Rationale And Special Features of Ambulatory Care Education

Ambulatory care internal medicine has a critical role in the US health care system

Internal medicine is the largest specialty in the United States. Among 820,000 active physicians, 216,000 (26%) are internists. Internists provide the bulk of medical care for adults, and conduct a large proportion of all clinical research in the US. At Yale, like most medical schools, the department of internal medicine comprises the largest number of faculty members. These physicians provide more patient care service, as measured in revenue, than any other department and bring in the most NIH research dollars.

Internal medicine comprises two broad areas: general internal medicine and 12 subspecialties. About 50% of internists are generalists. In recent years, generalists have tended to identify themselves either as ambulatory care physicians who practice primary care internal medicine in the office, or hospitalists who practice acute care internal medicine in the hospital. Some generalists still follow their patients from the office into the hospital, but this has become difficult for several reasons. Reimbursement for hospital visits is low when travel time between office and hospital is considered. Time away from the office to see a hospitalized patient may result in lost work productivity in the office or longer work hours. Short stays and intense activity in the hospital mean that it is advantageous to have the attending physician on-site. Effective acute care is sufficiently challenging to require special expertise.

In contrast to the situation for generalists, subspecialists, with rare exceptions (e.g., some invasive cardiologists), see patients both in the office and in the hospital. They are expected to provide subspecialty care to their patients when they become hospitalized.

Most health policy experts agree that an effective national health system should be based on a network of primary care providers. The essential function of these providers is to evaluate acute symptoms, manage chronic illness, and prevent disease. Under an effective primary care system, patients have rapid access to care before conditions reach advanced stages and overall disease burden is reduced by thorough management and prevention. Countries with advanced primary care systems and nationalized health care (e.g., Germany, the UK, and Italy), also control health care costs more effectively than other nations (e.g., the US). In the US, general internists provide most of the primary care for adults. Family physicians are also a very important source of adult primary care. For a more detailed discussion of the current state of primary care and future prospects, please see "Primary Care Internal Medicine" on the clerkship website.

The Ambulatory Component of the Internal Medicine Clerkship is designed to assure that students graduate from Yale with a thorough understanding of the organization and delivery of ambulatory care internal medicine, particularly primary care internal medicine. Health care delivery is somewhat regionalized within the US and even within each state, so the practical experience we provide to students will represent a sampling of sorts. Nevertheless, a thorough familiarity with ambulatory care internal medicine is a necessary foundation for almost any specialist. Surgeons, psychiatrists, pediatricians, neurologists, and other specialists all collaborate with internists in the care of individual patients and need to understand the capabilities of an internist and the conditions that make consultation most effective and efficient. Students who pursue careers in health policy, health administration, or health services research need a thorough understanding of our current health care system, its limitations and potential.