Training on the wards

I find it difficult to understand what problem Kenneth Flegel and Anita Palepu1 are trying to solve when they argue that a greater proportion of internal medicine resident training should take place in ambulatory clinics. They cite a need to correlate the information taught with what the trainee is planning to do in the future (contextual learning), but for generations, trainees have matured as physicians in the ward setting, without any apparent difficulty in adapting to ambulatory practice once training was complete. In fact, the key to medical training at any level is to equip trainees with the ability to learn independently, if only so they can match their eventual practice with their talents and with community needs at the time of graduation.

Moreover, ward teaching has a number of advantages. During bedside rounds, trainees learn to appreciate first-hand how the unique perspectives of different health care providers can contribute to patient management. Ward teaching is also efficient, because several trainees at different levels can be taught at the same time. Furthermore, trainees at various levels teach each other. Hospital patients are usually ill, so residents become intimately acquainted with the protean manifestations of disease. This experience is invaluable in meeting one of the main challenges of outpatient medicine — differentiating the “worried well” from those with organic illness requiring priority management. In addition, hospital patients tend to be the most challenging to treat, stimulating the most thought, since memorized “care pathways” are only rarely sufficient to deal with their complicated multisystem problems. There is also an economic incentive to keeping teaching on the wards: in our current medical system, time truly is money, and residents in the hospital save time, whereas trainees in the clinic consume time. Until this issue is addressed, teachers are likely to resist the switch from inpatient to outpatient teaching.

A trainee's educational experience seems to be determined neither by the type of patient encountered nor by the setting in which the patient is seen, but rather by the characteristics of the individual doing the teaching. Rotations in which physician-teachers transmit to their students the satisfactions of medical practice, stimulate thought and encourage the trainee beyond his or her apparent abilities are usually the rotations most highly sought and most fondly remembered. In my view, both teachers and trainees would be better off if we focused on identifying, supporting and multiplying such teachers rather than concentrating on the specifics of what is taught where.

G. Kandel Division of Gastroenterology St. Michael's Hospital Toronto, Ont.