The training of the internist with some messages from practice.

Efforts to provide an increased focus on the primary care activities of internists have been characterized by some as requiring a substantial increase in experience with ambulatory patients and significant training time invested in office gynecology, office orthopedics, otorhinolaryngology, and dermatology. These changes have been recommended as more reflective of the "real world" of the internist's practice than intensive experience with seriously ill inpatients. It is argued that such skills in training threaten to reduce clinical scope and deep competence and will thereby reduce rather than enhance effectiveness in the care of ambulatory patients. Deep clinical competence should be the hallmark of the internist, and training programs in internal medicine should be designed to produce this type of physician. In addition, consultant-level general internists should be trained for consultative, teaching, and investigative responsibilities and would be powerful role models for trainees.