“That makes no sense!” a friend recently blurted out to me after I finished helping her understand how the vast majority of internal medicine residents are trained in this country. Her incredulousness was less about the "how," and more about the “where.”
No doubt. When you consider that the overwhelming majority of practitioners will ultimately be practicing almost exclusively in the outpatient environment, and that cost-conscious health care reform efforts are specifically trying to replace hospital-based, predominantly late, “sick care” with proactive and preventative ambulatory care, it’s remarkable that future physicians spend so much of their time training on the wards of academic hospitals. The research supports what so many of us avidly question.
For some time, a number of primary care advocates have been trying to call attention to the imbalance between ambulatory and hospital-based training in this nation. They have grown impatient with the manner in which inpatient, largely reactive care is prioritized in curriculum while primary care is treated as an afterthought at best, or superfluous at worst. And these advocates have grown increasingly frustrated watching this phenomenon drive unnecessary health spending tied to overprovision of expensive tests, overutilization of inpatient services, and a lack of commitment to basic prevention and coordination activities.
But while primary care advocates are tuned in to these problems, the typical patient has no idea of the level of dysfunction. And honestly, I can’t help but wonder if they would even see the current situation as problematic. Americans are in love with technology. They view specialization as progress. Many patients would voluntarily go for the full-body CT scan (much to the horror of their primary care practitioners) because they’ve been taught to believe that more information and tests are better. The academic hospital, housing the most cutting-edge technology, biomedical science, and specialized medical professionals, therefore becomes the Promised Land. Yet only 1% of American patients will be treated in these super-specialized institutions in any 3-month period. The vast majority of us have a set of health care needs requiring treatment approaches that can’t be found within most of these institutions. “We don’t carry that,” would be the honest response an average American would hear if they approached the academic hospital information desk to find out where in the hospital they could go to get help to lose weight non-surgically, control their blood pressure and other chronic diseases, find resources to treat their depression and anxiety, or meet health coaches to help them manage their overall health. “But that’s what I need,” they’d say. “That’s what the vast majority of us need!"
So if that’s what your average American needs to promote and protect their health, and those things are frequently absent from the basic services of the academic hospital, why do almost all of our trainees spend the preponderance of their medical training confined to these halls, taking care of the 1%? You’re probably thinking, “This is partly due to our collective desire to prepare them to be able to identify and care for the sickest of the sick and manage difficult diagnostic dilemmas.” But does that require that they spend two-thirds of their time in the hospital? Is it possible that our predominantly hospital-based approach to training is leaving the next generation of practitioners relatively ill-prepared to care for the other 99% of us?
“Let me make sure I understand this,” my friend continued after I laid this all out for her. “It’s as if we took all of the veterinary students in the US, sent them off to the Galapagos Islands for 3 years to care for swimming lizards and flightless birds, and then brought them back to the US and expected them to figure out what’s wrong with our cats and dogs. They wouldn’t know where to start! They’d probably think my cat Sprinkles’ purr was pathological or something . . . and they’d end up ordering a billion tests to figure out if she was dying! They might even stick a needle in her.”
Bowen JL, Salerno M, Chamberlain JK, et al. Changing habits of practice: transforming internal medicine residency education in ambulatory settings. J Gen Intern Med. 2005;20:1181-1187.