Assessing quality and costs of education in the ambulatory setting: a review of the literature.
OBJECTIVE
Time-pressured interactions with little direct observation or feedback characterize teaching in ambulatory settings. The authors report findings from the literature on teaching and learning in the ambulatory setting and propose opportunities for further research that addresses these barriers.


METHODS
The authors searched 1995-1999 databases for all empirical studies that focused on research conducted in ambulatory settings. Publications were reviewed for evidence of inclusion criteria. Findings were sorted into categories previously described for defining and evaluating quality of ambulatory care educational programs.


RESULTS
Most studies were conducted in departments of internal medicine (40%), focused on medical students (43%), and took place in a single program (77%), making generalizations difficult. Students and residents are learning in ambulatory environments, and the types of patients they encounter are likely to prepare them for practice. Patient care outcomes have emerged as a measure of learning. Teachers may be the single most important factor, yet they lack self-confidence as teachers. Community-based preceptors teach because of enjoyment of teaching and the opportunity to stay current. However, none of the studies addressed the impact of the Medicare documentation requirements on satisfaction with teaching. Teaching settings cost about one third more than non-teaching settings to operate.


CONCLUSIONS
This review identifies many gaps in our knowledge of effective clinical teaching practices, and of learning environments in which that teaching takes place. The predominance of single-institution studies limits generalizability of current findings. A prioritized research agenda should be established and funded, focusing on improving the efficiency and effectiveness of teaching and learning in ambulatory settings.
Department of Medicine, Oregon Health & Science University, Portland, Oregon 97201-3098, USA. bowenj@ohsu.edu
Judith L
JL
Bowen
David M
DM
Irby
D000553:Ambulatory Care / Q000191:economics* / Q000639:trends; D003365:Costs and Cost Analysis / Q000191:economics* / Q000639:trends; D003479:Curriculum / Q000706:statistics & numerical data; D004501:Education, Medical / Q000191:economics* / Q000639:trends; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007396:Internship and Residency / Q000706:statistics & numerical data; D007858:Learning; D016239:MEDLINE; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D010549:Personal Satisfaction; D011785:Quality Assurance, Health Care / Q000191:economics* / Q000639:trends; D013663:Teaching / Q000191:economics / Q000639:trends; D014481:United States