This article on pediatrie education in the ambulatory setting outlines some assumptions about residency education in general, expands on what is meant by the term "ambulatory setting," describes the content of what can be taught in one of those settings, the community-based primary care practice, and suggests some strategies to make that a successful educational experience. The underlying assumption is that if pediatricians are to remain central to the provision of primary care, then the study and teaching of primary care must be central to the educational mission of academic departments of pediatrics.
PEDIATRIC MEDICAL EDUCATION
A further assumption is that pediatricians will continue to be the major providers of primary care to children. In fact, the proportion of primary care provided to children by pediatricians in the United States is increasing, particularly for those under 10 years of age.1 A 1991 American Medical Association survey reported that 87.4% of pediatricians who have completed training and are involved in patient care are office-based primary care providers.2 Unpublished data regarding the 1992 General Pediatrics Certifying Examination of the American Board of Pediatrics indicate that among first-time takers of the examination, 60% intend to enter general pediatrics and 30% intend to enter a pediatrie subspecialty training (a proportion of whom will end up in practice as well). It is logical, therefore, to ensure that the educational preparation of those who elect to practice is optimal. That should include a well thought-out experience in ambulatory settings where the majority of trainees eventually will work.
Ambulatory Settings for Medical Education
The inpatient ward has been the centerpiece of medical education since the days of William Osler. In fact, medical students and residents still spend the majority of their time in inpatient settings, usually in a tertiary-care hospital. A 1984 GPEP Report, "Physicians for the 21st Century," commented "Although fewer than 5% of all physicians/patient contacts result in hospitalization, clinical clerkships are predominantly based on hospital inpatient settings. Clerkships in ambulatory settings are relatively uncommon."p 3 Although a proportion of pediatrie residency education takes place in ambulatory settings, relatively little of it occurs outside of the tertiary-care center. Why should this still be so? Why has it been difficult to shift more medical education experience to ambulatory settings in general and to the community in particular?
The basic fact is that graduate medical education for most specialties is a hospital-sponsored activity, and residents are hospital employees. The underlying assumption has been that the work of the hospital-the patients seen, conditions treated, and physicians employed to attend to their needs-are all close or at least generalizable to practice to make the hospital setting the appropriate principal learning environment. That, in fact, is a reasonable assumption for subspecialty training. For example, in radiology, surgery, anesthesia, and obstetrics/gynecology, physicians do in residency training more or less what they will do in practice. However, the assumption is less true for the primary care disciplines and probably least true of all for pediatrics, which must be the most extreme example of what has been called the "residency-practice training mismatch."p 4 In no other specialty is the experience of the resident so different from that of the practitioner.
Moreover, hospital settings, both ambulatory and inpatient, have been getting progressively less like primary care over the past several decades. Hospitalized children have more complex and severe illnesses, with shorter lengths of stay than was true in the past. Hospital ambulatory services differ from practice as well: general clinic patients are disproportionately drawn from poor or socially disorganized families; patients seen in the emergency room are usually unknown to the provider, and the philosophy of case management in the emergency room often differs markedly from that in practice for the same illness.
For example, the febrile child seen in an emergency room usually will receive a more extensive laboratory evaluation than will a comparable child seen in the office, where fewer tests and a "watch and wait" approach is more common. The ER management is not unreasonable given uncertain compliance and follow-up. However, residents may miss the point that management of the same illness may appropriately vary by setting, and they may believe that the ER standard should be applicable to community practice as well. In subspecialty clinics, patients usually have more complex illness than those seen in primary care settings, and nurse clinicians, social workers, and other support staff are more readily available than they are in a private office.
As a result of these changes, the community-based practitioner is less visible, and at times less welcome, within the university hospital inpatient and ambulatory service than in the past. The practitioner may, in feet, be uncomfortable functioning in the hospital environment where patients, diseases, and medical systems are less familiar. The result is that the average resident is less likely to observe the average primary care clinician functioning knowledgeably and effectively in the hospital setting than was true in the past. Although primary care clinicians do have a role within the hospital, if trainees are to fully understand how practitioners function, they will need to move out into the community.
We use the term "ambulatory setting" as if it were one entity. In feet, there are a variety of ambulatory settings that can be used for medical education, both in the hospital and in the community (Table 1). The remainder of this article focuses on one of these, the primary care practice in the community. Office practices have not been as extensively used for educational purposes as they might be, and the principles discussed are applicable to other ambulatory settings as well.
The challenge in designing a successful primary care educational experience is to develop settings, curriculum, and faculty to accomplish for primary care education what has been successfully accomplished for subspecialty education. At the present time in most pediatric residency programs, on completion of their training, most graduates are well-prepared to enter fellowship or, paradoxically, for a career as a chief resident-a job that does not exist.
What Can Be Learned in Community Primary Practice Settings
It is useful to keep in mind that medical education remains basically an apprenticeship model. The teaching structure that has worked well for subspecialty education can be outlined as follows: students are exposed to a trained, experienced subspecialist practicing the subspecialty and teaching it in an appropriate setting. That, I submit, is what needs to be done for primary care education. We should use as a teacher, a trained, experienced primary care clinician who practices and teaches in a real practice setting (either within the medical center or the community). Basing longitudinal ambulatory teaching in most hospital-based continuity clinics does not meet these criteria. Continuity clinics rarely resemble functioning office practices and usually have been established only to meet a specific educational purpose. Many of the faculty who teach in that clinic either never practiced or no longer do so, or their office practice is located elsewhere. For comparison, we would think it irrational to teach neonatal intensive care in an artificial neonatal intensive care unit staffed by neonatologists who have never practiced, no longer do so, or practice elsewhere.
Admittedly, many pediatric programs involve community practitioners as teachers within the hospital setting, usually in the ambulatory clinic. While that does expose trainees to practicing physicians, it is less successful in providing the resident insight into how the practitioner actually functions in his or her own practice. In a tertiary-care hospital setting, practitioners may be at a disadvantage dealing with an administrative system, a patient population, and a set of medical conditions with which they may not be intimately familiar.
COMMUNITY-BASED PRIMARY CARE PRACTICE
Given the constraints of the hospital setting, it's worth exploring how to create effective longitudinal experiences in community practice. First, what can be learned in such settings? If the educational goal is to teach about primary care, that subject may be subdivided into patient-, office-, and physician-centered objectives (Table 2).
Under patient-centered objectives, the primary care physician plays an important role in the area of health promotion and disease prevention. For example, the practitioner should be involved in injury prevention and in discouraging young adolescents from initiating tobacco use. Learning to care for patients with low-severity and high-frequency conditions in the office can be contrasted with dealing with the high-severity and low-frequency conditions seen in a tertiary-care center. It is particularly important for trainees to be exposed to the role the primary care practitioner plays in the management of children with chronic conditions. If residents only see endocrinologists treating diabetic children, psychologists caring for those with behavioral disorders, and neurologists treating children with seizures, they learn a powerful lesson about who their teachers think are appropriate providers of care.
There are a variety of office-centered objectives that are important for the education of the generalist.
The use of patient or parent resource materials is a rich field that residents should be exposed to. Office telephone management is another example of a subject central to running a successful practice, since nearly half of all contacts by the public for health problems in children are by telephone.
Finally, there are a number of physician-centered objectives to be learned in the primary care practice. Residents need to understand and learn about the practitioner's role in the community, an important and satisfying aspect of community practice. An underlying educational objective is for trainees to learn about the "life and times" of the generalist. As in the hospital, they need to work alongside competent faculty role models satisfied with their life's work.
Those are some examples of curricular issues to be addressed. What about the faculty? The key lies in selecting practitioners from within the practicing community with the capability of being skilled teachers and then preparing them carefully for that role. At the University of Massachusetts Medical Center, we have had experience over the last 5 years involving more than 50 practicing physicians in a formal training program designed by Drs Thomas DeWitt, Kenneth Roberts, and Renee Goldberg. Central to the success of this program-in addition to selecting the appropriate physicians-is assuring that the training occurs in protected blocks of time, taking the physician away from the business of practice, and requiring a substantive 1- or 2-year commitment in advance from the "practitioner student."
We have found that physicians who have gone through our training program in the first several years have become valued faculty in the program itself, teaching the new community trainees and playing a central role in further curriculum development. An important by-product of this program is that these community faculty become acutely aware of what they need to know in order to teach effectively. They are diligent in pressing us about the most current management of asthma, seizures, screening tests in practice, and the management of behavioral problems. For example, we currently conduct two ongoing monthly behavioral workshops for practicing physicians, predominantly filled with physicians who have gone through the faculty development program.
I would emphasize the value of ongoing faculty development for the practitioners. Like any educational effort, continued involvement of the teaching faculty over time helps ensure that the curriculum (and the teachers) continue to grow.
IMPLEMENTING COMMUNITY-BASED EDUCATION
Finally, there certainly are problems or issues that need to be addressed to successfully implement community-based education for a large number of residents. Hospitals may resent the time "their" residents spend seeing patients in the community rather than in hospital clinics. Placing residents in settings throughout a region requires careful attention to complex scheduling details to accommodate both resident and practice needs. Financial issues need to be discussed in advance as well: should community faculty be paid for their efforts and, if so, how much? While it makes good sense to pay for teaching, the practices benefit as well. Practices (particularly managed care organizations) clearly recognize the benefit in having such trainees as indicators of the quality of their practice to the community. Moreover, the satisfactions of this teaching role helps the practice recruit new physicians. These issues tequire discussion beyond the scope of this article.
There can be significant value to community-based education for both residents and medical students. Such education accomplishes several things. First, it helps students and residents formulate and clarify their career decisions. Second, it strengthens the bond between community practice and the medical center. Primary care, community-based physician teachers become an important part of the faculty. Last, and perhaps most important, it has the potential to improve the quality of practice-and ultimately benefit the nation's children.
The science of medicine has advanced in a large part because it is practiced in academic settings where learning, mutual scrutiny of clinical practice, and critical thinking are part of our everyday experience. Our hope and expectation is that including community practice in the academic environment will enhance the science of primary care medicine. Academic pediatrics has much to offer this partnership, and much to gain from it.
1. Martinez G, Ryan A. The pediatric marketplace. Am J Dis Child. 1989; 143:924-928.
2. Roback F, Randolf L. Seidman B. Physician Characteristics and Distribution in the United States. Chicago, III: American Medical Association; 1992.
3. Association of American Medical Colleges. Physicians for the 21st century. The GPET Report. 1984:16.
4. Reuben D. McCue J. Gerbert B. The residency-practice training mismatch. Arch Intern Med. 1988:148:914-919.
Ambulatory Settings for Medical Education
What Can Be Learned in Community Primary Practice Settings