"Who are these guys?" said Butch Cassidy to the Sundance Kid as Pinkerton's detectives chased the outlaws across the West. That was my question as I read Dr. Rivo's review [1] of factions that intend to force young people into internal medicine. Are they the stodgy academic types who are never on call, who rarely see a patient at night or on weekends, and who are protected by the residents they are finding increasingly difficult to hire? Whoever they are, they are not addressing the real issues. Recent surveys by the American College of Physicians suggest that most practicing internists would not repeat training in internal medicine.

Today's medical students easily see that primary care physicians carry the bulk of patient responsibility, are poorly paid, are harassed by needless reviews, fight continuously with insurance companies, and have one eye open at all times for potential litigation. They have given the intelligent answer to internal medicine: "No, thank you".

If internists are unprepared to practice in managed care, it is undoubtedly because they have no desire to restrict health care, to act as a patient adversary, or to churn profits for stockholders of corporations? "No, thank you".

It is un-American to force medical students to study what they do not want. The last thing patients need is a cadre of unhappy, reluctant physicians. Fix the problems, reduce regulation, and allow students to look forward to being independent fee-for-service practitioners in a single-payer insurance system for all Americans. Put the concept of health service restriction (managed care) in the garbage and punish those that gouge the system. Then the vanishing generalist will, like the buffalo, return.

One last word for Dr. Rivo: Alice knows where she wants to go, but she needs smart government to listen to physicians as resources to fix these problems, not to destroy the good things we have that are rapidly fading into the profit-making machines of corporate America.