Practical approaches to a major educational challenge. Training students in the ambulatory setting.

Medical schools and residency training programs are recognizing the need to expand education in ambulatory medicine. Inpatients wards increasingly provide treatment for only the most critically ill patients and are required only for very specialized procedure-oriented technology. Most diagnostic and management decisions are being made in outpatient settings. This shift in where medical care occurs has led to a reassessment of the educational value of training students and house staff primarily on hospital-based wards. New training initiatives in ambulatory medicine are being developed in medicine, pediatrics, and family medicine, and the principal sites for most of this training are primary care offices, clinics, and health maintenance organizations. Program planners and individual preceptors are confronting numerous obstacles in their efforts to find effective solutions to the dilemmas raised by the need to train large numbers of students in these settings. This article will explore many of these obstacles, including the unique learning requirements of third-year students, the elements of a quality clinical training environment, and the precepting skills needed for this educational task. Finally, we propose for debate a model for ambulatory medical education that focuses on strengthening the ties between academia and the numerous training sites. By taking optimal advantage of academic and community attributes, we are more likely to be assured quality medical education, skilled teaching, and rigorous scholarship in ambulatory medicine.