EDUCATING CHILD HEALTH PROFESSIONALS The Search for Effective and Efficient Ambulatory Teaching Methods Through the Literature

Objective. Education in ambulatory settings is characterized by the conflicting agendas of clinical efficiency and educational effectiveness. In recognition of the challenge to teach more effectively, this review was undertaken to identify literature-based teaching methods for ambulatory-based education. Design. Literature search resources included electronic databases and relevant journal indices. After preliminary title/abstract review, final critical review using a coding sheet was undertaken to define the teaching behavior or characteristic in each article, and to evaluate empirical data related to effectiveness and/or efficiency. Results. Our literature search and subsequent article analysis yielded 11 clinical teaching methods, but no agreed upon descriptor or key features for these methods. Synthesis of this literature lead to succinct descriptions of each method and a label. Conclusions. There is limited evidence regarding the effectiveness of ambulatory teaching methods in cited literature. By establishing a common nomenclature and descriptions for 11 methods, this review lays the foundation for investigators to systematically study the effectiveness and efficiency of ambulatory-focused clinical teaching methods both within and across specialties. Pediatrics 2000;105:231–237; ambulatory education, clinical education, clinical teaching, medical education, precepting teaching behaviors, teaching methods. ABBREVIATIONS. ERIC, Educational Resources Information Center; TIPP, teaching in the patient’s presence. The pressures for clinical productivity and research funding pose critical challenges to ambulatory-based clinicians who fulfill the education mission of our medical schools. Skeff and colleagues1 argue that the charge to physicians to teach more efficiently, so that they will have more time available for patient care, is merely an illusion. Teaching takes time. The ambulatory environment, in particular, is characterized by variability, unpredictability, immediacy, and lack of continuity. Irby’s 1995 thematic review of the literature on teaching and learning in ambulatory care settings2 highlighted the lack of research on clinical teaching methods. In 1998, Bordage and colleagues3 identified a series of important research questions to be answered about education in ambulatory settings. Among the critical questions was a cluster that focused on teaching and instructional strategies. More specifically, for the ambulatory setting, Bordage and colleagues asked, “Are there effective ”micro-teaching“ skills or techniques? What are the characteristics of an effective teacher or preceptor in the ambulatory setting?” Irby’s 1995 review, which focused on the literature from 1980– 1994, began to address the question of the characteristics of effective clinical teaching, (eg, enthusiastic, clinically competent, organized, accessible). However, this review did not identify the specific teaching methods used by effective ambulatory clinical teachers. Rather, Irby presented a series of recommended clinical teaching methods based on principles of learning and cognitive psychology: to set clear and realistic expectations, to teach to the learners needs, to give specific feedback based on observation of the learner’s performance, and to create a positive learning environment. Several authors, referencing Irby’s model, have proposed precepting “systems,” which are reported elsewhere.4,5 The “microskills” and “one-minute” models of structuring ambulatory teaching encounters describe components of the teaching encounter that are discussed separately below. In recognition of the challenge facing clinical teachers to be effective and efficient, and the call to answer questions about ambulatory teaching, this literature review focuses on identifying specific teaching methods, and to determine if there is any evidence supporting their association with effective (increased student learning; learner achieving educational objectives) and efficient (time/cost to the teacher) teaching in the ambulatory setting.