Is Ambulatory Patient Safety Just Like Hospital Safety, Only without the “Stat”?

When I was a resident in internal medicine 2 decades ago, we spent virtually all of our time in the hospital and very little of it in the ambulatory setting. This structure reflected the traditions of medical residency training, the relative importance that chairs of medicine and the Residency Review Committee placed on the 2 settings, and the economic realities of residency funding. However, it also reflected a premise that a physician well trained in the care of the very ill could easily translate these skills into excellent care in an environment where the pace was slower, the patients were less sick, and the word “stat” was rarely heard.

We later came to realize that this logic was flawed. We now understand that the ambulatory environment is so different from the hospital environment that expertise in hospital care might not predict excellent outpatient care and might even create skills and instincts that are harmful in the ambulatory care environment. In the ambulatory world, most patients are well or have stable or gradually deteriorating chronic illness. Many symptoms resolve with time; prevention is the core activity; and patients are anything but captive, supine beings in flimsy gowns. These differences are not trivial; indeed, they are fundamental. Thankfully, our residency accreditors now insist on more and better training in ambulatory care (1). Newly graduated residents continue to have a steep learning curve on entering primary care practice, but at least they are not starting nearly at square one, as many of the physicians of my generation did.

As patient safety has become a consuming issue for both seasoned practitioners and new graduates, we are beginning to understand the nature of medical errors in a variety of environments. The study by Gandhi and colleagues in this issue (2) uses settled malpractice claims …