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.
MEDICAL KNOWLEDGE
The outpatient setting provides a remarkable opportunity to increase your medical knowledge. You will repeatedly see patients with common chronic and acute illnesses, such as diabetes or back pain. You may also have the opportunity to see patients with rare diseases or acute presentations of severe illnesses. You cannot possibly anticipate everything, but familiarizing yourself with common symptoms and diseases will certainly help. Another large part of primary care practice is disease prevention. This includes screening tests, immunizations, and patient education. Take time to learn the evidence-based recommendations for commonly used vaccinations and screening tests. Organizations such as the United States Preventive Service Task Force (USPSTF), American Cancer Society (ACS), and Centers for Disease Control and Prevention (CDC) have easily accessible published guidelines that are utilized in everyday practice. There are also evidence-based treatment guidelines for common diseases such as hypertension and diabetes. You can use the following website to easily identify different evidence-based guidelines: http://www.guidelines.gov/. Many of these guidelines are also available on handhelds for easy reference (see list at http://www.studentconsult.com). Utilize both your patients and your clerkship learning objectives to guide your reading. Use every opportunity available to you to increase your knowledge; ask questions, observe your teachers, read, and listen to your patients.
PRACTICE-BASED LEARNING AND IMPROVEMENT
The clinical rotations bring many opportunities for self-directed learning. Reading about your patients at the end of each day will allow you to focus on the subjects about which you need to learn more. Keep a notebook, a working document, or another tracking system with you in the clinic. Write down questions or issues that came up during your clinic day. These questions may come from your preceptor, patients, colleagues, or yourself. One important goal is to try to read about at least one patient-related complaint, condition, or preventive strategy each night. Resources such as online cases (SIMPLE, DXR, CLIPP) can also be valuable resources for learning. Use your clerkship manual to help guide your reading and set goals for the depth of knowledge required. You may have the opportunity to share your learning with your patients, your preceptor, or even the clinic team, providing you with more opportunities to further your learning. If you are having trouble identifying areas to work on, ask your preceptor for feedback and use this information as a guide.
In addition to increasing your medical knowledge, use the Ambulatory Clerkship to help you improve your clinical skills. Ask for feedback from your supervising preceptor, nurses, or other members of the interdisciplinary team. When asking for feedback, make sure the timing is appropriate. Ask specific questions about things you can work on to improve (e.g., How was my oral presentation? Would you have done anything differently on that physical examination? Are there parts of the history I left out that you thought were important?), helping your preceptor to provide specific and constructive feedback. Listen and incorporate the feedback into your practice.
INTERPERSONAL AND COMMUNICATION SKILLS
Oral presentation skills are important in any setting, and they become essential for success in the clinic. Because of the time constraints of the preceptor’s schedule, you must present your findings succinctly and maintain focus on the issues that have to be dealt with during that visit. Many patients present with both acute and chronic concerns, which need to be prioritized and addressed appropriately. The SNAPPS approach to oral presentation has been successfully utilized in the outpatient setting. This acronym stands for (1) Summarize the history and physical exam findings, (2) Narrow the differential diagnosis, (3) Analyze the differential diagnosis, (4) Probe the preceptor with questions about the diagnosis, (5) Plan management of the patient’s problems, and (6) Select a relevant issue for self-directed learning.*
Your communication skills are important not only when presenting to your preceptor but also when talking with patients and to the health care team. In patient communication, be sure to speak clearly, make eye contact, and use terms that are easily understood by nonmedical professionals. If your management plans are complicated, make sure to write them down. Ensure that your patient understands the problems and treatment plans by asking questions and having the patient explain the information you have provided.
Written communication is a vital component of outpatient medicine. It is how we document our findings, clinical decision making, and plans for treatment. It is the way we communicate this information to ourselves (so we can remember at the next visit) and often the way we communicate to our partners, interdisciplinary team members, and consultants. SOAP notes (i.e., subjective, objective, assessment, and plan) are the most common form of written communication, although consultant letters are also quite common. Review the guidelines in your clerkship syllabus—and ask your preceptor his or her expectations of you—for note writing, including format, length, and whether or not these notes will become an official part of the medical record.
PROFESSIONALISM
In your role as a third-year medical student, patients are seeing you as a treating provider, a professional. This requires you to exhibit professional behavior at all times, both in and out of the clinic. Dress professionally, and show compassion and respect for others. Be on time, or even early, as you might be able to help someone. Arrive eager to work and learn, putting the patient’s needs above your own. Respect patient privacy by following the guidelines from the Health Insurance Portability and Accountability Act (HIPAA). Appreciate diversity and leave judgment behind. Communicate with your preceptor and the clinic staff about any potential absences or tardiness. Demonstrate respect for your clinic and patients by operating efficiently. Learn names and roles of team members, treating all with the same respect you give your patients and preceptor. Know your limitations as a student, and do not be afraid to ask for help.
SYSTEMS-BASED PRACTICE
Ambulatory practices vary dramatically in the services and approach afforded to patients during their visit. Many practices are converting to an electronic health record for documentation, while others still rely on paper charts. Understanding the system in which you will be working is vital to ensure efficiency and accuracy. Take the time to familiarize yourself with the systems and people who make the clinic work before embarking on your own patient encounter. Be sure to recognize and identify all the members of the health care team, learning their roles and how they can help you provide care for your patients. Be aware of how much time you have for your encounter, as it may be only 10 minutes. Finally, have an understanding of some of the patient-related resources. There are many easily accessible, reputable web-based resources to provide to patients when time is of the essence and extended discussions are not feasible. Providing such educational resources will help reinforce important concepts.
KEY POINTS
Time is of essence in the outpatient setting.
Look at your preceptor’s schedule in advance to identify patients with problems about which you want to learn more.
Discuss expectations with your preceptor at the beginning of the rotation. Find out how he or she likes to work and when feedback will be provided. Uncover any other expectations the preceptor might have.
Familiarize yourself with the goals and expectations of the clerkship, and make sure you are meeting them.
Ask to see patients independently so you can have the first attempt at formulating the differential diagnosis and plan.
Briefly review the patient’s chart before the visit, and choose one or two issues on which to focus.
Impress your preceptor with your knowledge of common diseases and screening guidelines.
Try to fit into the practice as best you can. Take the time to get to know the names and roles of office staff.
Be on time and eager to work.
Keep your appearance professional, and get to know the medical team caring for the patients.
Enjoy the opportunity to work with patients who have a trusting relationship with their doctors.
Learn, have fun, and work hard.
Suggested Readings
Dent JA. AMEE Guide No 26: clinical teaching in ambulatory care settings: making the most of learning opportunities with outpatients. Med Teacher. 2005;27:302–315.
Kernan WN, Hershman W, Alper EJ, et al. Disagreement between students and preceptors regarding the value of teaching behaviors for ambulatory care settings. Teach Learn Med. 2008;20:143–150.
*From Wolpaw TM, Wolpaw DR, Papp KK: SNAPPS: A Learner-centered Model for Outpatient Education, Academic Medicine, September 2003, vol. 78, no. 9, 893–898; by permission of Wolters Kluwer Health.
