In the exchange of letters concerning curriculum reform in internal medicine [1], the editors of the supplement [2] chose to rebuff the proposal that generalists be trained in procedures, saying it would only work where specialists are in short supply. Such thinking underscores and reinforces the second-class citizenship of generalists in the internal medicine community.

For years, departments of internal medicine have given away the core competencies of the general internist to the subspecialty divisions. The basic curriculum has few explicit expectations of the 3-year trainee. Recently, I visited another medical school and was shocked to hear the chairman state that generalists were not competent to manage diabetes. When I asked him what generalists were trained to do during their 3 years of residency, he responded "Not much." Is it any wonder then that people do not choose careers as generalists when they can choose other residency programs where leaders expect competency at completion of training?

The re-transfer of procedural competencies to the generalist can be successful even in areas with a high density of specialists. If the generalist is a gatekeeper and competently trained to do certain procedures, over time the public will come to expect that practitioner to do those procedures.

It is time we used the 3 years of training to give individuals specific skills on completion rather than the random clinical experiences that result in unspecified competencies and frustration in a real world practice.