effectiveness of putative prevention modalities is abundant and, often, conflicting. To meet patient's expectations for clear, authoritative guidance on disease prevention, physicians must be well-informed, skilled in critical appraisal of the literature, and skilled at negotiating treatment plans with patients who may have distinct preferences and values. Disease prevention is a major intellectual and humanistic challenge for modern internists. It is an area of medicine that is not emphasized or conveniently taught in hospital-based curricula, but which must be a major focus of a practice-based curriculum.

Among the skills required for the practice of internal medicine, several pertain principally or exclusively to outpatient practice. These include skills related to the diagnosis and treatment of conditions seen primarily in the outpatient setting (e.g.: alcoholism, sinusitis, monarthropathy, shoulder pain). They also include the skills of orchestrating a brief (20 minute) office visit, maintaining an office record, assuring proper follow-up for acute and chronic conditions, and making subspeciality referrals. These key skills are most conveniently taught where they are applied - in the office.

Special Opportunities For A Practice-Based Curriculum

Emphasis On Values And Attitudes

The Department's move toward an ambulatory curriculum is substantially motivated by the need to enrich the education of students with emphasis on values and attitudes. The medical office is an excellent milieu in which to accomplish this enrichment. The circumstances of an office visit cast doctor and patient as partners in a therapeutic alliance. To be successful in helping the patient, the physician must earn the patients confidence and work to maintain it. Any failure by the physician to provide expected care, to account for the patients values, or to indicate respect will weaken the alliance and impair the physician's ability to provide help. An effective physician must be smart about medicine, empathetic, and discerning of patient's beliefs and fears. Above all, an effective physician must refrain from making value judgments about patients because of their ethnicity, age, gender or choices for life style and health. A physician who views an alcoholic or intravenous drug user as a "bad" person, for example, is not likely to be able to help that patient. A physician who becomes angry with a patient who declines a recommended therapy may loose the patient's confidence. A physician who prescribes therapy that is not in-line with a patient's values may not observe compliance.

Unlike patients in a hospital, patients in an office who are dissatisfied with their physician will leave at their own discretion and not return. This option is a symbol of the greater equality in the relationship between doctor and patient in the office. From this greater equality stems the opportunity for students to mature in their approach to patient care

Bedside Teaching

In office-based precepting bedside teaching is an inextricable part of routine education and good patient care. The student may accompany the attending as a passive observer. Alternatively, if the student sees the patient first, the attending may later join them to speak directly with the patient, verify the history, confirm physical findings, or observe the student's performance. Attending physicians virtually never allow patients to leave an office having been seen only by a student.

In contrast, bedside teaching is less routine during inpatient rotations (Linfors 1980). During inpatient rotations, furthermore, bedside teaching customarily involves one attending with a group of students and houseofficers. Typical practice-based precepting is a more direct interaction between one attending and one student.

Bedside (or tableside) teaching is an excellent technique to help students acquire new skills in interviewing and examination. Attending physician may coach students in practicing specific new skills, or students may observe their effective use by a mature physician. In every meeting between a student, patient, and attending, the attending has a convenient opportunity to demonstrate attitudes that are essential to successful patient care. They include the attitude that diagnostic and treatment strategies must be negotiated with each patient to assure they are in line with the patient's values and health beliefs.

Observation of students is a key component of effective clinical education. As a component of bedside teaching preceptors in this clerkship will routinely observe students performing the skills they are attempting to acquire, particularly interviewing and physical exam. To preserve work flow in the office, observation will usually be brief and focused on skills. For example a preceptor may observe just the first few minutes of an interview before leaving the student on his or her own. Observation is necessary as a basis for assessment, feedback and skill improvement.

In summary, the circumstances of ambulatory precepting assures that each student will have constant one-on-one contact with an attending physician. Provided that the attending is prepared, this close relationship has distinct educational merit. Students receive direct coaching for rapid skill development. They also may observe constantly the attitudes and skills of mature role models. Through role models, the students themselves may be challenged to grow into individuals who are better prepared to meet the needs of their patients.

Summary

For years, the Department of Medicine has recognized that the care of hospitalized patients is a key skill for general internists or subspecialists whose responsibility to the patient must not stop at the onset of severe illness. With the revised clerkship, the Department is now creating a more balanced curriculum that includes instruction in distinct skills required for practice outside the hospital. The new curriculum will improve students' preparation for medical practice. Very importantly, it will also help students acquire a more accurate understanding of modern internal medicine and its career opportunities.