Publication on Ambulatory Clinic: More from Dr. Irby

In the publication titled “Teaching and Learning in Ambulatory Care Setting: ThematicReview of the Literature”, Dr. Irby painted a bleak picture of education in ambulatory care clinics in late 1980s to early 1990s. Findings suggest that the ambulatory clinic setting is often poorly conductive to learning because of a variety of factors including tight time constraints, lack of continuity, and insufficient use of observation of trainees for the purpose of feedback. Most concerning of all, is the conclusion that students make dubious gains through their ambulatory care experience and many significant deficiencies remain (although one can argue that improved diagnostic pattern-recognition is important and one ambulatory rotation is not meant to cure all of a learner’s problems).

Some of the points raised in this publication was very refreshingly provokative. For example, it deliberated the issue of how preceptors correct trainee’s clinical errors. A referenced study found that preceptors often apply “face-saving” strategies such as create opportunities for revision, treat wrong answer as plausible but requiring modification, and hinting to invoke the right answer. These methods, though compassionate towards students, bear the heavy limitation of possibly impeding trainees’ “accurate self-assessment”. This is not a trivial point, as I recall instances where I have wondered if an answer given was actually outright wrong or simply in need of tweaking. One of the strategies that I have observed to be both clear and not confrontational was to acknowledge an answer given e.g. with “I can see why you may think that” and then continue with “but the actual answer is this and here is why”.

This publication was overall critical of the state of education in the ambulatory setting at the time of its study. It emphasizes that without thoughtful organization, an ambulatory setting can naturally decay to a state of educational chaos. Dr. Irby recommends a few strategies to improve ambulatory care education including: 

1. improve continuity e.g. with more longitudinal ambulatory experiences
2. improve collaborative and self-directed learning e.g. by offering ambulatory morning reports
3. provide faculty development: e.g. teach teachers to set expectations with students, teach to students’ needs, observe and give feedback, encourage reflection, provide mentorship and positive learning environment, and reflect on one’s own teaching strategies

-Jenny