Community-based Ambulatory Clerkships in Internal Medicine

There is a national trend in undergraduate medical education to include a variety of clinical experiences for students with practicing physicians throughout the 4 years of medical school. An area of major emphasis in clinical education involves the clerkship year wherein students spend an average of 4 weeks with office-based general internists seeing patients and learning the skills of ambulatory practice. These rotations have become popular with students. They receive more direct mentoring from their attending physicians (interns and residents are usually not present) and they have the opportunity to directly interact with more patients than on the traditional inpatient service. They get to see a wider variety of clinical problems, to participate in the process of clinical decision making, and to appreciate the realities of modern clinical practice.

All three medical schools in Virginia have ambulatory components as part of the medical clerkship. At Eastern Virginia Medical School the ambulatory rotation of the clerkship was initiated in 1996. All students spend 4 weeks in an ambulatory setting, the first week of which is spent at one of seven local health departments. The remaining 3 weeks are spent in the office of private practitioners or in a multidisciplinary ambulatory care clinic. Students are given the option of rotating with a general internist, medical subspecialist, or a neurologist. One of the many advantages of this system is the opportunity for exposure to a particular subspeciality early in their educational experience that may facilitate career planning. This is reflected in increased scores on the NBME exam administered at the termination of the clerkship, as well as improved performance in the clinical setting.

At Virginia Commonwealth University, all 180 students spend four weeks of the twelve-week Internal Medicine Rotation in the outpatient setting. Approximately one-half of students rotate through the outpatient clinics at Medical College of Virginia Hospitals or the McGuire Veterans Affairs Medical Center. The remaining students spend four weeks in an internist's office, with students electing to go to physician offices throughout Virginia, including the Eastern Shore, and occasionally, in other states. Students rate the outpatient experience very highly, and often form lasting mentoring relationships with their preceptors.

In 1999, the University of Virginia converted one month of its inpatient clerkship to an ambulatory experience. All 140 students are required to spend 4 weeks in the office of a general internist. During this, up to 30% of the students time may be spent in practice inpatient activities and subspecialty experiences. Students go to physician offices throughout central, northern and southwest Virginia. This experience not only has become the most highly rated clerkship experience by the students. It has also resulted in a significant improvement in the students' performance on internal medicine board-like examinations.

For all of the schools, there is a continuing need to identify internists who are interested in teaching students at the clerkship level. The general requirements for eligibility include board certification in internal medicine, state licensure and a practice which is predominantly (but not solely) general in scope. A willingness to participate in student evaluation and faculty development activities is usually expected. Schools offer a variety of perks, and the ACP offers recognition awards to participating physicians. The schools tell us that most mentors keep continuing relationships with little turnover. Physicians enjoy the chance to educate future physicians and to assist them in their career and professional development.

The clerkship directors for Virginia schools are:

EVMS: Ronald W. Flenner, M.D., Department of Internal Medicine, 825 Fairfax Avenue, Suite 410, Norfolk, VA 23507, email: flennerw@evms.edu, phone: 757-446-7439.

VCU: Judy Brannen, MD, MBA, Department of Internal Medicine, MCV Station Box 980663, Richmond, Virginia 23298, email judy.brannen@med.va.gov, phone 804 675-5000 x4293.

UVA: Eugene C. Corbett, Jr., F.A.C.P., Department of Medicine, Box 800744, UVA-HSC, Charlottesville, VA, 22908, email ecc9h@virginia.edu, phone 434-924-1685