Steven A. Schroeder, MD; Harold C. Sox, MD, Editor
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Dr. Sox: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
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Michael A. Patmas
Clinical Assistant Professor of Medicine, Oregon Health and Science University
June 29, 2006
Redesigning Residency Education: Programming Failure
TO THE EDITOR: Schroeder and Sox (1) correctly identify deficiencies in the APDIM (2) and ACP (3) position papers on redesigning residency education. Notably absent from both papers and their editorial is yet another crucial deficiency, the lack of adequate preparation for the business side of medical practice. Most internists emerge from training well prepared for their clinical roles but vastly underprepared for success in practice. It is the management of our practices that generates the greatest frustration. Yet, the knowledge and skills needed for success in today's medical marketplace are all but ignored in residency training. Precious few programs provide any content on economics, practice or financial management, operations management, legal and regulatory aspects of medical practice or innovation mangement. Relying upon outdated operational models and century old practice workflows, we are thrust into a rapidly evolving system programmed to fail. If the goal of residency redesign is to better prepare future physicians for success, program directors would be wise to include sufficient exposure to management education. This need not require a graduate degree in management, merely an essential skills practicum that exposes residents to that which they will need to know to effectively manage their practices and thrive dspite the vagaries of the marketplace.
Michael A. Patmas, MD, MMM, FACP. Oregon Health and Science University Portland, Oregon
References 1. Schroeder SA, Sox HC. Internal medicine training: putt or get off the green. Ann Intern Med. 2006; 144:938-939. 2. Fitzgibbons JP, Bordley DR, Berkowitz LR, Miller BW, Henderson, MC. Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal medicine. Ann Intern Med. 2006; 144:920-6. 3. Weinberger SE, Smith LG, Collier VU. Redesigning training for internal medicine. Ann Intern Med. 2006; 144:927-32.
Board of Directors, American College of Physician Executives
Linda N. Prieto
July 2, 2006
Get off the Green
I am a General Internist, in a solo practice as far out of the hospital as I could have imagined. I have a home care practice seeing the most frail elderly in their homes, assisted living facilities and nursing homes. Having graduated from a residency in 1993, where I never left the hospital, but felt very competent in taking care of very sick patients, I really had no problems transitioning to other places of care. I have learned to become an expert at what I do, because I learned how to find the answers and to whom I needed to talk. Internal Medicine should not shrink from Schroeder and Sox's suggestion that it "get off the green." How many cardiologists or gastroenterologists (or any other specialists) really consider themselves Internists? Even during residency they only saw Internal Medicine as a stop along the way. What percentage of non-academic specialists continue their membership in the ACP? How many recertify in Internal Medicine unless they are forced by their hospital? I say it is time to make two tracks of Internal Medicine residency and train excellent Generalists and Specialists.
Ira R. Sharp
Albert Einstein Medical Center (Philadelphia), Abington Memorial Hospital - Abington , PA.
July 14, 2006
Whither General Internal Medicine?
I am a general internist in an internal medicine group, 24 years out from residency, and have had residents from several Philadelphia area hospitals rotate throught our offices for several years. Most of the residents we have hosted are PGY-1 American graduates who are doing a transitional year in preparation for their future residencies in Radiology, Dermatology, Ophthalmology and Anesthesia. Each resident has a one month rotation in prmary care IM in our office. I always ask them why they choose their respective fields and how many of their graduation classmates chose internal medicine - especially primary care (almost none did). It is amazing the uniformity of answers. Almost all chose their fields because of lifestyle and money. I really can't blame them, but I wonder where the future doctors will come from whose goal is to actually take care of people and be "their doctor". It seems to me that the future of our health care system will be based on general internists and FP's who graduated from foreign schools. As with other endeavors, it seems that foreign graduates will fill a void that Americans can't or won't fill.
Schroeder SA, Sox HC. Internal Medicine Training: Putt or Get Off the Green. Ann Intern Med. 2006;144:938–939. doi: https://doi.org/10.7326/0003-4819-144-12-200606200-00014
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Published: Ann Intern Med. 2006;144(12):938-939.
Education and Training, Hospital Medicine.
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