Rationale And Special Features of Ambulatory Care Education

Most interaction between internists and patients occur in ambulatory care

To see the full spectrum of patients who visit internists and to learn the full spectrum of skills required for the practice of internal medicine, students must be educated both inside and outside the hospital. Among all encounters between internists and patients, about 10% occur in the hospital and 90% occur in the office or other outpatient location. This simple ecological fact underlies the strongest rationale for ambulatory care education. Students need to be where the patients are.

Typical patients who visit internists outside the hospital are adults who seek diagnosis and treatment for acute symptoms, care of chronic conditions, or health maintenance.

Patients Seeking Diagnosis and Treatment of Acute Symptoms:

The most common symptoms include headache, fatigue, abdominal pain, weight loss, diarrhea, dizziness, dysuria, chest pain, shortness of breath, cough, insomnia, malaise, back pain, and rhinitis. Most patients who present with one of these will be found to have a readily treatable condition. Only a minority will require hospitalization. To learn to diagnose and treat common symptoms, students must work in clinics and private practices.

Patients Seeking Management of Chronic Conditions:

Among the chronic conditions for which patients see internists, some rarely cause hospital admission and will not be seen by students during hospital clerkships. Examples include rheumatoid arthritis, venereal disease, osteoarthritis, dementia, thyroid disease, asthma, hypertension, and allergic rhinitis.

When chronic diseases do precipitate hospital admission, the emphasis of physicians' care is on short-term management. The goals and principles of short term management are often very different from the goals and principles of definitive, long-term management. For example, when a diabetic patient is hospitalized, the reason is usually ketoacidosis, nonketotic hyperosmolar coma, another severe complication, or a comorbid illness. In the hospital, care is then directed toward restoring homeostasis or treating the comorbid condition. Definitive long-term treatment of diabetes is not emphasized. In office-based care, however, long-term care is the physician's principal concern. Students who work in offices, therefore, have an excellent opportunity to learn about glucose monitoring, insulin adjustment, diet, exercise, and special health maintenance protocols for diabetics.

Patients Seeking Disease Prevention:

A principle concern for many patients who visit internists is disease prevention. The spectrum of preventable conditions is broad and includes prevalent chronic diseases such as breast cancer, lung cancer, colon cancer, coronary artery disease, osteoporosis, emphysema, and AIDS. The scientific literature on the effectiveness of putative prevention modalities is abundant and, often, conflicting. To meet patient's expectations for clear, authoritative guidance on disease prevention, physicians must be well-informed, skilled in critical appraisal of the literature, and skilled at negotiating treatment plans with patients who may have distinct preferences and values. Disease prevention is a major intellectual and humanistic challenge for modern internists. It is an area of medicine that is not emphasized or conveniently taught in hospital-based curricula, but which must be a major focus of a practice-based curriculum.