Internal medicine residency training on topics in ambulatory care: a status report.

The Association of Professors of Medicine (APM) is the national organization of departments of internal medicine at the US medical schools and numerous affiliated teaching hospitals as represented by chairs and appointed leaders. As the official sponsor of The American Journal of Medicine, the association invites authors to publish commentaries on issues concerning academic internal medicine. For the latest information about departments of internal medicine, please visit APM's website at www.im.org/APM. In the US, medical care for most consists of an ambulatory visit. 1-3 When a new medical concern arises, the general internist is typically the first contact. 4 Over the years, ambulatory care has grown to include postacute care from recently hospitalized patients, as well as increasingly complex chronic disease management for diabetes, hypertension, and other diseases. 1 As a result, the need for general internists is growing. 5 Despite this projected increasing need, our current system of training is not producing more general internists. The number of medical students choosing residencies in primary care-oriented internal medicine programs is decreasing , and the number of internal medicine residents choosing careers as general internists is decreasing. 6 There is a structural disconnect between internal medicine residency training and the primary care needs of the population. 1-3,7,8 Internal medicine residency training is heavily inpatient-based, often at the expense of training in ambulatory care. 1,2,7,8 Training in ambulatory care is valued less by residents than are the general medical wards and intensive care unit rotations, despite the fact that the majority of residents will pursue careers that include a strong ambulatory component. 9 Residents graduate from internal medicine residency training programs without the necessary skills to effectively practice ambulatory care, and report feeling unprepared to provide outpatient care. Society's need for competent ambulatory care is growing. Hospitalization rates and Medicare expenditures are both improved by access to a talented pool of general internists. 4,5 The shrinking number of general internists and the shortcomings of internal medicine residency training may be contributing to suboptimal care of common chronic diseases such as diabetes and hypertension. 2,4,11 Internal medicine residents are receiving inadequate training in chronic disease management , and training should be redesigned to improve teaching in ambulatory care. Many of the suggestions for internal medicine residency redesign have focused on structural aspects of training, including a better balance of the time committed to teaching in ambulatory care. There has been little discussion of …