I appreciate the responses of Drs. Robinson and Greenberg. The primary issues are and will remain the quality and coherence of the care received by our patients and the impact of fragmented, technology-intensive care that characterizes our present system.

Internal medicine, once the most popular specialty choice of medical graduates, has undergone an amazing slide in its popularity, a decline that does not appear to have ended. The repayment of debts incurred during the educational process, while obviously important, is not the primary reason for this remarkable change. The erosion of the intellectual content and clinical challenges of general internal medicine offers an explanation at least as compelling (and to my mind more so).

Inviting the medical schools to press half their classes into generalist careers without adjusting, at least in the case of internal medicine, the level of the clinical challenges to be met is unlikely to resolve the eroding attractiveness of general internal medicine. Without sharp reductions in the number of subspecialty training slots, we are unlikely to produce the enhanced quality and reduced fragmentation of care that can be provided by the sophisticated generalist. Primary care is an activity, not a field. Attempts to make it attractive by increasing the payment levels it commands are unlikely to reverse the shrinking interest in internal medicine or to enhance the care of the sick. Reinvigorating internal medicine by expanding its content is more likely to reverse the current trend.