MEDICAL
EDUCATION
Outpatient teaching in family medicine
residency training programs in Taiwan
Shiuan-Chih CHEN1, Chi-Hua YEN1,
Chun-Chieh
CHEN1, Wei-Ya WU1, Ming-Chih CHOU1, W. BELL1,
E. Y. T. YEN2, Meng-Chih LEE1
1Department
of Family and Community Medicine, Chung Shan Medical University,
Taichung, Taiwan, 2Harbor/UCLA Family Health Center,
Harbor City, California, USA
Abstract
The Taiwan Association of Family Medicine (TAFM) was established in 1986. At the present time Taiwan has a total of 66 residency training programs with approximately 150 first-year residents accepted per year. The TAFM realizes and values the importance of outpatient teaching for family medicine residents. Following the guidelines of outpatient training for residents set in 1989, the first-year, second-year, and third-year residents should attend the outpatient teaching at least once, twice, and three times per week, respectively, at the designated Family Medicine Clinic. Residents also receive outpatient training from qualified preceptors during their community rotations, wherein services are provided to patients in the clinics, their homes or communities where they live. In this review article, guidelines on outpatient teaching in the family medicine residency training programs made by the Taiwan Association of Family Medicine will be described, followed by my personal experiences about teaching family medicine at an outpatient clinic.
Family practice is characterized by its first-contact, office-based, patient-centred, family-as-a-unit, and prevention-oriented care. Obviously, the outpatient clinic is the proper place to demonstrate and practice the characteristics of family medicine. A family physician spends approximately 90% of his/her working time on outpatient services, followed by inpatient care, institutional care and home visits. Moreover, outpatient practice at the Family Practice Center has been the most important training curriculum for family medicine residents throughout the world.
Quality ambulatory teaching requires the following:
1 Preliminary class: introduction to the practice, operating procedures for the practice, communication skills, use of computer, and evidence-based medicine.
2 Teaching primer: at least two partially connected examination rooms for each learner must be provided.
3 Teaching facilities: standardized outpatient facilities, documents, and computer systems.
4 Trainers: attending staff, chief residents, and allied professionals who have received adequate preparation for both first-time teachers and continuing professional development training.
5 Evaluation system: video-taping, one-way mirror, review of medical records, clinical performance examination with standardized patients for learners, and also evaluation of the learning experience by the learners.
6 Financial arrangements: rewards and credits to the trainers, funds to support the expenses, and maintenance of teacher enthusiasm.
Key words: outpatient teaching, family medicine, residency training.
Introduction
Family practice is characterized by first-contact, office-based,
patient-centered, family-as-a-unit, and prevention-oriented care.1
Obviously, the outpatient clinic is the proper place to demonstrate
and perform the characteristics of family practice.2
A family physician spends approximately 80-90% of his working
time in outpatient services, followed by inpatient care, institutional
care, and home visits.3
At the Johns Hopkins University School of Medicine, US, a 4-5
week ambulatory medicine clerkship is required for every medical
student.4
Moreover, outpatient practice at the Family Practice Center has
been the most important training site for family medicine residents
throughout the world.2
Historical
perspectives
Before the mid-19th century, apprenticeship was the main model
of medical education.5
Utilizing the proposal by Sir William Osler, the Johns Hopkins
University School of Medicine was the first medical institution
in North America to organize outpatient teaching for medical students
(1901).6
The Flexner Report on medical education in the US and Canada in
1910 highlighted outpatient teaching.7
Moreover, ambulatory care has been one of the main issues in medical
education reform since the late 1980s, and outpatient teaching
has become an essential component of graduate training for all
specialties, especially for family practice.8,9
Outpatient
medicine and family medicine
It has been recognized that the family practice clinic is the
proper setting to demonstrate the characteristics of family medicine.2
This implies an office-based practice, utilizing first-contact
care and using a biopsychosocial model. It also integrates prevention
and medical care, and stresses a team approach. It is patient-centred
but revolves around the family-as-a-unit-of-care and is oriented
towards the community. Outpatient practice is the main way to
test and enrich the principles of family medicine. Certainly,
the outpatient clinic is also the main workplace for family physicians.
The American Academy of Family Physicians (AAFP) reports that
on the average, family physicians work approximately 50 hours
and see 100 patients per week, and 80% of the working time is
used for outpatient care.3
In Taiwan, an average family physician/general practitioner works
60 hours and sees 200 patients per week in the clinic, and the
working time is used mostly for outpatient care.1
Contents
of outpatient teaching
In every patient encounter, family physicians deal not only with
the patients' chief complaints, but also with their unresolved
problems and other issues. In addition, family physicians see
the patient encounter as an opportunity to provide needed preventive
services and to promote the doctor-patient relationship. All of
these considerations are what we must teach our residents. We
should also impart the importance of practice management, and
clinical approach relying heavily on evidence-based medicine and
informatics. The emergence of managed care and social health insurance
are other issues to touch on, especially since this is a common
experience in Asia-Pacific region.1
Preparations for outpatient teaching
Implementation of outpatient teaching requires that the following
are done or be made available:10-12
1 Preliminary class: trainees shall be oriented properly
about the practice, its operating procedures, communication skills,
use of computer, and evidence-based medicine.
2 Teaching premise: at least two partially connected examination
rooms for each learner must be available, one for consultation
and the other may be used for physical examination.
3 Teaching facilities: standardized outpatient facilities
such as comfortable chairs and facilities for physical examinations,
documents and records, and computer systems.
4 Trainers: attending staff, chief residents, and allied
professionals who have received adequate preparation for being
very new teachers or have received adequate continuing professional
development training. For example, our department has two phases
of faculty development programs, namely: orientations phase (2
days) for every new faculty member and those with less than 3
years of teaching experience; and proficiency phase (2 days) enabling
one to progress into a proficient medical teacher.
5 Financial arrangement: rewards and credits to the trainers,
funds to support the expenses, and maintenance of teacher enthusiasm.
Process
of outpatient teaching
In our program at the Department of Family and Community Medicine,
Chung Shan Medical University, all medical interns, residents
and staff get together for a morning meeting in the outpatient
department. We preview medical records of the patients who have
made appointments and discuss possible plans for them before the
patient encounter.12
Initially, the junior resident shall observe and work with the
faculty for 6 months, and then they may see a limited number of
patients (five per clinic session) with close supervision by the
faculty (e.g. every patient should receive a double-check before
he or she leaves). For senior residents, they may see a reasonable
number of patients (around 15 per clinic session) with subsequent
faculty review (Fig. 1). The faculty
usually introduces the resident to the patients and explains the
process of their consultation, so that residents will interact
comfortably with patients whom they might not otherwise be very
familiar. At the end of the outpatient session, the faculty and
residents will get together to discuss whatever questions they
have and to process experiences (Fig. 2).
Time for reflection is given.2,12
For some procedures performed in the outpatient department such
as a Pap smear, intra-articular injection, cauterization, cryotherapy,
skin biopsy and so on, the faculty should demonstrate these and
then assist the residents until they become proficient.
Looking into the impact of clinical experience in family medicine
outpatient clinics, at least one has study indicated that medical
students who have completed their outpatient clerkship at the
Family Medicine Clinic in this kind of set-up showed a greater
positive attitude toward family practice as a future career13
than prior to the outpatient rotation.
Teach
problem-solving in the outpatient setting
Since there is limited time and resources in the outpatient setting,
residents should learn how to resolve patients' problems efficiently
and effectively. Residents are encouraged and guided to apply
epidemiology,13-15
for example the concept of probability (frequency, prevalence,
the positive and negative predicative value), and risk (relative
risk/odds ratio) in the diagnosis and management of patient problems.
In addition, informatics-assisted practice, and legal as well
as ethical concerns, should also be taken into consideration.16-18
In the 21st century, everyone must be fully acquainted with the
informatics system. This may be quite helpful for medical practice.
Informatics can help in clinical decision-making, and as a reminder
for preventive services.
A good example of utilization of informatics in our practice is
the family profile. We are able to monitor patients' families
in terms of the mean time of each individual consultation by just
clicking 'the family profile' (Fig.
3) which contains family structure, family life cycle
and events, and the individual health summary of each family member.
This obviously is very significant for family care. For example,
you can see one family member and monitor or talk about health
status of all other family members based on the on-line family
profile system.
Evaluation of outpatient teaching
Traditionally, we use a one-way mirror, video-tapes and audits
of medical records to review learners' performances. In recent
years, objective structured clinical examination (OSCE)19,20
using standardized patients has become popular and proven to be
practical. The learner's assessment of faculty teaching is also
needed for improving the outcome of outpatient teaching.
Future
direction
The discipline of family/community medicine has performed outpatient
teaching for more than 20-30 years. What are our future directions?
First, we must address and clarify the following points:21,22
1 Has outpatient teaching been carried out seriously?
2 To what extent should every learner be closely supervised
by the faculty?
3 Does the practice have enough patients and health problems
for teaching?
4 Have both the behavioral and the social sciences been
highlighted in outpatient teaching?
Conclusion
In conclusion, the outpatient clinic is the main place for family
medicine residents and medical students in Taiwan to learn ambulatory
medicine, and to realize and demonstrate the principles and characteristics
of family medicine. Therefore, an ambulatory rotation is required
for each resident and student. Through required ambulatory experience,
the family medicine resident will learn to be an effective family
doctor.
References
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Fig.
1. Senior residents may see a reasonable number of patients
(around 15 per clinic session) with subsequent faculty review
Fig. 2. At the end of the outpatient session, the faculty and residents will get together to discuss whatever questions they have and to process experiences