CASE HISTORY OF TRAINING OUTSIDE THE HOSPITAL AND ITS FUTURE

Hospital-based medical residencies are slowly changing to include experience in ambulatory practices. This development is traced by the case example of the medical residency at the Massachusetts General Hospital which has always contained a component of ambulatory training. The history reveals that the institution's economy and work have determined the content and sequence of residency training, perhaps more than educational ideas on the proper training of the doctor. The early ambulatory experience (1900-1940) was prompted by the need to take care of a large number of outpatients, supported by the view of training for future private practice in the office. The residency became hospital-based (1940-1972) with the expansion of hospital beds, hospital insurance and of specialized jobs in academic medical centers. Residents were now required to care for more hospital patients, to manage the technology of acute care and to aid the growth of subspecialization. Although public interests today demand more ambulatory care, the future of expanded ambulatory training remains problematic, although a modern necessity if medicine is to redirect its attention to prevention and care outside the hospital. Expanded training outside the hospital depends on better financing of ambulatory services, the modernization of outpatient departments as group practices providing primary care, the development of teaching units and research in ambulatory practices, along with support for the idea of the generalist, which itself has had limited support by treatment and learning institutions. © 1979.