Internal Medicine Training: Putt or Get Off the Green
- Steven A. Schroeder, MD; and
- Harold C. Sox, MD, Editor
- From University of California, San Francisco, San Francisco, CA 94143-1211, and the American College of Physicians, Philadelphia, PA 19106.
This issue features 2 position papers on reforming internal medicine residency education (1, 2), 1 from the American College of Physicians (ACP) and 1 from the Association of Program Directors in Internal Medicine (APDIM). Both acknowledge aspects of internal medicine practice—reimbursement, lifestyle, autonomy, managed care hassles, the burden of chronic illness—that contribute to low residency fill rates. But they then correctly point out that educational reforms could make a big difference (1, 2). They argue cogently that the traditional training model lacks many ingredients that are essential preparation for internal medicine practice. Other aspects of residency training are unattractive to students taking internal medicine clerkships: unnecessary stress, devaluation of office-based training, and too little exposure to excellent role models. The proposed reforms are visionary, far-reaching, and appealing. The 2 reports are remarkably similar, except that the ACP also calls for redesign of the internal medicine student clerkship.
The 2 position papers strongly affirm the importance of training good generalists. The underlying premise is that most internists should know how to provide front-line care for the major diseases in any specialty of internal medicine. The case for training good generalists is based on strong evidence. First, patients want good generalist physicians to take responsibility for their care (3). Second, many health care systems (for example, Kaiser Permanente, the Veterans Administration, Group Health Cooperative, the military health system, and the Palo Alto Medical Clinic) organize their practice around primary care physicians (4, 5). Third, many internal medicine subspecialists also need to function as generalists. While the position papers make a strong case for substantially more ambulatory learning time, the current system gives first priority to the care of fragile hospital patients. Shifting the balance toward more ambulatory care during training would be expensive, as shown by efforts to …
This 100-word excerpt has been provided in the absence of an abstract.
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