The management of high-utilizing patients is an area of active research with broad implications for the healthcare system. There are significant operational challenges to designing primary care models for these medically complex, high-needs patients. Although it is crucial to provide a high degree of continuity of care for this population, managing a cohort of these patients can lead to provider over-work and attrition. This may be magnified by the lack of training dedicated to addressing the unique care needs of these patients. While academic medical centers would seem well suited to care for individuals with multimorbidity needing intensive and specialized treatment, primary care providers in this setting need additional support to be clinically available for patients while pursuing scholarship and teaching. Formally recognizing intensive outpatient care as a specialty within internal medicine would help overcome some of these challenges. This would require a committed effort to high-level systems changes including a new focus on graduate medical education, the creation of division-level infrastructure within academic departments of medicine, and realistic levels of financial support to make this a viable career path.