Teaching on the run tips 14: teaching in ambulatory care

Key factors of teaching and learning in ambulatory settings include:

• Defining the outcomes (including unique ones available in the community setting).4,11 These may include managing common presentations and understanding the role of the practice nurse. Discussion of outcomes with the learner will allow joint expectations to be explored.

• Good orientation to the practice, patient care, learning and resources.3,4,13 If this is the learner’s first experience in a community setting, he or she may not be used to exposure to multiple social and often emotional aspects of patients’ lives.4 Orientation helps learners to have the confidence and competence to be involved.

Learners should be active members of the team, which means you need to provide them with authentic patient experiences.3,5-7 Trainees initially may value simply watching and learning from role modelling by clinicians, but soon they will want to take responsibility for interaction with patients.3,4 Encourage learners to consider why a particular patient is coming to the clinic, provide guidance as to how long they should spend with a patient, and tell them that interaction needs to be focused rather than extensive. At the same time, ensure they are not missing important aspects of the consultation by focusing too much on one area. Consider what types of patient are appropriate for trainees’ learning needs (eg, in health care assessment, chronic disease management and aged care).

Teaching with or in front of patients, such as when the trainee sees the patient alone first and then presents and plans management in front of the patient, doesn’t add much time to the clinician’s work, but significantly increases the time the patient spends with the health care team.2 This requires the use of a second room and flexibility in patient scheduling (eg, “wave” scheduling [see Box 1 footnote]3). In general, clinicians tend to extend their workday by 30–50 minutes per half day to accommodate this type of teaching arrangement, rather than reduce their clinical load.2

Depending on the learner’s level of experience, you may wish to:

• Jointly review the patient after the initial review or get the learner actively involved during the consultation (when teaching students) (Box 2); or

• Provide advice outside the door on each patient, and/or follow-up at the end of the clinic (when teaching trainees).

Trainees generally prefer to work alone and do not like having the supervising doctor come in and review the patient with them, feeling that it changes the doctor–patient relationship they have established.7 But they do want input. Identify areas of uncertainty for learners, help them find resources, and agree on a time for follow-up. Students and trainees value formalised time for teaching, so set aside an hour a week for that purpose.

Learning in clinics can be challenging. In an outpatient setting, learners may find themselves alone with patients, as opposed to a hospital setting, where there are often other people available to give advice. Furthermore, direct observation of trainees in outpatient settings is harder, even though it is important for determining their strengths and areas for improvement. You may wish to sit in with the trainee for a clinic every few months. Gather feedback from others (the receptionist often knows whether patients want to see your trainee again!).3 Finally, self-reflection by the teacher on individual teaching encounters and on the entire attachment will improve subsequent teaching.