Dear Sir
Outpatient clinics offer students the opportunity to observe the process of a consultation in the outpatient setting: a skill important to develop at an early stage of clinical training. In rheumatology a reduction in the number of inpatients has led to a shift in clinical teaching to outpatient clinics. Our medical students spend six weeks in musculoskeletal medicine and the majority of their teaching will be in the outpatient clinic. The mode of teaching in this environment is fundamentally distinct from the traditional bedside teaching, as it is opportunistic and conducted in parallel to service provision. We attempted to determine what factors might contribute to an effective teaching experience in the clinic. We surveyed the attitudes of patients attending clinic (44 adult patients surveyed over four weeks), medical students (44 students surveyed at the end of their musculoskeletal medicine block) and clinical teachers (11 clinical teachers involved in teaching in clinic).
In our survey most students described their participation as ‘passive’ with only a fifth of students reporting seeing patients independently to obtain a history, perform a physical examination and present their findings to the clinician. Students performed a physical examination in 52% of their encounters with patients in clinic; however, this was observed by a clinician in only 18% of cases. When asked how students would like to participate in clinic, 86% of students wished to see patients alone and then present their findings and 91% wished to be observed performing a clinical examination by the teacher. Students who had the opportunity to participate more actively in clinic reported more confidence in clinical skills such as history taking and clinical examination. Patients also expressed their willingness to be more actively involved in teaching with 95% of patients reporting a willingness to be examined by students and 48% willing to spend time with students alone in clinic. Our results suggest that to improve the teaching experience in clinic we must, when possible, allow students the opportunity to talk to patients, perform clinical examinations and facilitate part of the patient consultation. The pressure of service provision and time and space within the clinic environment are potential barriers which must be overcome if we are to increase the learning opportunities that students encounter in clinic.