HEALTH SYSTEM REFORM AND THE GENERALIST PHYSICIAN

The quality of primary care services is central to reforming the healt h care system of the United States. The well-trained generalist is ess ential in a delivery system that emphasizes high-quality, cost-effecti ve care. Several analyses estimate that within a few years the United States will have 100,000-150,000 too many specialists, and some estima tes show a shortage of perhaps 35,000 generalists. Residents and resid ency programs in nongeneralist areas continue to increase, and two-thi rds of graduates enter careers as specialists. Academic medical center s must assume major responsibility for changing their programs to prod uce the types of practitioners that U.S. society needs. Among the chan ges recommended or directed by advisory bodies and professional organi zations are establishing a workforce commission to set long-term goals , limiting the number of first-year residency positions and allocating them to generalist and nongeneralist specialties, establishing a nati onal payment system to support residency training, setting up transiti on payments to teaching hospitals that reduce their number of residenc y positions, and initiatives to graduate more minority and generalist physicians, improve geographic distribution, and expand the capacity f or primary-care teaching.