Ambulatory internal medicine training

Evolutions in medical care and changes in program accreditation rules have gradually changed internal medicine training from a largely inpatient experience to one with a major ambulatory component, with well-developed current resources.1–3 The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements in Internal Medicine that became effective in July, 2001 state that “clinical experiences must include a minimum of one third of the time in ambulatory sites… and over the 36 months of training, at least 1/2 day each week must be spent managing a panel of general internal medicine patients in continuity.”4 New regulations, related to resident work hour limits, will challenge training programs to find the most effective and efficient strategies for ambulatory training. Many training programs, already having strained resources, are challenged to provide breadth of subspecialty exposure to residents as well as high-quality ambulatory general internal medicine experiences. A common model of subspecialty rotation, with hospital-based consultation services, may not provide ambulatory experiences for residents. General internal medicine teaching clinics have long served as a teaching resource to internal medicine training programs. They have often also served as sites of indigent patient care, clinical research, and support of inpatient teaching services. In some institutions, faculty practice alongside residents in the teaching clinic, while in others, the teaching clinic is solely a resident domain that often operates at a low level of efficiency and serves as a poor model to encourage residents to consider careers in general internal medicine. Like most clinical services, teaching clinics are under increasing pressure to improve financial performance. The importance of the ambulatory setting will be sustained and probably increased as programs move to a competency-based assessment model. Some of the 6 core competencies described by the ACGME are especially suitable for development in the ambulatory setting: practice-based learning and improvement, interpersonal and communication skills, and systems-based practice. In this issue of the Journal of General Internal Medicine, 2 very different reports describe investigations aimed at improving ambulatory internal medicine training and provide models for future improvements. Bharel et al.5 describe a restructuring of ambulatory medicine training aimed at improving residents’ subspecialty education. This is often overlooked in the focus on general internal medicine continuity clinics and primary care residency tracks, but it undoubtedly augments the continuity experience. By performing a needs assessment specific to categorical residents, the authors were able to change the curriculum in a way that met specific educational objectives and significantly improved important resident assessment parameters. Experience shows that general internal medicine clinics are often educationally better when separated from inpatient general medicine; subspecialty education may also work better when ambulatory and inpatient components are separate. Stahl et al.6 used computer simulation to analyze the impact of key variables in general internal medicine teaching clinics on throughput and revenue. They concluded that teaching clinics operate optimally (minimizing patient and trainee waiting times while maximizing revenue) with trainee-to-preceptor ratios between 3 and 7 to 1. This is certainly in the range of most teaching clinics, except those that act on an apprentice model with 1 preceptor for each resident. More important than the actual result is demonstrating the use of simulation. This allows one to predict changes in overall clinic operations (a tremendously complex system) when key components change, and could be used to optimize the educational and care experiences in teaching clinics. Ambulatory internal medicine training will continue to evolve as the need to prepare physicians for primarily ambulatory roles increases. The expansion of hospitalists will demand that physicians who practice in the ambulatory setting learn additional liaison skills. Continued curricular innovations to better meet our trainees' needs, such as those described by Bharel et al.,5 are essential to meeting our educational missions. We need to use innovative methods to optimize ambulatory care from the point of view of patients7 and trainees. This will help meet educational goals as well as train new physicians in the importance of their role in quality and systems improvement.4,8,9 Over the short run, as training programs work to deal with resident work hour restrictions, strong efforts will be needed to avoid negative impacts on ambulatory training. It is likely that members of the Society of General Internal Medicine will be leaders in these efforts.