this committee's definition of primary care—requires that students gain experience in practices and sites that are primary care based.

This does not now happen to nearly the extent the committee sees as desirable. The reasons are varied. Financing issues have been a major impediment to undergraduate education in ambulatory settings. Training costs are increased, and the logistics can be complex; finding ways to offset such costs has been difficult. Other objections to ambulatory training have been raised as well (Petersdorf and Turner, 1995). Some faculty, for example, believe that inpatient education with its intense exposure to acute disease provides better education and can be transferred to the ambulatory setting more readily than vice versa. Others are concerned that, during office visits, patients may not be willing to devote the extra time that might be required to accommodate undergraduate teaching and that, similarly, community-based physicians may be unwilling to have their patient schedules disrupted by student involvement.

The committee did not find these arguments about the problems of conducting some undergraduate medical education in outpatient or primary care settings persuasive. Calls for greater emphasis on out-of-hospital primary care training in both undergraduate and graduate medical training are not new; they have been raised with increasing frequency in the last several decades (Alpert and Charney, 1973; IOM, 1983). As discussed below, therefore, the committee concluded that the benefits of such training can and do outweigh the drawbacks and that concrete steps therefore need to be taken to provide all future medical students with such exposure. For this reason, it recommends the following:

Recommendation 7.1 Training in Primary Care Sites

All medical schools should require their undergraduate medical students to experience training in settings that deliver primary care as defined by this committee.

The committee concluded that useful, indeed crucial, educational experiences can take place in doctors' offices, community health centers, and other out-of-hospital community sites. It also judged that such exposure to primary care settings and practices should be relatively intense; that is, an occasional short rotation in several sites is unlikely to provide an adequate experience.

References in this chapter to ambulatory in regard to student and resident training should be understood as ambulatory care in primary care settings. The committee strongly cautions against the view that a "rotation in an ambulatory setting" is equivalent to experience with primary care. Substituting ambulatory for inpatient service at either the undergraduate or graduate level will not necessarily yield primary care experience to trainees, because much of ambulatory care is not primary care. For example, many procedures that were once performed in an inpatient setting are now done in offices or ambulatory surgery



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