Ambulatory Curriculum Design and Delivery for Internal Medicine Residents

  • Margaret C. LoEmail author
  • Alia Chisty
  • Emily Mullen


This chapter guides ambulatory educators through the key educational principles, components, and steps needed for a robust ambulatory curriculum with a longitudinal design and a diverse delivery mechanism. Ambulatory medical education for residents is structured into three major curricula designs—ambulatory block rotations, longitudinal continuity clinics, and ambulatory long blocks. Embedded into these curricular designs is a core curricular thread comprised of high-yield ambulatory topics and delivered through various teaching pedagogies. Highlighted in this chapter are specific formal instructional strategies as well as resident-directed learning modalities. The chapter concludes with a step-by-step guide of the essential elements in developing an ambulatory curriculum. Sample implementation tools provide deliverables for educators to utilize in their own ambulatory teaching environment. These include needs assessment tools, mini-CEX forms, and a goal and objective template for resident continuity clinics.


Ambulatory curriculum Ambulatory instructional strategies Ambulatory clinic design 


  1. 1.
    Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements—Faculty Evaluation. 29 Sept 2013. Accessed 14 Aug 2016.
  2. 2.
    Meyers FJ, Weinberger SE, Fitzgibbons JP, Glassroth J, Duffy FD, Clayton CP, et al. Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Acad Med. 2007;82(12):1211–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Nadkarni M, Reddy S, Bates CK, Fosburgh B, Babbott S, Holmboe E. Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors. J Gen Intern Med. 2011;26(1):16–20.CrossRefPubMedGoogle Scholar
  4. 4.
    Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum development for medical education: a six-step approach. 3rd ed. Baltimore: Johns Hopkins University Press; 2016.Google Scholar
  5. 5.
    Deutsch SL, Noble J. Community-based teaching: a guide to developing education programs for medical students and residents in the practitioner’s office. American College of Physicians: Philadelphia; 1997.Google Scholar
  6. 6.
    Aboff B, Chick D, Holmboe E, McKinney S, Schultz H, Yacht A, et al. Developing a curriculum. In: Ficalora R, Costa S, editors. The toolkit series: a textbook for internal medicine education programs. 11th ed. Alliance for Academic Internal Medicine; 2011. p. 265–83.Google Scholar
  7. 7.
    Thomas PA, Kern DE. Internet resources for curriculum development in medical education: an annotated bibliography. J Gen Intern Med. 2004;19(5 Pt 2):599–605.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Green ML. Identifying, appraising, and implementing medical education curricula: a guide for medical educators. Ann Intern Med. 2001;135(10):889–96.CrossRefPubMedGoogle Scholar
  9. 9.
    Doran GT. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manag Rev. 1981;70:35–6.Google Scholar
  10. 10.
    Meyer PJ. Attitude is everything: if you want to succeed above and beyond. Waco: Meyer Resource Group; 2003.Google Scholar
  11. 11.
    Accreditation Council for Graduate Medical Education. ACGME milestones. Accessed 17 Nov 2016.
  12. 12.
    Johns Hopkins School of Medicine. Writing better objective. Accessed 13 Aug 2016.
  13. 13.
    Irby DM. Teaching and learning in ambulatory care settings: a thematic review of the literature. Acad Med. 1995;70(10):898–931.CrossRefPubMedGoogle Scholar
  14. 14.
    Bowen JL, Irby DM. Assessing quality and costs of education in the ambulatory setting: a review of the literature. Acad Med. 2002;77(7):621–80.CrossRefPubMedGoogle Scholar
  15. 15.
    Lesky LG, Borkan SC. Strategies to improve teaching in the ambulatory medicine setting. Arch Intern Med. 1990;150(10):2133–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Skeff KM. Enhancing teaching effectiveness and vitality in the ambulatory setting. J Gen Intern Med. 1988;3(2 Suppl):S26–33.CrossRefPubMedGoogle Scholar
  17. 17.
    Holmboe ES, Bowen JL, Green M, Gregg J, DiFrancesco L, Reynolds E, et al. Reforming internal medicine residency training. A report from the Society of General Internal Medicine’s task force for residency reform. J Gen Intern Med. 2005;20(12):1165–72.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Lesky LG, Hershman WY. Practical approaches to a major educational challenge. Training students in the ambulatory setting. Arch Intern Med. 1995;155(9):897–904.CrossRefPubMedGoogle Scholar
  19. 19.
    Branch WT Jr. Teaching models in an ambulatory training program. J Gen Intern Med. 1990;5(1 Suppl):S15–26.CrossRefPubMedGoogle Scholar
  20. 20.
    Jones R, Higgs R, de Angelis C, Prideaux D. Changing face of medical curricula. Lancet. 2001;357(9257):699–703.CrossRefPubMedGoogle Scholar
  21. 21.
    Kulasegaram KM, Martimianakis MA, Mylopoulos M, Whitehead CR, Woods NN. Cognition before curriculum: rethinking the integration of basic science and clinical learning. Acad Med. 2013;88(10):1578–85.CrossRefPubMedGoogle Scholar
  22. 22.
    Furney SL, Orsini AN, Orsetti KE, Stern DT, Gruppen LD, Irby DM. Teaching the one-minute preceptor. A randomized controlled trial. J Gen Intern Med. 2001;16(9):620–4.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered model for outpatient education. Acad Med. 2003;78(9):893–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Aagaard E, Teherani A, Irby DM. Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: proof of concept. Acad Med. 2004;79(1):42–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Irby DM, Aagaard E, Teherani A. Teaching points identified by preceptors observing one-minute preceptor and traditional preceptor encounters. Acad Med. 2004;79(1):50–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Weinberger SE, Smith LG, Collier VU. Education Committee of the American College of Physicians. Redesigning training for internal medicine. Ann Intern Med. 2006;144(12):927–32.CrossRefPubMedGoogle Scholar
  27. 27.
    Bharel M, Jain S, Hollander H. Comprehensive ambulatory medicine training for categorical internal medicine residents. J Gen Intern Med. 2003;18(4):288–93.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    DaRosa DA, Dunnington GL, Stearns J, Ferenchick G, Bowen JL, Simpson DE. Ambulatory teaching “lite”: less clinic time, more educationally fulfilling. Acad Med. 1997;72(5):358–61.CrossRefPubMedGoogle Scholar
  29. 29.
    Stevens DP, Bowen JL, Johnson JK, Woods DM, Provost LP, Holman HR, et al. A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices. J Gen Intern Med. 2010;25(Suppl 4):S574–80.CrossRefPubMedGoogle Scholar
  30. 30.
    Mladenovic J, Shea JA, Duffy FD, Lynn LA, Holmboe ES, Lipner RS. Variation in internal medicine residency clinic practices: assessing practice environments and quality of care. J Gen Intern Med. 2008;23(7):914–20.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Yale University. Yale office-based medicine curriculum. 2016. Accessed 1 Sept 2016.
  32. 32.
    Kernan WN, Quagliarello V, Green ML. Student faculty rounds: a peer-mediated learning activity for internal medicine clerkships. Med Teach. 2005;27(2):140–4.CrossRefPubMedGoogle Scholar
  33. 33.
    Leung J, Bhutani M, Leigh R, Pelletier D, Good C, Sin DD. Empowering family physicians to impart proper inhaler teaching to patients with chronic obstructive pulmonary disease and asthma. Can Respir J. 2015;22(5):266.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Chou C, Lee K. Improving residents’ interviewing skills by group videotape review. Acad Med. 2002;77(7):744.CrossRefPubMedGoogle Scholar
  35. 35.
    McNeill M, Ali SK, Banks DE, Mansi IA. Morning report: can an established medical education tradition be validated? J Grad Med Educ. 2013;5:374.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Demopoulos B, Pelzman F, Wenderoth S. Ambulatory morning report: an underutilized educational modality. Teach Learn Med. 2001;13(1):49–52.CrossRefPubMedGoogle Scholar
  37. 37.
    Spickard A 3rd, Hales JB, Ellis S. Outpatient morning report: a new educational venue. Acad Med. 2000;75(2):197.CrossRefPubMedGoogle Scholar
  38. 38.
    Malone ML, Jackson TC. Educational characteristics of ambulatory morning report. J Gen Intern Med. 1993;8(9):512.CrossRefPubMedGoogle Scholar
  39. 39.
    Luciano GL, Visintainer PF, Kleppel R, Rothberg MB. Ambulatory morning report: a case-based method of teaching EBM through experiential learning. South Med J. 2016;109(2):108.CrossRefPubMedGoogle Scholar
  40. 40.
    Wong C, Evans G. The ambulatory morbidity and mortality conference meets the morning report. Med Educ. 2012;46:501.CrossRefGoogle Scholar
  41. 41.
    Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem-solving. BMJ. 1995;310(6987):1122–6.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Fazio SB, Steinmann AF. A new era for residency training in internal medicine. JAMA Intern Med. 2016;176(2):161–2.CrossRefPubMedGoogle Scholar
  43. 43.
    van Dijk N, Hooft L, Wieringa-de Waard M. What are the barriers to residents’ practicing evidence-based medicine? A systematic review. Acad Med. 2010;85(7):1163–70.CrossRefPubMedGoogle Scholar
  44. 44.
    Green ML. Graduate medical education training in clinical epidemiology, critical appraisal, and evidence-based medicine: a critical review of curricula. Acad Med. 1999;74(6):686–94.CrossRefPubMedGoogle Scholar
  45. 45.
    Linzer M, Brown JT, Frazier LM, DeLong ER, Siegel WC. Impact of a medical journal club on house-staff reading habits, knowledge, and critical appraisal skills. A randomized control trial. JAMA. 1988;260(17):2537–41.CrossRefPubMedGoogle Scholar
  46. 46.
    Green ML, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Med. 1997;12(12):742–50.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Ebbert JO, Montori VM, Schultz HJ. The journal club in postgraduate medical education: a systematic review. Med Teach. 2001;23(5):455–61.CrossRefPubMedGoogle Scholar
  48. 48.
    Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995;123(3):A12–3.PubMedGoogle Scholar
  49. 49.
    Liao K, Pu S, Liu M, Yang C, Kuo H. Development and implementation of a mini-Clinical Evaluation Exercise (mini-CEX) program to assess the clinical competencies of internal medicine residents: from faculty development to curriculum evaluation. BMC Med Educ. 2013;13:31.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Alves de Lima A, Conde D, Aldunate L, van der Vleuten C. Teachers’ experiences of the role and function of the mini clinical evaluation exercise in post-graduate training. Int J Med Educ. 2010;1:68.CrossRefGoogle Scholar
  51. 51.
    American Board of Internal Medicine. Mini-CEX clinical evaluation for trainees: direct observation assessment tool. 2016. Accessed Aug 2016.
  52. 52.
    Pelgrim EA, Kramer AW, Mokkink HG, van den Elsen L, Grol RP, van der Vleuten CP. In-training assessment using direct observation of single-patient encounters: a literature review. Adv Health Sci Educ Theory Pract. 2011;16(1):131.CrossRefPubMedGoogle Scholar
  53. 53.
    Kogan JR, Bellini LM, Shea JA. Feasibility, reliability, and validity of the mini-clinical evaluation exercise (mCEX) in a medicine core clerkship. Acad Med. 2003;78(10 Suppl):S33.CrossRefPubMedGoogle Scholar
  54. 54.
    Hauer KE. Enhancing feedback to students using the mini-CEX (Clinical Evaluation Exercise). Acad Med. 2000;75(5):524.CrossRefPubMedGoogle Scholar
  55. 55.
    McLaughlin S, Fitch MT, Goyal DG, Hayden E, Kauh CY, Laack TA, et al. Simulation in graduate medical education 2008: a review for emergency medicine. Acad Emerg Med. 2008;15:1117.CrossRefPubMedGoogle Scholar
  56. 56.
    Gaba DM. The future vision of simulation in healthcare. Qual Saf Health Care. 2004;13(Suppl 1):i2.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Parmelee D, Michaelsen LK, Cook S, Hudes PD. Team-based learning: a practical guide: AMEE guide no. 65. Med Teach. 2012;34(5):e275–87.CrossRefPubMedGoogle Scholar
  58. 58.
    Parmelee DX, Michaelsen LK. Twelve tips for doing effective Team-Based Learning (TBL). Med Teach. 2010;32(2):118–22.CrossRefPubMedGoogle Scholar
  59. 59.
    Searle NS, Haidet P, Kelly PA, Schneider VF, Seidel CL, Richards BF. Team learning in medical education: initial experiences at ten institutions. Acad Med. 2003;78(10 Suppl):S55–8.CrossRefPubMedGoogle Scholar
  60. 60.
    Balwan S, Fornari A, DiMarzio P, Verbsky J, Pekmezaris R, Stein J, et al. Use of team-based learning pedagogy for internal medicine ambulatory resident teaching. J Grad Med Educ. 2015;7(4):643–8.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Poeppelman RS, Liebert CA, Vegas DB, Germann CA, Volerman A. A narrative review and novel framework for application of team-based learning in graduate medical education. J Grad Med Educ. 2016;8(4):510–7.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Davis MH. AMEE Medical Education Guide No. 15: problem-based learning: a practical guide. Med Teach. 1999;21(2):130–40.CrossRefPubMedGoogle Scholar
  63. 63.
    Dolmans D, Michaelsen L, van Merrienboer J, van der Vleuten C. Should we choose between problem-based learning and team-based learning? No, combine the best of both worlds! Med Teach. 2015;37(4):354–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Prober CG, Khan S. Medical education reimagined: a call to action. Acad Med. 2013;88(10):1407–10.CrossRefPubMedGoogle Scholar
  65. 65.
    McLaughlin JE, Roth MT, Glatt DM, Gharkholonarehe N, Davidson CA, Griffin LM, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med. 2014;89(2):236–43.CrossRefPubMedGoogle Scholar
  66. 66.
    Young TP, Bailey CJ, Guptill M, Thorp AW, Thomas TL. The flipped classroom: a modality for mixed asynchronous and synchronous learning in a residency program. West J Emerg Med. 2014;15(7):938–44.CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Truncali A, Lee JD, Ark TK, Gillespie C, Triola M, Hanley K, et al. Teaching physicians to address unhealthy alcohol use: a randomized controlled trial assessing the effect of a Web-based module on medical student performance. J Subst Abus Treat. 2011;40(2):203.CrossRefGoogle Scholar
  68. 68.
    Desai T, Stankeyeva D, Chapman A, Bailey J. Nephrology fellows show consistent use of, and improved knowledge from, a nephrologist-programmed teaching instrument. J Nephrol. 2011;24(3):345.CrossRefPubMedGoogle Scholar
  69. 69.
    Lee CA, Chang A, Chou CL, Boscardin C, Hauer KE. Standardized patient-narrated web-based learning modules improve students’ communication skills on a high-stakes clinical skills examination. J Gen Intern Med. 2011;26(11):1374.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Ross DD, Shpritz DW, Wolfsthal SD, Zimrin AB, Keay TJ, Fang H, et al. Creative solution for implementation of experiential, competency-based palliative care training for internal medicine residents. J Cancer Educ. 2011;26:436.CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Bell DS, Fonarow GC, Hays RD, Mangione CM. Self-Study from web-based and printed guideline materials. A randomized controlled trial among resident physicians. Ann Intern Med. 2000;132(12):938.CrossRefPubMedGoogle Scholar
  72. 72.
    William JH, Huang GC. How we make nephrology easier to learn: computer-based modules at the point-of-care. Med Teach. 2014;36:13.CrossRefPubMedGoogle Scholar
  73. 73.
    Yu CH, Straus S, Brydges R. The ABCs of DKA: development and validation of a computer-based simulator and scoring system. J Gen Intern Med. 2015;30(9):1319.CrossRefPubMedPubMedCentralGoogle Scholar
  74. 74.
    McCleskey PE. Clinic teaching made easy: a prospective study of the American Academy of Dermatology core curriculum in primary care learners. J Am Acad Dermatol. 2013;69(2):273.CrossRefPubMedGoogle Scholar
  75. 75.
    Staton LJ, Estrada C, Panda M, Ortiz D, Roddy D. A multimethod approach for cross-cultural training in an internal medicine residency program. Med Educ Online. 2013;18:20352.CrossRefGoogle Scholar
  76. 76.
    Institute for Healthcare Improvement. IHI Open School courses. 2016. Accessed 1 Sept 2016.
  77. 77.
    Centers to Advance Palliative Care. CAPC CME courses. Accessed 1 Sept 2016.
  78. 78.
    American Academy of Dermatology. Basic dermatology curriculum. 2016. Accessed 1 Sept 2016.
  79. 79.
    Zafar MA, Diers T, Schauer DP. Connecting resident education to patient outcomes: the evolution of a quality improvement curriculum in an internal medicine residency. Acad Med. 2014;89(10):1341.CrossRefPubMedGoogle Scholar
  80. 80.
    Potts S, Shields S, Upshur C. Preparing future leaders: an integrated quality improvement residency curriculum. Fam Med. 2016;48(6):477.PubMedGoogle Scholar
  81. 81.
    Thomas KG, West CP, Popkave C, Bellini LM, Weinberger SE, Kolars JC, et al. Alternative approaches to ambulatory training: internal medicine residents’ and program directors’ perspectives. J Gen Intern Med. 2009;24(8):904–10.CrossRefPubMedPubMedCentralGoogle Scholar
  82. 82.
    Julian K, Riegels NS, Baron RB. Perspective: creating the next generation of general internists: a call for medical education reform. Acad Med. 2011;86(11):1443–7.CrossRefPubMedGoogle Scholar
  83. 83.
    Zebrack JR, Fletcher KE, Beasley BW, Whittle J. Ambulatory training since duty hour regulations: a survey of program directors. Am J Med. 2010;123(1):89–94.CrossRefPubMedGoogle Scholar
  84. 84.
    Bard FJ, Shu Z, Morrice JD, Leykum KL. Annual block scheduling for internal medicine residents with 4+1 templates. J Oper Res Soc. 2016;67(7):911–27.CrossRefGoogle Scholar
  85. 85.
    Chaudhry SI, Balwan S, Friedman KA, Sunday S, Chaudhry B, DiMisa D, et al. Moving forward in GME reform: a 4 + 1 model of resident ambulatory training. J Gen Intern Med. 2013;28(8):1100–4.CrossRefPubMedPubMedCentralGoogle Scholar
  86. 86.
    Shalaby M, Yaich S, Donnelly J, Chippendale R, DeOliveira MC, Noronha C. X + Y scheduling models for internal medicine residency programs-a look back and a look forward. J Grad Med Educ. 2014;6(4):639–42.CrossRefPubMedPubMedCentralGoogle Scholar
  87. 87.
    Huddle TS, Heudebert GR. Internal medicine training in the 21st century. Acad Med. 2008;83(10):910–5.CrossRefPubMedGoogle Scholar
  88. 88.
    Warm EJ, Schauer DP, Diers T, Mathis BR, Neirouz Y, Boex JR, et al. The ambulatory long-block: an accreditation council for graduate medical education (ACGME) educational innovations project (EIP). J Gen Intern Med. 2008;23(7):921–6.CrossRefPubMedPubMedCentralGoogle Scholar
  89. 89.
    Warm EJ. Interval examination: the ambulatory long block. J Gen Intern Med. 2010;25(7):750–2.CrossRefPubMedPubMedCentralGoogle Scholar
  90. 90.
    Reynolds EE. Fostering educational innovation through measuring outcomes. J Gen Intern Med. 2011;26(11):1241–2.CrossRefPubMedPubMedCentralGoogle Scholar
  91. 91.
    Johns Hopkins University Physician Education and Assessment Center. Internal medicine curriculum. 2016. Accessed Oct 2016.

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.University of Florida College of MedicineGainesvilleUSA
  2. 2.Lewis Katz School of Medicine at Temple UniversityPhiladelphiaUSA
  3. 3.Moses H. Cone Health SystemsGreensboroUSA

Personalised recommendations