title: Beyond diagnosis: patient mix and challenges to patient care in ambulatory training sites.
abstract: BACKGROUND
  Educational experiences in ambulatory medicine vary by site.
  
  
  OBJECTIVE
  To evaluate variations in patient mix and challenges in patient care at 3 ambulatory training sites.
  
  
  METHODS
  Patients (n=123) receiving care at a VA medical center (VA), an urban academic medical center's primary care center (PCC), and a community group practice (CGP) were evaluated.
  
  
  RESULTS
  Patients at the VA (n=55), compared with those at the PCC (n=44) and the CGP (n=24), were older, more likely to be male, and white (all P<0.05). Patients at the VA and the PCC reported difficulty with functional and health status more frequently than those at the CGP (all P<0.05). Common medical diagnoses varied across sites and comorbidity scores were > or = 2 in 48% of VA subjects compared with 16% at the PCC and 29% at the CGP (P<0.05). Challenges most frequently cited were administrative issues at the VA (44%), patient-physician communication at the PCC (39%), and medical decisions at the CGP (50%) (P<0.05).
  
  
  CONCLUSIONS
  Ambulatory training sites can differ greatly with respect to characteristics beyond diagnosis. Plans for increased and improved ambulatory training of internal medicine residents should include attention to these issues to ensure exposure to an adequate patient spectrum.
authors.affiliation: Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520-8025, USA. david.fiellin@yale.edu
authors.forename: D A
authors.initials: DA
authors.lastname: Fiellin
authors.forename: J
authors.initials: J
authors.lastname: Concato
mesh_terms: D000046:Academic Medical Centers / Q000592:standards; D000203:Activities of Daily Living; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000592:standards* / Q000706:statistics & numerical data; D015897:Comorbidity; D003953:Diagnosis-Related Groups; D005260:Female; D006123:Group Practice / Q000592:standards; D006304:Health Status; D006787:Hospitals, Veterans / Q000592:standards; D006801:Humans; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D011320:Primary Health Care / Q000592:standards; D014481:United States