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Purpose: The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change., Methods: The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance., Results: Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education., Conclusion: This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.

Oral phenylpropanolamine is commonly used to treat congestion and obesity. Clinicians often wonder what effect it has on blood pressure and whether they are safe in hypertensive patients. The purpose of our systematic review was to assess whether these drugs cause clinically meaningful elevations in pulse or blood pressure. English-language, randomized, placebo-controlled trials of oral phenylpropanolamine in adults with extractable data on pulse or blood pressure were studied. MEDLINE (1966-2003), Embase, the Cochrane library and reviewed article references were used as sources. Systolic (SBP) and diastolic blood pressure (DBP) and heart rate data were extracted. Additional extracted data included demographics, year, study design, study duration, drug dose and frequency, duration of washout and country. Study quality was assessed using the methods of Jadad and data were synthesized using a random effects model using weighted mean differences. In all, 33 trials reporting 48 treatment arms with 2165 patients were included. Phenylpropanolamine increased SBP 5.5 mmHg (95% CI: 3.1-8.0) and DBP 4.1 mmHg (95% CI: 2.2-6.0) with no effect on pulse. Patients with controlled hypertension were not at greater risk of blood pressure elevation. Immediate release preparations had greater effects on blood pressure than sustained release ones. Higher doses and shorter duration use also caused greater increases. Eighteen studies contained at least one treated subjects having blood pressure elevations > or =140/90 mmHg, an increase in SBP > or =15 mmHg or an increase in DBP > or =10 mmHg. In conclusion, phenylpropanolamine caused a small, but significant increase in systolic blood pressure. The effect was more pronounced with shorter-term administration, higher doses of medication and immediate release formulations.

We performed a pre-post study of the impact of three 90-minute faculty development workshops on written feedback from encounters during an ambulatory internal medicine clerkship. We coded 47 encounters before and 43 after the workshops, involving 9 preceptors and 44 third-year students, using qualitative and semiquantitative methods. Postworkshop, the mean number of feedback statements increased from 2.8 to 3.6 statements (P =.06); specific (P =.04), formative (P =.03), and student skills feedback (P =.01) increased, but attitudinal (P =.13) and corrective feedback did not (P =.41). Brief, interactive, faculty development workshops may refine written feedback, resulting in more formative specific written feedback comments.

Objective: While several models of medical student instruction in the ambulatory setting exist, few have been formally studied. We wished to assess the impact of a faculty development workshop based on the One-Minute Preceptor model on the amount and quality of feedback in the outpatient setting., Design: Ambulatory teaching behaviors were studied during consecutive outpatient precepting sessions before and after 3 faculty development workshops. Student-teacher interactions were assessed using audiotapes of teaching encounters coded through qualitative techniques, and surveys of teacher, learner, and patient satisfaction., Setting: Ambulatory internal medicine clinic in a tertiary care medical center., Patients/participants: Nine board-certified internist faculty preceptors and 44 third-year medical students., Interventions: Three 90-minute faculty development seminars based on the One-Minute Preceptor teaching model., Measurements and Main Results: Ninety-four encounters with 18577 utterances were recorded, half before and half after the seminars. After the workshops, the proportion of utterances that contained feedback increased from 17% to 22% (P =.09) and was more likely to be specific (9% vs 15%; P =.02). After the workshops, teachers reported that the learning encounters were more successful (P =.03) and that they were better at letting the students reach their own Conclusions (P =.001), at evaluating the learners (P =.03), and at creating plans for post-encounter learning (P =.02). The workshops had no effect on the duration of the student-teacher encounter or on student or patient satisfaction with the encounters., Conclusions: Brief, interactive, faculty development workshops based on the One-Minute Preceptor model of clinical teaching resulted in modest improvements in the quality of feedback delivered in the ambulatory setting.

A 44-year-old female is described who developed persistent upper extremity and orolingual dystonia several weeks after suspected onset of central pontine myelinolysis (CPM), later confirmed by characteristic pontine lesions on MRI. No foci of the extrapontine myelinolysis were evident. This case confirms that dystonia may be a late and persistent sequela of CPM and may occur in the absence of visible lesions outside the brainstem.