sues). Of 16 measure collections, just 3 contained an appreciable (≥10%) representation of overuse measures; nearly half (7 of 16) contained no overuse measures (Figure). Most overuse measures (82.4%) addressed either diagnostic imaging or medication prescription (Figure). By comparison, underuse was well represented (over half of measures) as a target of measures across all categories of clinical service. Discussion | Providing high-quality health care requires both providing beneficial care and reducing nonbeneficial care. Increasingly, primary care clinicians 3,4 and others 2,5 worry that performance measurement may, through an emphasis on identifying and penalizing underuse, foster a culture of "more is better" and inadvertently encourage overuse. To our knowledge, our study is the first to systematically examine and quantify the existence of such an emphasis: current outpatient clinical process measures, both overall and within nearly all major measure collections, overwhelmingly target underuse of clinical services. Performance measurement is well positioned to address both underuse and overuse-if, in the aggregate, clinicians are encouraged to ask themselves, "Am I doing enough for this patient without doing too much?" We believe our findings highlight the need to anticipate and monitor the aggregate effectsboth intended and unintended-of measure program implementation. We would, moreover, advocate the development and implementation of a prospective underuse/ overuse taxonomy as one means by which to promote greater balance across measure collections-or within individual measures-that simultaneously address underuse and overuse. Such a Goldilocks approach to performance measurement, as has been previously proposed, 1,4 could encourage clinicians and institutions to target a balance of care that is just right. Notwithstanding certain limitations of the present study, which focuses on measures themselves rather than on the putative connection between measure balance and physician behavior, we have shown that the current state of outpatient clinical performance measurement fails to address overuse-and may inadvertently reward it.

Background: The Canadian healthcare system faces increasing patient volumes and complexity amidst funding constraints. Ambulatory care offers a potential solution to some of these challenges. Despite growing emphasis on the provision of ambulatory care, there has been a relative paucity of ambulatory care training curricula within Canadian internal medicine residency programs. We conducted a narrative review to understand the current state of knowledge on postgraduate ambulatory care education (ACE), in order to frame a research agenda for Canadian Internal Medicine ACE. Methods: We searched OVID Medline, Embase, and PsycINFO for articles that included the concepts of ambulatory care and medical or health professions education from 2005-2015. After sorting for inclusion/exclusion, we analyzed 30 articles, looking for dominant claims about ACE in Internal Medicine literature. Results: We found three claims. First, ACE is considered to be a necessary component of medical training because of its distinction from inpatient learning environments. Second, current models of ambulatory care clinics do not meet residency education needs. Third, ACE presents opportunities to develop non-medical expert roles.  Conclusions: The findings of our narrative review highlight a need for additional research regarding ACE in Canada to inform optimal ambulatory internal medicine training structures and alignment of educational and societal needs.

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