I was saddened while reading the position paper on the role of the future general internist [1]. I wonder whether a learned dinosaur in the Mesozoic period wrote similarly of the need for the continued existence of his species? Would such shallow arguments have been raised?

The training I received in my 4 postgraduate years at a medical center in the Midwest was superb. When I entered practice in 1981, the scope of care I delivered covered the breadth of my specialty, internal medicine. Yet, the availability of subspecialty care continues to grow, and my valued and trusting patients, both deserve and demand subspecialty expertise. The scope of my general internal medicine practice continues to erode. That is the future of general internal medicine. One has only to look in the 10th edition of the Medical Knowledge Self-Assessment Program under the category of general internal medicine to see to what level internists in private practice have been relegated. The training I received was excellent, but I did not choose internal medicine to handle only what does not interest a subspecialist, nor did I choose internal medicine to be a family physician.

The reality is that in the medical environment of the United States, a system consisting of family physicians and subspecialists would deliver high-quality health care. It is unlikely that the cost of that care would be lowered by the continued availability of general internists. A narrow role may still be available for us, as preoperative consultants, as physicians for adults ill enough to require a closely monitored hospitalization, and as diagnosticians. But much of this can be provided by well-trained family physicians. It is doubtful that a lean health care system will support redundancy.

I perceive that the future role of the internist will not change but rather will flourish in centers of medical education. I believe that the three aspects of internal medicine will always be excellent teaching, research, and patient care. Although the manpower needs will diminish significantly, the role will survive out of necessity. Internal medicine was originally like the Marines—a few "good men" who took on the challenge, rising above their fellow physicians to define a specialty with respect. If we allow the evolution of internal medicine to continue, our specialty will shrink in number but not in prestige. We can again be the elite "diagnosticians."

We should not struggle to preserve our numbers by inventing roles such as managers of resources and information or continuing the guise of internists as those who prevent disease, all of which is better left to others. We need to concentrate on what we have done best, what led me and many others to internal medicine. We need to focus efforts on strengthening the role of our specialty in centers of medical education. We need to encourage by example the best students to follow the path we have chosen, reaffirming the role that provides an example for and educates other physicians. Expanding the principles of areas such as clinical epidemiology, decision analysis, and ethics will benefit daily practice and medicine as a whole.