The Future of Generalism

Internal medicine has, in recent decades, altered radically its traditional generalist complexion in favor of redefinition along subspecialty lines; in recent years, 60% to 70% [1, 2] of physicians completing categorical internal medicine residency training have entered subspecialty fellowships. The United States has developed subspecialty medicine to a degree seen in no other Western country (Figure 1). As a consequence, general internal medicine has lost much of its identity as a specific area of expertise, as a critical element in educational and training programs, and as the most rational basis for the clinical care of most of the adult population.

An expanding literature bears witness to the increasing pace of scrutiny of these developments [3-10]; this examination has occurred broadly among policymakers at federal and state levels [11] and in various key areas of the private sector, including the governance structure of medical education and training [12-14]. Many have concluded that our current arrangements limit the capacity of our system to meet appropriately the health care needs of the population and to use health resources judiciously [15].

The purpose of this paper is to examine the impact and extent of these shifts in the array of internists, especially as these relate to patient care, and to examine the virtues and deficits of a widely recommended remedy, namely a broad countervailing emphasis on primary care.

The thesis to be explored is threefold:

1. The future of generalism in internal medicine is tightly bound to the future of subspecialization, and neither can be addressed effectively without a linked adjustment of the other.

2. The degree of subspecialization we have developed adversely affects patient care, access to care, and health care costs.

3. Redefining general internal medicine in a manner that equates it with its primary care responsibilities is unlikely …