Commentary: Osler in a brave new world.

The current issue of Academic Medicine includes a proposal to reform internal medicine residency education by returning to the Oslerian ideal of an internist as a consultant-generalist. To meet this goal, the proposed model focuses on a traditional inpatient learning experience with outpatient learning structured in blocks rather than continuity clinics. In this commentary, the author contends that today's learning environment is significantly different from the learning environment of the 1890s when the Oslerian ideal was conceived. Inpatient wards are often filled with patients who arrive to the hospital ward with a diagnosis already made. Residency education needs to take into account the technological and scientific advances of today's age to ensure that residents are learning the fundamental skills required of all physicians--delivering a precise differential diagnosis which leads to the ultimate evaluation and treatment plan. Meaningful experience with patients who cover the full spectrum of health and illness will bring the most robust learning for our residents. To attain these experiences, our residents must practice in a variety of environments, including in inpatient services, intensive care units, and outpatient clinics. Just as in designing a well-balanced financial portfolio, educational programs must be equally well balanced to achieve the learning and patient outcomes that residents expect and patients deserve.