Outpatient Training: An Obscure and Old Challenge in Medical Education


Habibeh Ahmadipour ORCID 1 , *

1 Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

How to Cite: Ahmadipour H. Outpatient Training: An Obscure and Old Challenge in Medical Education, Strides Dev Med Educ. 2019 ; 16(1):e100142. doi: 10.5812/sdme.100142.


Strides in Development of Medical Education: 16 (1); e100142
Published Online: December 24, 2019
Article Type: Editorial
Received: December 13, 2019
Accepted: December 15, 2019
Copyright © 2019, Strides in Development of Medical Education. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

In our country, the educational curriculum of general medicine starts with basic sciences, which often lasts 2.5 years. After passing a basic sciences comprehensive exam, the clinical stage starts in which medical students deal with the management (diagnosis and treatment) of the diseases (1).

Clinical education is a process in which medical students attend different clinical settings to gradually acquire skills and be prepared for rational and evidence-based decision making (2, 3). It is expected at the end of the clinical courses, the graduating physicians poses the competencies will help them to practice effectively in their new practice setting (4).

Although the quality of clinical education can guarantee safe independent practice for future doctors, numerous studies have shown that a number of clinical education programs are not able to provide the necessary skills in their graduate, since the trainees practice and learn in a dysfunctional environment (3-7). In our country, the majority of clinical training is provided in a tertiary educational hospital while the graduates, in the future, should be worked at the first and second level of health services system.

This challenge dates back to 1988 when International Meeting on Medical Education recommended the establishment of community-oriented medical education and the extension of clinical education from hospitals to the community (8). In 2001, the Accreditation Council of Graduate Medical Education (ACGME) stated that one-third of clinical training should be provided in outpatient settings (9).

Since then, in our country, community-oriented medical education was taken into consideration by Ministry of Health and many medical schools have sought to extend their clinical training programs to the outpatient setting. Over the years so far, under different titles; community-oriented medical education, community-based medical education, and social accountable medical education, Educational Health Network ,etc.), the issue has been studied, its strengths, weaknesses, opportunities and threats have been stated and even some effective interventions have been carried out in some medical schools (10, 11). But this obscure and old challenge, in spite of many efforts, still exists in our education system and no tangible result was found. Why?

Recently, by the Secretariat of the General Medical Council, a new issue has been raised as “field training” to extend and improve the outpatient training. According to the announcement of this council, a field can be a hospital affiliated clinic, and urban, suburb or even rural health care center, etc. with appropriate number and diversity of the patients in order to achieve the outpatient training goals.

If we want this new directive not to be caught in the fate of previous similar ones, some points should be considered seriously by medical education planners and policy maker before finalizing and communicating the new directive to all medical schools.

• To Fix a Misunderstanding: When it comes to outpatient and field training, all minds go to the Community Medicine Department Training but it is not right. Due to its nature, the training in the Community Medicine Department is not possible elsewhere except in the urban or rural health centers. According to the curriculum, during community medicine clerkship/internship, medical students should become familiar with the structure and processes of the health care system, concepts such as integrated care for vulnerable population, national programs for the control and prevention of diseases, measurement and analysis of health indicators, and assessment of social determinants of health, etc.

Given the low proportion of these courses in general medicine curriculum (1/21 of the clerkship and 1/17 of the internship) and also their approved educational content, the outpatient training, in its true sense, is not possible during these periods. Therefore, medical school should involve other departments (at least major departments) in the outpatient training.

• To Specify the Outpatient Training Content: All contributing departments should specify their educational content for outpatient training, the content which could not be taught in the ward-based training programs. If this content does not exist clearly, students and professors get confused and the motivation for teaching and learning is reduced.

• To Identify the Appropriate Place for Outpatient Training: As mentioned above, a field can be a hospital affiliated clinic, and urban, suburb or even rural health care center, etc. To determine which of these centers are suitable for the outpatient training, each contributing department is responsible to identify the appropriate location based on its outpatient educational goals.

• To Specify Executive Responsibilities: After the content and location have been determined by the Training departments, the time has come for the contribution of the university deputies such as education, health, treatment and even management and resources development. Because if a department determines that its hospital-affiliated centers are not suitable for outpatient education, in terms of the number and diversity of the patients, each of these deputies can help the department to find a more suitable center. Finding, equipping and coordinating a training center for field training is beyond the responsibility of that departments and requires an agreement between all considered deputies with a clear description of their duties and responsibilities. If this contribution not done correctly, in addition to jeopardizing the implementation of new outpatient training program, routine service delivery processes also face problems.

However, it seems that the above points are the least things that must be considered for successful implementation of an ambulatory care training before the new introduced program “field training” is forgotten as previous similar programs.



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