Ambulatory-based clinical education: Flexner revisited.

Howcanmedicalschoolsmakesure that their students will regularly encounter patients with common clinical conditions during their clinical training? This is a major challenge because patients who previously would have been hospitalized for the management of such conditions can now be cared for in ambulatory settings, thanks to advances in medical practice. As a result, most of the patients seen by students during their inpatient clerkships have serious complications of underlying diseases, or complex conditions that require specialized care. Also, changes in the organization and financing of medical care have adversely affected students' experiences on those clerkships by altering the way care is provided on inpatient services and by shortening the length of hospitals stays. As a result, clerkships based on the inpatient services of major teaching hospitals no longer provide the optimal range of experiences for students to learn clinical medicine. Many schools, recognizing this to be the case, have increased the amount of time students spend in ambulatory settings during their clerkships. But there is still a significant imbalance between the time students spend on inpatient services during most clerkships and the time they spend in ambulatory settings. One of the problems schools face in changing their clerkships is knowing how to organize ambulatory-based experiences so they provide quality education. To remedy this, models of ambulatory-based clerkships need to be established around the country so that schools can learn from them what might be effective at their institutions. The model being employed by the Florida State University College of Medicine and the pilot project under way at Harvard Medical School and the Cambridge Health Care Alliance are examples of the kinds of innovative approaches for teaching clinical medicine in ambulatory settings that are badly needed. Now, I recognize that some faculty are more than a little uncomfortable with the notion of moving to a more ambulatory-based model of clinical education during core clerkships. They see this as too dramatic a departure from the longstanding and strongly held view that students must learn clinical medicine primarily on the inpatient services of hospitals. They see the move to ambulatory-based clinical education as one that threatens to undermine the quality of medical students' education by abandoning the Flexnerian model established in this country over 75 years ago. But those who believe that Flexner argued that medicine has to be learned on the inpatient services of hospitals fail to appreciate fully Flexner's views. In his …