Medical Education in the Ambulatory Setting (#2)

Tina Zhu

While sitting outside of Starbucks on this rare balmy March night, I perused through Dr. Bowen's paper on Changing habits of practice - Transforming internal medicine residency education in ambulatory settings ¹.  The paper reviewed existing studies that focused on curriculum, teaching, and evaluation of internal medicine (IM) residents in the ambulatory setting. 

I must agree with the authors in that IM learners are under-exposed to learning in the ambulatory setting.  This has certainly been my experience thus far during my core IM clerkship rotation.  I spent  a total of 4 half-days in various ambulatory medicine clinics, which is about 3.5% of the time spent during my 8-weeks rotation.  This pattern seems to persist during residency.  At Wednesday's Grand-Rounds on Toronto's new IM residency curriculum, it has been revealed that starting in July 2012, PGY-1 residents will no longer be participating in the AIMGP (Ambulatory Internal Medicine Group Practice) clinics.  The reasons presented for this change are multi-fold and fall outside the scope of this particular blog, but it was proposed that PGY-3 residents may benefit more from the AIMGP experience instead of the PGY-1s.  Here is my question: shouldn't both PGY-1 AND PGY-3 residents participate in AIMGP?  After all, it is one of the only longitudinal ambulatory experience that our residents receive during their training and it should therefore be well emphasized...no?  I am sure there are various barriers to this model that I am ignorant of...maybe this can be a point of discussion with Dr. C during our Monday meeting. 

Another comment I found interesting was the authors' note that "the heterogeneity of the published studies, and the lack of methodological rigor and multi-center designs significantly limits our ability to draw broad conclusions from this literature" ¹.  This comment struck a chord with a recent series of papers we read on the "epistemological crisis" in medical education.  They consisted of a back-and-forth debate between Glenn Regehr^2,3 and Geoff Norman⁴ on the value of using the traditional physicist's reductionist approach to experimental design to explore the complicated/ complex/ chaotic context of medical education.  While I recognize that there are many components of medical education that can be explored using rigorous methodological design and subsequently applied widely across multiple institutions, the interaction between student, teacher, and learning environment is often so complex and individualized to each institution that the ability to draw broad conclusions need not always be the goal of medical education research.  Rather, it may be equally important to explore education strategies that can be effectively implemented at particular institutions and the factors that engender successes. 

References

1. Bowen, JL et al. Changing habits of practice: Transforming internal medicine residency education in ambulatory settings. J Gen Intern Med 2005; 20:1181-1187.

2. Regehr, G. It's NOT rocket science: rethinking our metaphors for research in health professions education. Medical Education 2010; 44:31-39.

3. Regehr, G. Highway spotters and traffic controllers: further reflections on complexity. Medical Education 2011; 45:542-543.

4. Norman, G. Chaos, complexity and complicatedness: lessons from rocket science. Medical Education 2011; 45:549-559.