Chapter 4
Tips for Learning on the Ambulatory Clerkship
Kelly J. White MD, Richard H. Miranda MD, and Eva Aagaard MD
As clinical medicine has progressively shifted to the outpatient setting, the Ambulatory Clerkship has become an increasingly important component of the clinical curriculum. Most medical schools in the United States have at least one required outpatient primary care experience in the core clinical year. This may be associated with the inpatient Internal Medicine Clerkship, a Family Medicine Clerkship, or a Pediatric Clerkship. Alternatively, it may be an integrated or longitudinal outpatient experience with multiple specialties or may function independently. The goal of the Ambulatory Clerkship is to expose students to the health care setting in which the majority of health care is provided—the outpatient clinic. In the Ambulatory Clerkship, students will have the opportunity to practice patient-centered care, focus on health promotion and disease prevention, and understand the pathophysiology, presentation, and management of common illnesses. While most students will have been exposed to primary care as a component of their preparatory doctoring curriculum, the expectations for students on the Ambulatory Clerkship are generally significantly different from that prior experience and often pose new challenges to learning. This chapter aims to provide the student with the proper tools to have a successful learning experience on the Ambulatory Clerkship.
When you meet your preceptor during your clerkship orientation, you should make sure to learn the basic expectations of the clerkship. Be aware of the learning goals, specific project work, examination dates, and all recommended reading. Learn what time you should be in the clinic, what you are expected to wear, if you can see patients independently, how much access you have to the patient chart or electronic health record, with whom else you might be working, what presentation style is preferred, whether you are responsible for documentation, and any other expectations the administrator(s) might have. If the expectations of your preceptor are vastly different from those of your clerkship director, speak to the clerkship director early in the rotation.
PATIENT CARE
The ambulatory care setting offers students an abundance of opportunities to interact with patients with a wide variety of disease processes and diverse backgrounds and to learn about unique approaches to health care provision. Patients present to their primary care provider with a variety of acute, chronic, and preventive care needs. These needs are addressed in brief appointment slots (often 20 minutes or less). This can often be a daunting task for even the most seasoned provider. As a result, students in this environment will often feel hurried, and patient care may seem incomplete. Students may not have the opportunity to provide continuity of care for their patients in these settings and often feel the need to address every complaint or problem on a patient’s problem list. This is not possible and can cause frustration for your preceptor, the patients, and the clinic staff. Thus, developing skills to identify and target the most important concerns is the best approach.
One highly effective technique is to review the patient’s medical record before the visit and identify one or two issues (often chronic or preventive care issues) that you hope to address. After entering the room, discuss with the patient his or her major concerns for that day. Together you can negotiate the two to four most important issues to be addressed at that visit. Begin with open-ended questions, but quickly direct your questioning to formulate an appropriate differential diagnosis. Perform a focused physical examination relevant to the patient’s primary complaint to narrow your differential diagnosis. After discussing the relevant information with your supervising preceptor either outside or inside the room, you will then discuss your findings and negotiate an appropriate plan with your patient. Patient encounters will be effective and efficient when they provide resources for further information as well as ensure timely and appropriate follow-up. Finally, early recognition of findings of concern must be addressed immediately with the preceptor to prevent delays in initiation of diagnostic or therapeutic interventions. If the patient looks ill or shows worrisome symptoms or signs of a potentially acute life-threatening event, stop the interview and notify your preceptor immediately.
