Training Internists in Ambulatory Settings

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Abstract
Residency training in internal medicine must adjust to two new realities: the change in the nature of hospitalized patients, and the growing oversupply of internal medicine subspecialists. Technology and economies have changed the substrate of hospital practice dramatically. Consequently, hospital training has increasingly focused on chronically disabled patients, those admitted for elective procedures, or those who are terminally ill.1 Thus, residents have less exposure to acute illnesses and to acute diagnostic and management decisions. Despite a growing oversupply of internal medicine subspecialists,2 at least 60% of internal medicine residency graduates go on to subspecialty training. Schleiter and Tarlov estimate that by the year 2000 more than 50% of all internists will be subspecialists.3 It is unlikely, however, that the typical internal medicine subspecialist can sustain a subspecialty practice exclusively; many subspecialty internists will also have to function as part-time generalists.4 Primary care internal medicine has emerged

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