Establishment of Primary Care Continuity Experiences in Community Pediatricians' Offices: Nuts and Bolts

During the past 30 years, there has been an increasing awareness of the importance of ambulatory care training in medical education. The discrepancy between education and practice was pointed out in the General Professional Education Panel report that indicated training was based largely in hospital settings even though the vast majority of doctor-patient encounters do not result in hospitalization.1 Perkoff,2 noting changes in hospital care such as shorter lengths of stay, increased outpatient care, and the need for well-trained primary care physicians, stated that programs need to make a major effort to emphasize clinical teaching in outpatient settings. Recognizing the need for these changes, the Accreditation Council on Graduate Medical Education (ACGME) has increased dramatically the requirement in primary care specialties for clinical ambulatory training.3 For pediatrics, these requirements have progressed from the suggestion that clinical training should be obtained in outpatient clinics (1961) to requiring clinical training in primary care clinics weekly for 3 years (1985). The problems in providing good training in ambulatory settings have been well described.2-4 In comparison inpatient teaching, training students and residents in an outpatient clinic is inefficient and costly. One of the methods suggested to address these problems has been to move ambulatory training out of tertiary care centers to community sites.5-9 Many pediatric programs are now using community sites for at least a portion of resident education.10 Alpert et al10 and Greenberg et al,11 although encouraging the use of these sites to reduce the gap between pediatric education and the service delivery system, pointed out that there are no standards for use of community sites.