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Taking a Proactive Approach to Learning on Your Ambulatory Medicine Rotation

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Ambulatory medicine is the backbone of our healthcare system. With the majority of healthcare being provided in the outpatient setting, your ambulatory rotations will provide the opportunity to see a variety of disease processes and learn the practical management of chronic illness. Additionally, you will begin to understand the ways in which culture and socioeconomic factors influence healthcare.

Unfortunately, ambulatory medicine rotations in any specialty can quickly turn into shadowing experiences, if you let them. Following these suggestions for a proactive approach to your ambulatory rotations will help you become more involved in the process and take responsibility for your own learning.

Be Prepared for Clinic

Chances are you will be working in a variety of clinics with many different faculty; on your first day of a new clinic, try to arrive at least ten minutes early. This will give you an opportunity to have a tour of the clinic and get acquainted with the logistics of the schedule. Make a point to introduce yourself to the nurses and other clinic staff; they will be able to point you in the right direction as you try to accomplish the day’s tasks with efficiency. Introduce yourself to your staff and/or resident physician and ask what they expect of you.1 Most experienced faculty will have relatively straightforward expectations in mind. An awareness of these expectations early in your clinic experience will improve your learning and your evaluations.

Ask for Independence

This one is pretty straightforward. Staff physicians always have something else they could be doing, so even if only one patient is waiting to be seen, ask if you can go see them on your own first. Most patients will be aware of your presence prior to your entering the room and will have made it known if they do not want to see a student. Often, patients at teaching institutions are familiar with the concept of students-in-training and will be happy to help you with your education. Be sure to thank each patient for working with you.

Show an Interest in the Specialty or Subspecialty

Try to read about a common disease you might encounter in a clinic before showing up. This will give you a foundation upon which you can base the history and physical examination of many patients in that clinic. If you are unsure of important history and physical exam components, visit the Physicians Information and Education Resource. This website has quick and easy tables with key history and physical exam components for most diseases encountered in the ambulatory clinic setting.

While you are in clinic, you may have to wait to staff a patient with your supervising physician. During the down time, take a moment to look up the condition you believe your patient may have. The additional knowledge you are able to acquire in just five spare minutes will improve the assessment and plan you are able to present to your supervising physician.

Be Aware of the Clinic Schedule

This can be one of the more difficult things to learn in an ambulatory rotation, in fact, many experienced physicians still have a hard time staying on schedule. Make a point to be aware of when each patient’s clinic appointment was supposed to start and when the patient arrived, in addition to how long for which the appointment was scheduled.

Attempt to alleviate congestion in the clinic schedule by going to see the patient on your own. Particularly with new patients, you can save your supervising physician a considerable amount of time by getting a complete history and review of systems before they enter the room.

Focus on the Interval History

In most ambulatory clinics, and particularly in internal medicine clinics, faculty physicians have well-established relationships with patients. You may never know as much about the patient as the staff physician but you can still contribute relevant information.

The interval history is the key to contributing new information to the medical record. You may have to remind your patient repeatedly to tell you what has gone on since their last visit, but this is really the most important information you need to know. Start by asking the patient what they would like to talk about and what they are most concerned about. For a patient with many medical problems, a good way to get at the pertinent interval history is to look at the assessment and plan from the previous visit. Going through the plan point by point with the patient will help you stick to the important issues. This technique will also give you a new appreciation for good documentation and a format to follow for your own clinic notes.

Make sure to ask which medications they are taking and how they are taking them. Patients frequently misunderstand the instructions given for taking their medications but may be afraid to bring this confusion to the attention of the physician. You are in a position to listen to your patients’ questions and try to clarify the confusion for them as well as bring the issue to the attention of the attending.

A Good Presentation Speaks Volumes

Usually you will only have a few minutes to synthesize a presentation, so have a format in mind and try to use the same format in every clinic. You should be able to present a patient in five to seven minutes. If you are interrupted it may take longer but a good format should minimize questions during the presentation. A “SOAP” format will work well for your presentations in most clinics, and your staff physician will be familiar with it. “SOAP” stands for subjective observations, objective observations, assessment and plan. Include pertinent history since the last visit, pertinent review of systems and positive findings on the physical exam. Include negative findings only if they are relevant to the patient’s chief complaint. For example, it is unnecessary to report the details of a normal abdominal exam in a patient who is presenting to pulmonary clinic for a follow-up lung nodule. On the other hand, in a new patient, perform a complete physical exam, as it may be the most thorough physical the patient has had in years.

During your first semester of clinical clerkships, you may get away with a “SO” presentation, but by the second semester, you should attempt to include an assessment and plan in your patient presentations. It is acceptable to be wrong about your assessment and plan, it is acceptable to suggest unnecessary tests; your staff physician understands that you are learning. Do not worry about sounding unfamiliar with the disease; you may make a valid suggestion that the staff physician had not considered.

Request Frequent Feedback

This is particularly important if you will be initiating an evaluation. To prevent surprises, ask for suggestions for improvement about half-way through your clinic experience with a preceptor. Always thank your preceptor for taking the time to explain what you did well and what you can improve. So be proactive, open to suggestions and remember this is your education—if you sit back it will pass you by.

Heather Strah
Central Region Representative, Council of Student Members
University of Iowa College of Medicine, 2007
E-mail: heather-strah@uiowa.edu

References

1. Alper, E. et.al. 2004. “Primer to the Internal Medicine Clerkship: A Guide Produced by the Clerkship Directors in Internal Medicine.” Pp. 14-17. Clerkship Directors in Internal Medicine. Available: www.im.org/cdim.

Back to February 2006 Issue of IMpact

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