Teaching and learning in ambulatory care settings: a thematic review of the literature.

A thematic review was conducted of the 1980-1994 research literature on teaching and learning in ambulatory care settings for both undergraduate and graduate medical education. Included in the review were 101 data-based research articles, along with other articles containing helpful recommendations for improving ambulatory education. The studies suggest that education in ambulatory care clinics is characterized by variability, unpredictability, immediacy, and lack of continuity. Learners often see a narrow range of patient problems in a single clinic and experience limited continuity of care. Few cases are discussed with attending physicians and even fewer are examined by them. Case discussions are short in duration, involve little teaching, and provide virtually no feedback. Excellent teachers are described as physician role models, effective supervisors, dynamic teachers, and supportive persons. Rather than block rotations, students and residents prefer longitudinal teaching programs, which offer continuity-of-care experiences with patients and preceptors. Although little can be concluded about learning outcomes, the studies indicate that some medical students and residents have deficient skills in interviewing, physical examination, and management of psychosocial issues. Based on the reviewed studies, the author recommends facilitating learning by increasing continuity-of-patient-care experiences and contact with faculty members, encouraging collaborative and self-directed learning, providing faculty development, and strengthening assessment and feedback procedures. The author also recommends further research to learn about medical specialties other than internal medicine and family medicine, to describe the knowledge and reasoning of both teachers and learners, and to assess the influences of various educational programs on learning and satisfaction.