Changing habits of practice. Transforming internal medicine residency education in ambulatory settings.
OBJECTIVE
The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change.


METHODS
The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance.


RESULTS
Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education.


CONCLUSIONS
This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.
Bowen
Judith L
JL
Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, OR 97239-3098, USA. bowenj@ohsu.edu
Salerno
Stephen M
SM
Chamberlain
John K
JK
Eckstrom
Elizabeth
E
Chen
Helen L
HL
Brandenburg
Suzanne
S
D000553:Ambulatory Care / Q000379:methods*; D004503:Education, Medical, Graduate / Q000379:methods*; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency / Q000379:methods*; D011364:Professional Practice / Q000458:organization & administration*