Perkoff G T
N Engl J Med. 1986 Jan 2;314(1):27-31. doi: 10.1056/NEJM198601023140105.
A resurgence of general interest in teaching clinical medicine in ambulatory-care settings has occurred for several reasons, including changes in the case mix in teaching hospitals, the new responsibilities of house officers and attending physicians brought about by the current payment systems for health care, the increased expectations of patients that medical care will be "personal," the progressive limitations imposed on the education of medical students by the shorter lengths of stay sought by hospitals under the diagnosis-related-groups system of payment, and the growing need for well-trained primary care physicians that has resulted from the increase in medical care organizations. In this paper, I review earlier attempts to emphasize ambulatory care, to identify the pitfalls that new efforts in this direction should avoid. I also compare inpatient and ambulatory-care teaching to provide a basis for understanding the educational goals that can be achieved more easily in each setting. In addition, I suggest major changes in the flow and use of clinical-practice funds and hospital payments so that they can become possible sources of the financing and organization of an expanded effort to teach clinical medicine in ambulatory-care settings.
对门诊医疗环境中临床医学教学的普遍兴趣再度兴起，原因有多个，包括教学医院病例组合的变化、现行医疗支付系统给住院医生和主治医生带来的新职责、患者对医疗服务“个性化”期望的增加、医院在诊断相关分组支付系统下寻求更短住院时间对医学生教育造成的渐进性限制，以及医疗服务组织增加导致对训练有素的初级保健医生的需求不断增长。在本文中，我回顾了早期强调门诊医疗的尝试，以确定新的此类努力应避免的陷阱。我还比较了住院和门诊医疗教学，为理解在每种环境中能更轻松实现的教育目标提供基础。此外，我建议对临床实践资金和医院支付的流程及使用进行重大变革，以便它们能够成为在门诊医疗环境中扩大临床医学教学努力的融资和组织的可能来源。
