Grand Cru versus generic: different approaches to altering the ratio of general internists to subspecialists

Article Abstract:

The popularity of the specialty of internal medicine as a career choice for medical school graduates, and the tendency of internists to undertake specialty training, have forced the profession in recent years to address its role in the provision of health care. A brief history of the growth in numbers of subspecialists versus generalists is presented, with suggestions of ways for redressing the balance. The lack of primary care physicians appears unique to the US; European countries have a much higher ratio of generalists to subspecialists. To a large extent, our problems stem from the Flexner report, a document published in the early 1900s that gave medicine its scientific (rather than clinical) basis. Other trends later in the century reinforced this tendency, and efforts to reverse the trend did not begin until the 1970s. These have not been successful. To interest more physicians in generalist, rather than subspecialty, training, the general internal medicine training period could be lengthened. This would make the field more rewarding, and allow for the development of more skills. Residents could choose added subspecialty training, which would enable them to act as consultants. In short, they would learn more. Since many physicians are encouraged to enter subspecialty training in medical centers because of the services they provide, allowing fourth-year medical residents to perform these services instead should reduce some incentives to subspecialty training. Possible problems resulting from the adoption of these plans are acknowledged. (Consumer Summary produced by Reliance Medical Information, Inc.)

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Subspecialists and internal medicine: a perspective

Article Abstract:

One of the most significant threats to the identity of internal medicine is the growing split between those who practice general internal medicine and those who practice subspecialties. More and more, generalists are concerned with a form of clinical epidemiology, which is an area of medicine that focuses on clinical decision making, practice guidelines, evaluation of new technology, and patients' complaints, family structures, and access to health care. At the same time, medical subspecialties are becoming increasingly specialized, a move that is fueled by the truly impressive discoveries about disease and physiology during recent years. The development of the team approach to treating specific diseases (such as heart disease) leads to internists' forming closer relationships with representatives of other specialties (surgeons, anesthesiologists, radiologists) than with internists. Thus, the internist's professional identity is undergoing a dramatic change. Organizational units are becoming horizontal (consisting of disease-oriented ''centers''), rather than vertical, the classic form. Arguments in favor of each organizational style are presented. Although horizontal structures must be developed to improve service delivery, internal medicine as it is known depends ultimately on a vertical (general to specific; whole patient down to organ system) structure. Subspecialists must retain their commitment to treating the whole patient, and must not allow themselves to become technicians in service of a larger medical team. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Employment, Organization

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Internal medicine at the crossroads: training subspecialists for the next century

Article Abstract:

An internal medicine task force has proposed eleven recommendations which may substantially change the current system of subspecialty training in this discipline. The task force recommends a divided pathway for medical training of internal medicine subspecialists, with some becoming doctors who see patients and others trained as investigators who conduct medical research. This recommendation may satisfy the need to train fewer internal medicine subspecialists while also providing more research to justify the services provided by these doctors. Another proposal suggests that the internal medicine subspecialist become the primary doctor for patients with complicated conditions. All of the proposals seek to align the training of internal medicine subspecialists with the health care needs of Americans and with society's limited resources.

Editorial, Study and teaching

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