The article on Internal Medicine training posted on our web site challenges recent calls for changes to internal medicine training. It raises the old controversy as to how much outpatient training is needed for those whose ultimate practices will be based in the outpatient environment. The authors of the two commentary articles disagree. What are everyone's thoughts about these issues?
Ruth Hoppe

I agree that the IM residency design needs to be seriously rethought, but I think the proposals to replace continuity clinics without outpatient blocks are seriously misguided. It is true that graduating IM residents tend to have negative experiences with outpatient clinics and primary care medicine, and are poorly prepared for this type of work. However, I think this is because the continuity clinics are largely treated as a side activity which takes away from inpatient time.

In my institution, residents have two continuity clinics, one at the VA hospital and the other at an University health center site, but only spend one half day each week in a clinic. As a result, they are in any one continuity clinic for one half day every other week (at best, when vacation and post-call periods are considered). The theory behind this is that is exposes residents to primary care in both VA and community settings, and it helps accommodate staffing demands in both institutions. However, longitudinal patient care is all but impossible under this model, and the so-called continuity clinics instead basically become an exercise in urgent-care training. I think this gives residents a very unfair view of outpatient care, and also gives them very little preparation if they should decide to go into outpatient medicine.

While I don't discount the instructive value of inpatient rotations, I think the ABIM has to consider the number of hours, days, and months spent on the inpatient care, and compare this to the time spent in continuity clinics; it is very, very heavily weighted towards the inpatient experience. Unless our speciality's goal is to exclusively produce hospitalists and subspecialists, I think there needs to be a less lopsided training program.

Unfortunately, I think the proposal to create outpatient blocks is not an appropriate solution. To develop continuity of care, a resident has to follow a patient over a period of months or years. In block rotations, it is unlikely that a resident will see a given patient more than twice, so any continuity will be very limited. I think the block approach will only aggravate the current devolution of continuity clinics into urgent care clinics.

I think the solution is to provide more rigidly protected time for outpatient care, spread throughout the residency program. Ideally, residents should be in their continuity clinic at least two to three half-days per week. This would allow for a more realistic view of outpatient practice and better opportunities to develop true continuity of care.

The objection to this is that such an approach will complicate inpatient rotations, and "take time away" from the wards. I think the latter attitude is very telling about the prevailing views in IM training; that competency in inpatient care is more important than competency in outpatient care. Unless we collectively decide that we want to turn IM into an exclusively inpatient specialty, we need to put equal emphasis on developing competency in both areas.

For full disclosure, dcooke was one of my clinic preceptors in residency. I agree that the university / VA system did turn my university clinic into urgent care. My VA clinic was definitely my clinic. The clinic nurses would e-mail and page me about my patients throughout the week, and those patient's saw me as their doctor.

The residents in my class who had university only clinics also had continuity. Unfortunately, continuity with a patient population that nobody else wanted, and therefore a very difficult population.

I think there was an aversion on the part of patients with health insurance to be seen by house officers at satelite clinics. I think it is this aversion on the patients side that made every other week urgent care morning.

Ambulatory care as blocks would limit the choppyness in the current system. When I was on an inpatient block, between on call and post call, I might miss one of my clinic sites for an entire month.