Historically, training within internal medicine has
offered a comprehensive and deep understanding of
adult medical issues, with a particular emphasis on critical
thinking as well as diagnosis and management of
complex medical disease. However, as hospital admissions
decline and length of stay shortens, it is not possible
to learn the breadth of internal medicine on the
basis of inpatient service alone. The management of
diseases in the inpatient setting and in the outpatient
setting is significantly different. For example, management
of diabetes mellitus, heart failure, and chronic
obstructive pulmonary disease are very distinctive in
inpatient versus outpatient settings. Some conditions,
such as asthma and human immunodeficiency virus,
are no longer seen frequently enough in the inpatient
setting to guarantee learning opportunities. The ability
to see the course of illness over time as well as appreciate
the relational aspects of care and prevention of
complications requires ambulatory training. The Liason
Committee on Medical Education and the
Accreditation Council for Graduate Medical Education
endorse ambulatory training for these reasons.
Despite the need for robust ambulatory education,
internal medicine educators face well-documented difficulties
in recruiting ambulatory training sites for both
students and residents
