INTERNAL-MEDICINE AND THE JOURNEY TO MEDICAL GENERALISM

The overspecialized U.S. physician workforce and mix of graduating res idents undermine strategies to provide quality and affordable health c are to all Americans. Several respected advisory bodies have recently proposed fundamental changes in federal policy to better match physici an supply and specialty mix with health care needs. They recommend tha t Congress limit the total number of filled first-year resident positi ons to 110% of the number of U.S. medical school graduates, a 20% redu ction from current levels. They have proposed that positions and fundi ng be allocated to medical schools, teaching hospitals, residency prog rams, or consortia of such entities to ensure that at least 50% of eac h graduating residency class enters generalist practice. An all-payer, graduate medical education pool and financing system have been sugges ted as ways to uncouple the physician workforce from hospital service needs and to eliminate disincentives toward ambulatory and primary car e training. Increases in generalist production must be accompanied by decreases in nonprimary care specialty and subspecialty positions. In addition, generalist physicians must be better prepared in managed car e competencies. Given today's subspecialist surplus, managed care orga nizations are considering how to retrain subspecialists as generalists . The Federated Council of Internal Medicine's goal that 50% of its gr aduates become general internists is an important step because interni sts compose one sixth of all physicians and one third of all first-yea r residents. This article identifies the challenges that lay ahead on the road to medical generalism and what it may take to get there.