What Is the Future of Internal Medicine?

Internal medicine faces unsettled times. Formerly the unchallenged leader of medicine, able to recruit the best students with promises of fulfilling patient care, intellectual challenge, and prestige, it now has an ambiguous image, unfilled residencies, and dissatisfaction in practice. Proposals for health care reform, most of which call for half of all physicians being generalists, may have more powerful and disruptive effects on internal medicine than on any other specialty. Either internal medicine will fundamentally alter itself to produce a far larger proportion of generalists than the present 30%, or the specialty as a whole will be forced to shrink in numbers and influence [1].

Annals of Internal Medicine, which attempts to represent internal medicine as a whole, has included the bright side [2] and the dark [3, 4] as the discipline struggles with these new, uncomfortable realities. Both sides are part of two articles in this issue of Annals, one by the Federated Council for Internal Medicine [5] and the other by Petersdorf and Goitein [6]. A common theme in these articles is the need for more generalists and the difficulties in getting them.

Discussions about the future of internal medicine usually have a relatively short time horizon, just a few years. The perspectives are political and economic (clinical privileges, payment reform, provider mix, autonomy, and other immediate questions); this approach emphasizes short-term effects far more than long-term ones [7]. We suggest that the political and economic changes are but expressions of more fundamental, long-term changes in demography, technology, and the social environment that will shape medicine and medical care in the decades to come.

The population is aging and it is the elderly who account for most medical care needs of the population. The elderly accumulate chronic, degenerative diseases that interact, increasing the complexity …