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Medicine and Public Policy |

Internal Medicine and the Journey to Medical Generalism

Marc L. Rivo, MD, MPH
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From the Bureau of Health Professions, Health Resources and Services Administration, Rockville, Maryland. Requests for Reprints: Marc L. Rivo, MD, MPH, Bureau of Health Professions, Division of Medicine, 5600 Fishers Lane, Parklawn Building, Room 4C 25, Rockville, MD 20857. Acknowledgments: The author thanks Steve Schroeder, MD; Steve Wartman, MD; Mack Lipkin, MD; John Noble, MD; Bob Politzer, ScD; and Larry Clare, MD for their helpful comments on manuscript drafts, and Jerald Katzoff, Paul Gilligan, and James Cultice for their assistance with the data and figures.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(2):146-152. doi:10.7326/0003-4819-119-2-199307150-00009
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The overspecialized U.S. physician workforce and mix of graduating residents undermine strategies to provide quality and affordable health care to all Americans. Several respected advisory bodies have recently proposed fundamental changes in federal policy to better match physician supply and specialty mix with health care needs. They recommend that Congress limit the total number of filled first-year resident positions to 110% of the number of U.S. medical school graduates, a 20% reduction from current levels. They have proposed that positions and funding be allocated to medical schools, teaching hospitals, residency programs, or consortia of such entities to ensure that at least 50% of each graduating residency class enters generalist practice. An all-payer, graduate medical education pool and financing system have been suggested as ways to uncouple the physician workforce from hospital service needs and to eliminate disincentives toward ambulatory and primary care training. Increases in generalist production must be accompanied by decreases in nonprimary care specialty and subspecialty positions. In addition, generalist physicians must be better prepared in managed care competencies. Given today's subspecialist surplus, managed care organizations are considering how to retrain subspecialists as generalists. The Federated Council of Internal Medicine's goal that 50% of its graduates become general internists is an important step because internists compose one sixth of all physicians and one third of all first-year residents. This article identifies the challenges that lay ahead on the road to medical generalism and what it may take to get there.


Grahic Jump Location
Figure 1.
Specialty mix of U.

S. resident cohort. Allopathic medical school graduates, 1987.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Specialty mix of U.

S. resident cohort given FCIM's 50% goal.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Specialty mix of U.

S. resident cohort given 75% GIM goal.

Grahic Jump Location




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