To the Editor.—Reuben and colleagues1 emphasize in "The Residency-Practice Training Mismatch" that inpatients of teaching hospitals are very unrepresentative of the ambulatory patients a physician spends most of his time treating after completing his training. Another important aspect of this mismatch has received little attention, namely, that both inpatients and outpatients of teaching hospitals often are socially and medically unrepresentative of the population as a whole. Most of the patients of many big-city teaching hospitals are poor and uneducated. Their diseases often result from self-indulgent behavior that is generally known to be inimical to health: overeating, smoking, abuse of drugs, and promiscuous sexual activity. They frequently ignore medical advice, do not follow prescribed treatment, and fail to modify self-injurious behavior.
The adverse consequences of training that deals mostly with such patients are obvious. Residents may find it difficult to empathize with these patients, and to respect persons who seem