Medical Teacher, Vol. 27, No. 4, 2005, pp.

302–315

AMEE GUIDE

AMEE Guide No 26: clinical teaching in

ambulatory care settings: making the most
of learning opportunities with outpatients

JOHN A. DENT
Department of Orthopaedic and Trauma Surgery, University of Dundee, Scotland, UK
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SUMMARY Increasing student numbers and changes in healthcare units, can be used to provide a variety of clinical experiences
delivery are making inpatient settings less ideal for teaching and opportunities. An ambulatory care teaching centre
undergraduate students. As the focus of healthcare provision shifts (ACTC) may be created for structured, supervised clinical
towards ambulatory care, increasing attention must now be given teaching and integrated learning. The increased use being
to developing opportunities for clinical teaching in this setting. made of the day surgery unit (DSU) and the recent
This Education Guide describes the opportunities to be made introduction of ambulatory diagnostic and treatment centres
available by introducing clinical teaching into ambulatory care (ADTCs) in the UK indicates that the ambulatory setting can
venues not usually used for undergraduate teaching as well as be expected to become the focus of increasing attention
different models for maximizing student/patient interaction in (Telegraph Group, 2002). It is therefore important that
traditional outpatient clinics. In general there has been only a strategies are made so that ‘teaching follows the patient’
For personal use only.

limited development of teaching initiatives in such ambulatory care to these new venues (Lawson & Moss, 1993). Maximizing
areas as accident and emergency departments, clinical investi- the learning opportunities that the ambulatory setting
gation units, radiology and imaging suites or the departments of can provide is now a focus of increasing interest in
professions allied to medicine. Each of these venues provides medical education.
different resources suitable for clinical teaching and has its own
advantages and disadvantages. A variety of models for facilitating
student groups in these venues can be used. Practical advice is
provided for the clinical tutor about to supervise clinical teaching
in any of these ambulatory care settings. In contrast the What is ambulatory care?
development of a dedicated Ambulatory Care Teaching Centre
Ambulatory care refers to any place where patients are seen
allows the use of specific instructional strategies and can focus
in hospital without being admitted as inpatients. Although
teaching on specific body systems illustrated by clinical volunteers
it is easy to think of ambulatory care as just another name
invited to attend from a ‘bank’ of previous patients with stable
for outpatient clinics, it in fact includes all those parts of
clinical conditions. Finally, a teaching programme based on the
the hospital where patients come for a consultation, or a
day surgery unit is described as a way of achieving a variety of
diagnostic or therapeutic procedure that does not require an
educational objectives in a busy resource that may not previously
overnight stay.
have been used for teaching.

Introduction
Well-documented changes in hospital practice, patient Teaching in ambulatory care settings
availability, student expectations and a redefinition of The move towards ambulatory care settings
expected learning outcomes are changing the emphasis of
clinical teaching away from traditional inpatient settings Changes in hospital practice. ‘‘Medical teaching at both
towards ambulatory care. The early introduction of clinical the undergraduate and postgraduate levels is based on the
experience, a feature of innovative curricula (GMC, 2002), premise that students and residents learn best by participat-
has focused attention on the need to provide increased ing, under supervision, in the day-to-day care of patients’’
opportunities for clinical teaching. Structured teaching (Bentley et al., 1989). However, changes in current patient
at postgraduate level and opportunities for advanced care mean that hospital wards today provide fewer oppor-
nursing studies contribute to the need for more clinical tunities for teaching large numbers of students in core
teaching opportunities.
In addition to familiar outpatient clinics, other ambulatory Correspondence: Mr J.A. Dent, Reader and Honorary Consultant,
Department of Orthopaedic and Trauma Surgery, TORT Centre, Ninewells
care venues that may currently be under-utilized for teaching, Hospital and Medical School, Dundee DD1 9SY, Scotland, UK. Email:
such as clinical investigation departments and day surgery j.a.dent@dundee.ac.uk

302 ISSN 0142–159X print/ISSN 1466–187X online/00/000302-14 ß 2005 Taylor & Francis Group Ltd
DOI: 10.1080/01421590500150999
 AMEE Guide No. 26

clinical problems (Fincher & Albritton, 1993; Krackov et al., commitments often compromise traditional ward-based
1993). As inpatients tend to be more representative of teaching. In contrast, outpatient facilities can offer large
subspecialty conditions or be more critically ill they become numbers of patients with common medical conditions more
less representative of routine medical practice (Fincher & representative of general medical practice (Butterfield &
Albritton, 1993; Seabrook et al., 1997). Libertin, 1993). They have a wealth of personal clinical
Patients in hospital are more likely to be under acute histories and specific physical findings but, unlike hospital
active management than convalescing. Contemporary inpatients, are not acutely unwell. More space is usually
practice and patient expectations are in favour of a shorter available and there is the possibility of selecting patients
hospital stay so more patients with common conditions appropriate for the students’ stage of learning. Increased
are being treated as outpatients than as inpatients. Fewer student numbers can be accommodated. Different skills can
patients suitable for undergraduate teaching are therefore be demonstrated and developed in the ambulatory care setting
available in a routine hospital ward in sufficient numbers to as indicated by Stearns & Glasser (1993). Their paradigm
accommodate the increased numbers of students. In 1970 for ambulatory medicine combines elements encountered
the average inpatient stay for acute specialties in the UK in routine ward-based teaching (aetiology, history, physical
was 11.3 days but by 1990 this had dropped to 6.1 days. examination, laboratory tests and therapy) with those more
As much as 70% of hospital patient contacts are now in likely to be encountered in ambulatory care (continuity,
an ambulatory care setting (Lawson & Moss, 1993). context, health education, economics and responsibility).
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DaRosa et al. (1992) estimated that in 1992 ambulatory Experiences in ambulatory care have been reported as
surgery removed 25–50% of surgical patients from usual enjoyable and profitable to patients, staff and students (Dent
educational (inpatient) settings. These changes in healthcare et al., 2001a; McGee & Irby, 1997). Students have been
delivery are an encouraging incentive to focus resources for described as having better relationships with patients and
medical education on the restructuring of surgical teaching in teachers (Kalet et al., 1998). Phinney & Hager (1998)
ambulatory care settings (Dunnington & DaRosa, 1994). describe benefits to fourth-year students in cardiology
in clinical skills competence as well as in familiarity
Changes in student requirements. Increased student numbers
with ‘high-tech’ procedures. Although some researchers
mean that less time is available per student for patient
(McLeod et al., 1997) found that students’ experiences with
contact. Although apparently timetabled for an adequate
inpatients were preferable for learning clinical skills and
amount of contact with inpatients, the actual time students
for making diagnoses, others found ambulatory care experi-
For personal use only.

spend with patients is probably less than the programme

ence effective in improving both students’ knowledge
suggests (McKergow et al., 1991; Davis & Dent, 1994).
and skills (Frye et al., 1998) and preferable to inpatient
Exposure to a broad educational base of clinical material is
experiences (Lynch et al., 1999). In reviewing day surgery
not only important for providing clinical training but also
unit teaching, Seabrook and colleagues (1998b) found no
has an important role in helping students to make future
significant difference in performance in MCQ and OSCE
career decisions (Fincher & Albritton, 1993).
performance between students who had undertaken a day
Changes in educational requirements. Recent changes in surgery unit course and those who had taken a traditional
medical education (GMC, 2002) favour a move from inpatient surgery programme.
apprenticeship/opportunistic learning to a more structured,
systems-based approach using a wider range of healthcare
settings. The introduction of learning outcomes has high- Resources for teaching in ambulatory care settings
lighted the wider spectrum of competences required of a Venues
doctor which require a wider range of teaching locations
if they are to be delivered (Harden et al., 1997, 1999). Depending on the size of the facility and the availability of
Adequate exposure to designated core clinical problems staff willing to teach students, a programme of ambulatory
should be made equally available to all students (Harden et teaching may be possible in a number of venues, some of
al., 1984) and opportunities for students to integrate their which may not have been considered previously: outpatient
learning to material presented elsewhere in the course should clinics; day surgery unit; accident & emergency department
be provided. (A&E); clinical investigation unit; and radiology and imaging
suites; professions allied to medicine; social work depart-
ment. However, access for teaching sessions in any area
Importance of teaching in ambulatory care settings
where students have not customarily been taught will require
The ambulatory care environment is able to respond to some negotiating (Dent, 2003) (see later section on
these changes and provide an environment where innova- ambulatory care teaching settings).
tions in clinical teaching can be developed. If hospital
Patients
wards no longer present a balanced overview of patterns
of health and disease then, as the King’s Fund review Patients may be available from a variety of sources:
concluded, ‘‘increased use of outpatients and general practice
New patients. Patients attending outpatient clinics, the
for teaching is essential to reflect the true spectrum of health
A&E department or clinical investigation and imaging
and disease in the community’’ (Towle, 1991).
suites may be seen by the students at the time they attend.
Alternatively, appropriate patients for student teaching
Benefits of teaching in ambulatory care settings
can be selected from those newly referred from their
The small number of appropriate patients, the difficulties of GP for outpatient appointments and invited to specially
structuring their availability and the pressures of service timetabled teaching sessions.

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 J.A. Dent

Clinical volunteers or ‘bank’ patients. A ‘bank’ of previous is necessary. Facilitating such small-group sessions can be
patients may be built up from volunteers whose clinical described as the educational equivalent of white-water
condition no longer requires particular medical care. These rafting—a skill not all clinicians will normally have acquired.
patients can be categorized by their various conditions AMEE Education Guide No. 8 (Crosby, 1997) looks at this
and invited to share their particular clinical histories and topic in detail. For example in teaching a psychomotor skill
demonstrate physical findings appropriate for the needs of five steps are described: teacher demonstration; teacher
the student group they will meet (Brush & Moore, 1994; demonstrates and describes actions; student attempts;
Dent et al., 2001b). teacher and group give constructive feedback; and student
practises.
Standardized/simulated patients. Although probably more Staff development sessions will be necessary to enlist
used in the simulated environment of the clinical and train colleagues. Anderson et al. (1997) emphasize that
skills centre (CSC), standardized or simulated patients such programmes should not only emphasize the content
may occasionally be required in special circumstances to of the teaching encounter itself but also give equal emphasis
demonstrate particular features of a medical interview such to the pre-instructional planning, the role of reflection and
as dealing with an angry patient. the importance of learners and ambulatory care staff
collaborating with faculty in planning the learning process.
Staff However, other methods of information sharing such as
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brief handouts and posters may be more popular with

Programme design and administration. A programme must
clinicians (Ker & Dent, 2002).
be devised for the students that makes the most of the
Informative brochures have been used to supply
learning opportunities each location can provide and learn-
‘on-the-spot’ information for clinicians who may be called
ing outcomes must be defined. All too often students
on to teach in an outpatient setting with little advance
are merely accommodated into an existing clinical situation
notice. They contain practical information on the prepara-
which, because of the size of the student group and the
tion and management of the session and highlight the
unselected nature of the patients attending, may be less than
importance of personal reflection after the event is over
ideal for student learning (Feltovitch et al., 1987). Thought
(Dent & Hesketh, 2003; Stewart, 2005).
has to be given to strategies that will help students achieve
the maximum educational benefit from the experience
For personal use only.

including opportunities for vertical and horizontal integra- Supplementary resources

tion and personal reflection. An ambulatory programme Experience has shown that readily available additional
director is required to develop the programme structure, resources are as important as patients in clinical teaching
organize student groups, coordinate attendances from situations (Dent et al., 2001a). These resources may include:
appropriate patients or clinical volunteers and help to train
clinical tutors. . patient case notes or summaries giving a précis of the
part of the patient’s history relevant for the current
Clinical tutors. Clinicians with enthusiasm for teaching session;
are required to act as tutors. Seven factors of teaching . laboratory reports of pertinent investigations to be used
effectiveness have been described by Irby et al. (1991): in discussion of patient management;
knowledge; organization and clarity; enthusiasm; group . radiographs, scans and clinical photographs;
instructional skills; clinical supervision skills; clinical com- . videos, if it is necessary to refer to the medical school’s
petence; and modelling professional characteristics. In their preferred approach to clinical examination;
survey they found the most valued characteristics of clinical . diagnostic equipment for students to practise basic
teachers to be the active involvement of the learners, the clinical skills.
promotion of learner autonomy and the demonstration of
patient-care skills.
Students
Staff development. The necessary emphasis on patient Students from the appropriate phase of the curriculum
welfare and convenience focuses clinical staff attention should be timetabled to attend in groups of an appropriate
away from teaching. Skeff (1988) has described a seven- size that can be accommodated in the setting being
component framework to enhance teaching effectiveness in used. Junior students may require a more supervised
the ambulatory setting: establishing a positive learning environment such as can be provided by a dedicated
climate; controlling the teaching session; communicating ambulatory care teaching centre (ACTC) using clinical
goals; enhancing understanding and retention; using for- volunteers (see later section on the role of an ACTC).
mative and summative methods of evaluating learners; Senior students are probably more able to interact with
providing feedback; and encouraging self-directed learning. new patients in a less structured ambulatory environment.
A reorientation of approaches to clinical teaching may
be necessary. Clinicians enjoy teaching in wards but may
Institutional support
prefer simply to demonstrate their clinical skills when under
pressure in busy outpatient clinics. To take advantage of All the above will be ineffective without support from the
educational opportunities as they present, clinical tutors in teaching institution. Support for the teaching faculty is
ambulatory care must acquire the mental agility required mandatory. As Skeff (1988) observed, ‘‘Many faculty
to capture each ‘teachable moment’ as it presents (Bowling, members have an intrinsic desire and enthusiasm for
1993). Knowledge of the principles of small-group teaching teaching, but they are drawn in several directions with

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 AMEE Guide No. 26

various responsibilities. Without clear emphasis on the Advantages. No time constraints or pressures from other
importance of clinical teaching in the ambulatory setting, clinical commitments on the tutor; independent learn-
they will understandably spend less time concentrating on ing promoted; opportunities for problem-solving can be
this role.’’ A secure source of faculty funding must be developed.
ensured to finance the developing ambulatory care teaching
programme (Bentley et al., 1989). Disadvantages. A designated tutor is required to deliver
the session; additional time for preparation must also be
found by the tutor.
Ambulatory care teaching settings
Routine outpatient clinics A&E departments
A scheduled clinic is usually made up of new or review Resources. Resources available may include: assessment
patients or a mixture of both. It may be staffed by one or areas, resuscitation suite, adjacent radiography facilities,
more doctors including a consultant, trainees, nursing treatment areas and plaster room; a variety of staff of dif-
staff and possibly other healthcare colleagues. There is ferent grades and disciplines; large numbers of patients
usually a large number of patients attending with common presenting with common injuries or as medical or surgical
clinical problems appropriate for undergraduate teaching but emergencies.
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additional space for teaching may be limited.

Opportunities. Opportunities exist for students to observe:
Resources. Resources available may include: clinicians, acute assessment, practical procedures, clinical decision-
nurses, therapists; GP letters, case notes, laboratory results, making, multi-professional activity and teamwork; to observe
radiographs; a vacant consulting room or procedure room. and participate in the large number of healthcare activities
going on at any time.
Opportunities. Opportunities exist for students to: see
patients independently; observe decision-making and the Advantages. Clinical histories and physical findings are
selection of appropriate investigations; be supervised in at their most acute; role modelling; realistic clinical settings;
communication and examination skills and attempt simple in many cases it will be the first time these patients meet
practical procedures. students.
For personal use only.

Advantages. From the large numbers attending it is easy to Disadvantages. Staff may be too busy to spend time with
select sufficient numbers of appropriate patients for similar students or to direct them to appropriate patients and lean-
conditions to be seen by all students. Independent learning ing situations; some patients will be too ill to have students
can be encouraged if sufficient rooms are available for with them; follow-up of the patients seen may not be possi-
students to see patients at their own pace and effective, one- ble as they are subsequently admitted to other parts of the
on-one tuition, much valued by students, may be possible. hospital or discharged.

Disadvantages. A heavy service commitment places time

Clinical investigation units
constraints on clinicians who are under some pressure to
see the large number of patients appointed to the clinic. Resources. Resources available may include: endoscopy
In these circumstances a large student group may be difficult unit, non-invasive vascular laboratory or gait analysis
to accommodate. laboratory; staff from various healthcare disciplines; results
of investigations.
Teaching clinics/standardized clinics Opportunities. Opportunities may exist for students to:
Patients illustrating the core clinical conditions that discuss the reasons for selecting various investigations and
students are required to see can be invited to a specially their interpretation; observe clinical judgement; observe
scheduled teaching clinic where longer appointment times patient management.
can be given. It may be possible to create a focused (themed)
Advantages. Exposure to a particular type of clinical
clinic by inviting patients with similar conditions to create
condition or specialist investigation is available; role model-
a structured session (Lawson & Moss, 1993). In an attempt
ling a career specialty; personal development.
to avoid inequalities of clinical exposure, Sullivan and
colleagues (2000) used standardized patients as part of a Disadvantages. Patients coming through the department
series of multimedia learning modules covering a spectrum of are not necessarily appropriate for the students’ stage
vascular disorders, so achieving uniformity of learning of learning; opportunities for students to see patients
outcomes. independently are probably difficult to provide.

Resources. Resources available may include: more time for

Radiology and imaging suites
focused clinical tuition; invited patients from new referrals or
the patient bank; clinical notes and results of investigations. Resources. Resources available may include: ‘plain’ X-ray
suite, contrast studies, MRI and CT scanning suites, nuclear
Opportunities. Opportunities exist for students to: con- medicine department; radiologists, radiographers and other
centrate their learning during this focused session; read specialists and technicians; a departmental collection of
around the teaching theme of the session if notice of it representative images; a large number of patient in
can be given in advance. the department.

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 J.A. Dent

Opportunities. Opportunities may exist for students to: ‘worksheet for ambulatory medicine’ (WAM), which
discuss the indication for various investigations; relate the incorporates learning objectives, has been described for
images to basic sciences such as cross-sectional anatomy; students to complete during each patient encounter
observe patient management; observe clinical reasoning. (Roth et al., 1997). These can be used to assess the student’s
degree of involvement with the course and to indicate the
Advantages. Concentrated exposure to a particular type of clinical cases they have still to see.
discipline; role modelling a career specialty; personal
development.
Task-based learning
Disadvantages. Radiation protection issues.
In task-based learning (TBL) a particular task that might
normally be carried out in the clinical setting (such as
Professions allied to medicine measuring blood pressure) is used to help students learn
Resources. Resources available may include: physiotherapist, by understanding the concepts and mechanism underlying
occupational therapist, podiatrist, orthotist, prosthetist; large the task (Harden et al., 1996). A programme reported
numbers of patients attending. from Finland (Virjo et al., 2001) uses a TBL module with
ward-based patients to compliment the active, self-directed
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Opportunities. Opportunities may exist for students to: learning fostered by a PBL programme in the earlier years
observe clinical assessment and treatment techniques; prac- of the course. The tasks they define that can be adapted for
tise communication skills with patients before and during use in the ambulatory care situation include: interview
treatment. and examine a patient and make records; participate in the
discharge of a patient and the associated documentation;
Advantages. Increased awareness of treatment modalities participate in consultations with the staff attending; make
and their impact on the patient; opportunity to observe how a home visit with the GP or home care nurse.
the role of a doctor relates to other healthcare disciplines.

Disadvantages. Only a limited number of students can be Study guides

accommodated at one time with any one patient. The role of study guides in facilitating and managing
For personal use only.

independent learning is well accepted (Laidlaw & Harden,

Ambulatory care teaching centre (ACTC) 1990). A two-part study guide used by Mires et al. (1998)
in obstetrics and gynaecology describes a ‘TOPICAL’
See the section on ACTCs later in this guide. approach. It contains:
Topics;
Day surgery units (DSU) Objectives;
See the section on DSUs later in this guide. Programme;
Issues for learning;
Clinical tasks;
Instructional strategies for maximizing learning Assessment;
opportunities Log book.
Strategies are required to facilitate student learning and to Students write their structured case report in the second
identify gaps in student experience. These omissions may part or ‘response book’, which can then be collected for
occur in both the breadth and depth of their patient assessment. This integration of learning and assessment aims
encounters in ambulatory care (Gruppen et al., 1993). to promote higher-order learning.
Various strategies can be adapted for use in ambulatory
care venues to help student learning.
Learner-centred approach
Logbooks In an attempt to avoid learner passivity in the outpatient
setting, a learner-centred model, using the acronym
The EPITOME logbook (Dent & Davis, 1995) encourages
‘SNAPPS’, has been described by Wolpaw and colleagues
students to record patient interactions and learning in seven
(2003). This requires students to present cases to their tutor
categories:
using the headings:
Enquiry or history-taking;
Summarize the history and physical findings;
Physical examination;
Narrow down the differential diagnosis to two or three
Interpretation of data;
possibilities;
Task or carrying out a procedure;
Analyse the differential diagnosis by comparing and con-
Options or differential diagnosis;
trasting the possibilities;
Management of the patient;
Probe the preceptor with questions about difficulties or
Education of the patient.
alternative approaches;
This provides a way of recording clinical experiences and Plan management for the patient’s problems;
promotes reflective practice. A similar approach using a Select a case-relevant issue for self-directed learning.

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 AMEE Guide No. 26

This approach has been found to engage the learner and Microskills for students
promote positive interaction with the tutor.
Tips to improve student learning skills prior to ambulatory
Another method promoting active student involvement care activities have been described (Lipsky et al., 1999).
in the learning process involves learning contracts. They focus on:
Handbooks incorporating a learning contract, a curriculum
. Self-orientation—students should set themselves a
of learning objectives and a mechanism for formal review
limited number of personal goals to be achieved dur-
have been used to encourage adult learning styles in
ing the period. They should be sure that tutors realize
senior house officers (Parsell, 1997). In this approach student
what stage of training they have reached.
and tutor agree the content and scope of material to be
. Preceptor preparation—students are given advance
studied. In a nursing degree course this strategy was
organizers of the medical conditions of the patients
found to increase student autonomy and motivation and
they are to see. Students are encouraged to formulate
to promote sharing between students and clinical tutors
a diagnosis or management plan and be able to indicate
(Chan & Chien, 2000).
the clinical findings that support it.
. Soliciting feedback—students are encouraged to share
Learning outcomes self-assessment of their performance with tutors at
appropriate times, so encouraging specific feedback
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The attributes or characteristics that it would be desirable

from them rather than receiving general statements.
to find in a doctor have been described (Harden et al., 1997;
Students are encouraged to ask questions related to
Harden et al., 1999). These can be used to focus teaching
their clinician’s decision-making processes in order
and can be identified to a variety of extent in any clinical
to promote dialogue and aid understanding of
teaching situation. The 12 learning outcomes described
clinical judgement.
include:
. Reflection—students record key points and questions
What a doctor is able to do: in a journal for future investigation and discussion in
order to promote thoughtful reflective practice.
. competence in clinical skills;
. competence in practical procedures; A five-step ‘microskills’ model of clinical teaching
. competence in patient investigation; has been described by Neber and colleagues (1992).
For personal use only.

. competence in patient management; The model includes: get a commitment; probe for
. competence in health promotion and disease supporting evidence; teach general rules; reinforce what
prevention; was done right; correct mistakes. This practical
. competence in communication; approach can be easily utilized and is especially useful for
inexperienced tutors.
. competence in handling and retrieval of information.
How the doctor approaches his/her practice:
Structured model for teaching and learning
. with understanding of basic and clinical sciences and
underlying principles; A list of step-by-step activities for students to follow
. with appropriate attitudes, ethical stance and legal when interviewing patients in a follow-up outpatient clinic
responsibilities; has been proposed by Kurth and colleagues (1997) as
. with appropriate decision-making, clinical reasoning a method of facilitating students’ orientation in a new sett-
and judgement. ing and of enhancing their leaning. Activities are grouped
into four sections: Preparation—(pre-visit); Practice—
The doctor as a professional:
(the patient’s visit); Evaluation and feedback—(during the
. an understanding of the doctor’s role in the health visit); Synthesis and analysis—(closing the visit). The model
service; was thought to clarify what was expected of students,
. an aptitude for personal development. to promote active self-directed leaning, to facilitate oppor-
tunities for assessment by the tutor and to assist in the
This approach has recently been adopted by the Deans of the acquisition of appropriate skills.
Scottish Medical Schools (Simpson et al., 2002).

Conferences and independent study activities Models for organizing student/patient contacts in
outpatient clinics
Before the visit to the ambulatory care venue a discussion
with the programme leader can be used to raise student A variety of different models for organizing student/patient
awareness of issues likely to be illustrated by the interactions in outpatient consultations have been described
patient encounters and to highlight areas for independent (Dent, 2005). These models take into account the number
study. This fosters higher-level thinking and a structured of clinicians present, the size of the student group and
approach to learning. Conferences and independent study the number of rooms available for student use. Each model
activities planned for after the event give students an has advantages and disadvantages. Some are more suitable
opportunity to reflect on what they have seen and learned for use with a single student and others help in managing
and to plan related self-directed leaning activities a large student group. A model can be chosen that best meets
(DaRosa et al., 1997). the students’ requirements.

307
 J.A. Dent

One student/one clinician clinician/patient dialogue may be inhibited. Junior students

have a good opportunity to observe the clinician’s commu-
Sitting-in model. In this familiar model the student ‘sits in’
nication and history-taking skills at first hand but there are
with the clinician and can usually talk freely to both the
limited opportunities for them to interact with patients
clinician and the patient. Students enjoy the ‘one-on-one’
themselves. It may be possible to demonstrate some
teaching, the ease of interaction with the clinician and will
examination techniques (Figure 1).
see the full range of patients attending that clinic. However,
the clinic time may be prolonged if the clinician does
not control the interactions and conversely a reserved student Supervising model. More experienced students can conduct
may participate minimally, becoming a mere passive obser- an entire interview and examine the patient in indepen-
ver. Such students should be manoeuvred to adopt a more dent rooms with only limited tutor supervision (Figure 2).
active role and may be encouraged by being asked to In this model the clinician selects a patient for each student
assist with various tasks such as completing laboratory to see individually in a separate room. After a suitable
request forms. time (during which other patients can be seen) the clinician
then goes to each room in turn to hear each student’s account
Apprenticeship model. In a contrasting model the student of her/his patient and to supervise various aspects of the
may be allowed to assume the role of the doctor and interview interview. Students have time and space to interview and
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the patient with the clinician this time acting as the observer. examine their patient and will receive individual feed-
Student/patient interaction in this model is obligatory but back on their performance. However, they do not see all
as aspects of the consultation may have to be repeated by the patients attending, the clinician is heavily occupied
the clinician the clinic time becomes prolonged. supervising the students and hearing them present the patient
they have just seen and some of the students’ time is
Team member model. In this model a more senior student wasted in waiting for their turn. Inevitably the clinic
is treated like a trainee in the clinical team and interviews becomes prolonged.
and examines patients in a separate room before either
being visited by the clinician or reporting back to the main Report-back model. Senior students may interview and
consulting room. In this model the student can interview examine patients independently or in pairs before report-
and examine patients at his or her own pace and can discuss ing back to the clinician on their consultation and discuss-
For personal use only.

such aspects as the impact of the illness on their lifestyle ing the proposed management (Figure 3). Patients are
or domestic circumstances. Meanwhile the remainder of allocated to students as in the previous model but this
the clinic can proceed at the usual pace with the clinician time the students return with their patient to the main
alone but with intermittent interruptions to review the consulting room and, when all are ready, introduce their
student’s progress. The student will miss the majority of patients and present the salient features of their consultation
the patients attending during this time and there are fewer to the clinician and their colleagues. As before, the students
opportunities for interaction with the clinician. have time and space to interview and examine their patient
but in this model they will all see something of each other’s
patients. A disadvantage from the patient’s perspective
Several students/one clinician is the probability of waiting first to be seen by the student
Grandstand model. All too often this is the model seen when and second by the clinician. Again the pace of the clinic
a large number of students are timetabled for the clinic at is slowed.
the same time and are obliged to crowd round the clinician
in a single room to observe the consultation. Although all Breakout model. All the students sit in with the clinician
the students will see all the patients attending, the patients and hear the whole of the interview with a patient and observe
may feel intimidated by the large number of observers and the the examination and following discussion. A student is then

Figure 1. Grandstand model.

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Figure 2. Supervising model.

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For personal use only.

Figure 3. Report-back model.

allocated to that patient and takes him/her to another room Flip-flop model. The student group spends half of the time
to interview and examine unsupervised. During this time the with each clinician who proceeds to use whatever model is
student consolidates aspects of his or her history-taking skills preferred but often the ‘grandstand’ model is the only one
and examination technique and may also have opportunities that is selected. The teaching session can proceed without
to complete laboratory request forms or, under supervision, pressure as the remainder of the patients attending are being
perform a practical procedure such as venepuncture. seen by a colleague. At half time the students switch to the
Subsequent patients are paired with each of the remaining other clinician.
students. This one-on-one experience gives students the
opportunity to work at their own pace but junior students Tutor model. The student group remains with one (usually,
will benefit most if feedback on their individual history-taking but not always, the senior) clinician who may then use any
and physical examination skills is provided (Figure 4). of the previous models but feels less constrained by the
demands of the clinic as the opportunity is now created to
see only selected patients with the students. More time-
Several students/several clinicians consuming teaching models can be selected. Patients
Shuttle model. The clinicians consult simultaneously and whom the tutor does not wish the students to see are seen
pass the students between them as cases of interest present. by the other clinicians present while the selected patients
However, some patients will be missed if they attend while are seen in optimal conditions using any of the teaching
the students are engaged with the other clinician. models described as resources permit.

Division model. The student group is divided between the

Role of an ambulatory care teaching centre
clinicians in the clinic who may then proceed using any of the
previously described models depending how many students Despite their advantages, the large numbers of patients
are attending. The advantages and disadvantages of these attending ambulatory facilities may actually prohibit the
models remain as before. delivery of a structured teaching programme. A shortage of

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Figure 4. Breakout model.

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available teaching space, the volume of clinical work to be 4. Find suitable accommodation:
done by the available staff and the unselected nature of
. An area already familiar to students and within the
the clinical conditions represented may make teaching less
outpatient department is ideal.
than ideal, especially for junior students. These difficulties
. A flexible space is best so that a variety of sizes
can be resolved by the creation of a dedicated teaching
of group and a variety of activities can be
facility in the ambulatory care setting to provide an indepen-
accommodated.
dent space where teaching and learning can be carried out
without the constraints of service commitments or interrup- 5. Secure a budget:
tions. Medical conditions required for the students’ partic-
ular level of study can be seen by selecting patients . A reliable source of centrally provided income is
with appropriate histories or physical findings from the required.
For personal use only.

bank of clinical volunteers. This clinical experience can . Budget for both recurring costs and capital
then be integrated with factual material presented elsewhere expenditure (Bentley et al., 1989).
in the course. Clinical teaching in this ambulatory care 6. Acquire suitable resources and equipment:
teaching centre (ACTC) provides an experience that bridges
the gap between initial exposure to clinical contact in the . It is necessary to make the facility look realistic and
clinical skills centre (CSC) and visits to the less structured attractive and also for it to be appropriately
environment of routine clinical venues. equipped with additional resource material to
reinforce learning.

Implementation Implementation:
Twelve tips have been described in the development of 7. Recruit and train enthusiastic staff:
an ACTC (Dent et al., 2001b).
. An ACTC programme coordinator is required
Design: to timetable students and tutors, to arrange
patient visits and to build up and classify a patient
1. Allow development time:
bank.
. to negotiate with hospital managers and potential . Tutors must be familiar with the objectives of the
stakeholders; ambulatory care teaching programme.
. to determine the nature of tenure of the proposed . Staff development opportunities will be necessary.
premises;
8. Evolve an implementation function for the steering
. to discuss the type of sessions envisioned;
group:
. to decide when to introduce the programme.
. Think of ways for future development perhaps
2. Integrate curriculum needs and identify organizational
involving multiprofessional input or postgraduate
constraints:
utilization.
. Decide which aspects of the curriculum are going
9. Build up a bank of referred patients or clinical
to be covered in this facility and what can feasibly
volunteers:
be delivered (Feltovitch et al., 1987).
. Patients referred by clinical colleagues can be asked
3. Identify interested parties and their strategic role as a
to volunteer to take part as required.
steering group:
10. Implement a teaching plan:
. Share ownership of the project among a group of
potential users and those who will take on an . Divide students into appropriately sized groups and
administrative role. decide how they will be deployed.

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. Choose a model for organizing student/patient . Tutors appreciated the absence of other clinical pres-
contacts (see section on ‘Models for organizing sures normally present in the ward setting. They liked
student/patient contact in routine outpatient having additional resource material readily available.
clinics’) and aim to integrate student learning. . Patients enjoyed longer times for consultation, contrib-
uting to the educational programme and learning more
Evaluation:
about their medical condition.
11. Develop a multifaceted evaluation process:
. Provide a forum for feedback for all users. Tips on developing an ambulatory teaching resource
in a new venue
12. Develop a research and development function for the
steering group: The introduction of a teaching programme in an ambulatory
care venue not previously accustomed to having under-
. Opportunities should be taken to evaluate the
graduate students needs to proceed with some thoughtful
experiences provided by the ACTC (Irby, 1995).
planning and discussion between the curriculum planners
and the staff of the target venue. Tips on setting up such
Resources. New patients or clinical volunteers can be used a programme might include:
but interviews with simulated patients are probably best
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Preparation
reserved for use in the simulated environment of the clinical
skills centre. Other pictorial or practical resource material as 1. Identify the learning objectives that students can
mentioned above together with dedicated tutors, support staff experience in this ambulatory care venue.
and facilitators. 2. Secure institutional support and form an
implementation/steering group representing all parties.
3. Decide which year of the course will most benefit
Opportunities. Opportunities are available for students to
from the programme and how many students can be
practise communication and examination skills at their
accommodated.
own pace and to integrate their learning. Multiprofessional
4. Decide how appropriate patients for students to see
input appropriate to the students’ current programme can
will be selected and briefed.
be arranged, for instance a dietitian or diabetic nurse can
For personal use only.

5. Identify space where students will see the patients.

contribute during the endocrinology course. Opportunities
6. Identify any particular preparation students should
may also arise to develop the resources of the ACTC to
undertake to prepare them for clinical experience in
create a programme suitable for postgraduate trainees or for
that venue.
inter-professional learning.
7. Provide staff development opportunities.
Delivery
Advantages. A safe and supportive learning environment is
created, which allows students to receive the amount of 8. Provide a study guide or logbook outlining the objec-
supervision they require without jeopardizing or hampering tives of the visit and providing space for recording of
patient care. A structured and standardized programme can clinical encounters and reflection.
be delivered ensuring that the same experiences are made 9. Employ a tutor/supervisor to be based in this new
available for all students. Delivery of a routine outpatient ambulatory care teaching venue.
service is not jeopardized. 10. Provide opportunities for student reflection, tuition and
assessment.
Disadvantages. A definite space has to be acquired and Evaluation
appropriately refurbished. A budget is required for maintain-
ing the facilities, for reimbursement of patients or clinical 11. Evaluate feedback from students, tutors and staff.
volunteers invited to attend and maybe for staff salaries. 12. Discuss research and development opportunities with
A full-time tutor or ambulatory care coordinator will be all parties involved.
needed to timetable and organize student and staff atten-
dances, to enlist and brief patients and to facilitate Experiences with introducing a teaching programme
the sessions. in a day surgery unit
Introduction
Evaluation Earlier hospital discharge and an increase in day surgery
operating have become possible following advances in
The perceptions of students, tutors and patients on the
surgical procedures and anaesthesia. Increasing specialization
opportunities for integrated learning provided by the ACTC
in teaching hospitals means that inpatients are often
have been reported (Dent et al., 2001a):
unrepresentative of patients seen in general medical practice
. Students appreciated the unhurried atmosphere, oppor- (Schwartz et al., 1992). In contrast, the DSU is an under-
tunities for personal tuition and feedback and time utilized teaching resource. In a survey of 227 DSU, Seabrook
to practise clinical skills with real patients rather than and colleagues (1997) found only 45% were used for
in simulation. Between 77% and 80% said their history- teaching and only 7% had students for more than one day
taking and examination skills were improved as a result. per week. Teaching tended to be unstructured, theatre-based

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and centred on shadowing the surgeons present. Nakayama & may exist between arrival and surgery when patients
Steiber (1990) reported that basic surgical skills had not been are available for clinical teaching (O’Riordan & Clark,
practised by students prior to graduation. 1997);
Lossing & Groetzsch (1992) introduced technical . a day surgery reception ward, operating theatre and
skills instruction in scrubbing, gowning, gloving, instrument recovery area;
handling, suturing, cutting and stapling and were able . staff from a variety of healthcare professions are available:
to demonstrate improved performance in these skills, surgeon, anaesthetist, nursing staff and therapists;
after training, in fourth-year students using a simulated . diagnostic, anaesthetic, monitoring and examination
appendectomy model. However, the operating theatre may equipment.
present a difficult environment for students, as Lyon (2003)
reports. Challenges present in three key domains:
Advantages. These include:
. the physical environment and the emotional impact of
surgery as work; . a holistic approach to patient-care can be experienced
in a short period of time;
. the educational task;
. a wide variety of common conditions closely related
. the social relations within the operating theatre.
to general medical practice may be seen;
To be successful students must manage the demands of
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. continuity of care may be observed from pre-operative

these three domains by adopting adult learning strategies, by assessment through surgery to giving post-operative
identifying student-friendly staff and by presenting them- instructions and the patient’s return to community care;
selves as deserving learners who have earned a place in the . an appreciation of the multiprofessional approach to
training queue. patient care can be gained.

Implementation Disadvantages. These include:

A DSU teaching firm has been described (Seabrook et al., . the presence of students may impede service delivery.
1998a) focusing on active learning and skills develop- However, only 6% of units studied by Seabrook and
ment using a multiprofessional team of tutors led by colleagues (1997) considered this likely;
an educationist.
For personal use only.

. only a limited number of students can attend the actual

Another programme described from South Australia operation to avoid overcrowding in theatre;
(O’Driscoll et al., 1998) incorporates opportunities for . extra theatre clothes, gowns and gloves are required
following patients through day surgery, practical procedure if students are to practise surgical techniques.
tutorials and problem-based learning tutorials. This was
carried out with a high degree of acceptance from DSU
staff and patients and without compromising patient care
(Rudkin et al., 1997). Twelve tips, similar to those described An example of a DSU teaching programme
previously, have been described for the setting up of an
integrated teaching programme in the Day Surgery Unit An integrated programme that reflects real clinical experience
(Dent, 2003). has been developed in the DSU.

Opportunities Part 1

Opportunities exist for students to: Students initially meet selected patients newly referred to
the orthopaedic department with minor operative conditions.
. practise communication skills, physical examination and They practise communication skills and physical examina-
procedural skills, especially the theatre skills required of tion under appropriate supervision in an ACTC setting.
junior doctors; Clinical judgement and decision-making skills are practised,
. practise and observe patient assessment and decision- diagnoses are reached and patients are assessed for suitability
making including clinical judgment and informed for day-case surgery. Issues related to informed consent are
consent; discussed.
. participate in multi-professional aspects of patient care
including surgery, anaesthesia, bedside nursing proce-
dures and an assessment of patients’ social or domestic Part 2
needs; Opportunities are then provided for students to practise
. practise common surgical procedures and theatre relevant surgical procedures. Using facilities in the CSC,
technique; the surgical scrub technique is practised. A CAL programme
. learn from the holistic approach to patient care seen and on wound-suturing technique is viewed and suturing
the opportunity for longitudinal case studies available. practised under supervision as described by Kneebone
(1999). This follows a five-stage approach: watching an
animated graphic; watching a clinical video; watching
Resources. Resources available may include:
a demonstration on a simulated tissue model; doing the
. patients attending for day surgery procedures in a variety procedure on a model; doing the procedure on a patient
of disciplines. A mean waiting time of three hours under supervision.

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 AMEE Guide No. 26

Part 3 What happens when you get there?

In the DSU students meet a variety of patients with A variety of models for structuring student/patient interviews
conditions similar to the ones they have already been see- can be used in the session depending on the number
ing in the ACTC. They have the opportunity to reassess of students present and the clinical venue being used
the indications for the proposed surgery, to assist at the (see ‘Models for organizing student/patient contact in routine
operation and to participate with other healthcare staff in outpatient clinics’).
peri-operative care. Finally, students participate in post-
operative care and patient discharge procedures. With the
What to do when the session is over
agreement of the patients students telephone them the next
morning to enquire about their post-operative condition
. Be sure the students have the opportunity to discuss
and to check arrangements for dressing changes, GP review
what they have seen and learned at the end of the session.
or outpatient follow-up. Any clinical problems raised are
. Identify aspects of the learning outcomes that have
reported back to the clinician.
been illustrated by the patients they have seen and clarify
By creating a supervised programme in a genuine clinical
any misunderstandings or uncertainties.
situation opportunities are created to provide structured
learning relevant to several of the curriculum outcomes. . Thank the patients who took part.
. Finally, consider what you did well in the session
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and which aspects you might like to improve on

Checklists for effective ambulatory care teaching next time.
It is important to monitor and evaluate the new teaching
programme so that it can constantly be refined and improved.
The Wisconsin Inventory of Clinical Teaching (WICT) has Conclusion
been shown to be valid and reliable to improve teaching Ambulatory care is becoming a key facet of modern
of residents in general internal medicine clinics (Hewson & medical practice. As patients are increasingly seen in this
Jenson, 1990). In this questionnaire residents (trainees) are environment medical student teaching must seek to develop
asked to give ratings to between three and 11 descriptors of learning opportunities that utilize this resource. However,
aspects of teaching behaviour within six broad categories simply scheduling students to attend new venues is not
For personal use only.

relating to the attending doctor (consultant) as a: clinical role the whole answer. Appropriate instructional strategies must
model; professional mentor; clinical supervisor; instructor; be selected and developed to facilitate student learning
evaluator; consultant (one who may be consulted by and maximize the resources and opportunities provided by
the resident). these venues. Provision must be made to cope with large
student groups. Although enthusiastic clinicians may be
available to participate, staff development needs must be
Tips on getting started as a tutor in an ambulatory
identified and provided for. Other resources necessary to
care setting
support the initiative will include a programme director and
What to do before you start a reliable budget. Periodic review of the teaching programme
in ambulatory care settings by all interested parties will
. Try to attend any staff development session or tutor help to ensure that optimal use continues to be made of these
briefing meetings and read any tutor support material valuable resources.
available. Try to ‘sit in’ on a session with a more
experienced tutor.
Notes on contributor
. Check the students’ study guide, if available, and any
other course material to see how the session should be JOHN A. DENT is a Consultant Orthopaedic Surgeon and a Reader in the
integrated to other aspects of the course. Department of Orthopaedic Surgery, Ninewells Hospital and Medical
. Review the case records of the patients expected so School, Dundee, UK.

you are familiar with their history and any physical

findings that can be demonstrated.
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