Dr. Golden quite properly points out that for years departments of medicine have given away many of the core competencies of the general internist to the subspecialty divisions. In large part, this shift has reflected the increasing subspecialty nature of departments, as well as a belief that added training ensures a higher quality of services. We did not intend to rebuff the notion that internists should be trained in "currently lucrative" procedures during a fourth year of training [1]. We agree that general internists who meet acceptable standards in training and competence should be allowed to do procedures now restricted in hospitals to specialists. A survey of 2500 general internists showed that many do a variety of procedures [2]. The number of procedures correlated with recent graduation and practice in smaller communities and smaller hospitals. In support of Dr. Golden's argument, most competencies were learned after the residency [3].

We further agree that the increasing restriction on privileges is a major impediment in attracting residents and students into careers as generalists. Not only are procedures limited for the generalist in large urban hospitals; the management of care for critically ill patients in the special units, even where appropriate consultation is obtained, may also be restricted. Given the call for at least 50% of residency graduates to enter general internal medicine, it is imperative that both the training and credentialing reflect competencies that allow for a more challenging ambulatory and in-hospital environment. As suggested, public education and acceptance are required if this is to be accomplished.