Shouldn’t I spend the rest of my time seeing the sick (i.e. “real”) patients in the hospital?
No, for a number of reasons:
- During ICM, one learns the basics of how to take a history and perform a physical exam. In order to generate an appropriate differential diagnosis, one needs to be able to take a history and do an exam that helps to distinguish between the different diseases on the differential diagnosis list. To do this, one needs a deeper understanding of the underlying pathophysiology and common presentations of the diseases that cause various symptoms. This comes during 3rd and 4th year. It is only by spending time actually evaluating patients, developing and defending a differential diagnosis and diagnostic/therapeutic plan that one is able to learn how to effectively evaluate and manage these symptoms/diseases.
- There are many common symptoms that you will not evaluate unless you spend an appropriate amount of time in the outpatient setting. These include skin complaints, headache, back and other musculoskeletal pains, abdominal pain, weight loss, diarrhea, dizziness, palpitations, dysuria, cough, and fatigue. One is not a complete doctor unless one is proficient in the evaluation and treatment of these symptoms.
- Patients who traverse the filter of primary care providers, specialists, and emergency rooms to be hospitalized are distinct from typical medical patients. For patients in the hospital, someone has already identified that they require further intense, inpatient medical intervention. Students need to learn how to filter these patients in the first place. The only place to learn how to do this efficiently and correctly is in the outpatient setting.
- When chronic diseases do precipitate a hospital admission, the emphasis of care is on short-term management. The goals and principles of short-term management are often very different from the goals and principles of long-term management. Diabetes is one example. When a patient with diabetes is hospitalized, the reason is usually ketoacidosis, nonketotic hyperosmolar coma, or another severe complication of diabetes. In the hospital, care is then directed toward restoring homeostasis and treating comorbid conditions. Definitive long-term treatment of diabetes is not emphasized. In office-based care, however, long-term care is the physician's principal concern. In the outpatient setting, students have an excellent opportunity to learn about all aspects of diabetes management, including nutritional and exercise recommendations, glucose monitoring, medication adjustment and monitoring, and screening and management of all the complications of diabetes.
- Internists follow many patients with advanced, complex illness (e.g., chronic kidney disease, cirrhosis, oxygen-dependent COPD, and end-stage CHF). Internists are specially trained to care for these patients and pride themselves on being able to do it effectively. Office-based management strategies for these sicker patients typically include frequent visits, between visit phone and e-mail contact, use of non-physician providers and home care agencies, and extensive patient education and self-monitoring. Medical students need to understand intensive office-based care and develop basic competencies in this area.
- Finally, one of the most important skills one needs to master in our current health care environment is the ability to do all the above within the constraints of a brief (20 minute) office visit. This takes a great deal of practice...