America may finally be finding its way out of its health care conundrum. Without a clear consensus on which way to go and given the proclivity for less national direction rather than more, the nation's health care system in the 1980s found itself in an Alice-in-Wonderland world of paradoxes. Increases in health care expenditures soared beyond increases in inflation and in health care spending of all other countries, yet not enough money was available to insure the 37 million Americans who lacked coverage. The United States accumulated one half of the world's computed tomography scanners and two thirds of the world's magnetic resonance imaging machines, and a growing number of medically underserved countries lacked basic primary care. Biomedical researchers unlocked the genetic code as public health officials announced the resurgence of measles and other vaccine-preventable diseases. Public consensus that the country's health care system needed reform emerged in the special Senatorial election in Pennsylvania in November 1991 and became a major issue in the Presidential election 1 year later [2].

The nation's medical education system is also seen as heading in the wrong direction. The Council on Graduate Medical Education, Physician Payment Review Commission, and Pew Health Professions Commission concluded that physician workforce deficiencies, particularly the dearth of generalists (that is, general internists, general pediatricians, and family physicians) and plethora of nonprimary care specialists and subspecialists undermine efforts to provide quality affordable health care to all Americans [3-5]. Others echo these concerns [6-8].

The Federated Council for Internal Medicine called for "50% of graduates from internal medicine residency programs to enter the practice of general internal medicine" [9]. Because this is a major goal for internal medicine, looking at it in more detail may help us to more fully understand where we are, how we got there, where we are heading, and what it may take to get there.

Health Care Reform: New Directions

Health care reform has raised the ante for fundamental physician workforce reform. The health care system of the future must provide universal access, emphasize primary care and prevention, and promote quality [10-13]. At the same time, financing mechanisms must be implemented to reduce unnecessary hospitalizations; curb the acquisition of costly, duplicative technology; and eliminate incentives to perform diagnostic tests and procedures of marginal benefit.

With health care reform, the demand for generalist physicians will intensify. Extending health care access to all Americans will result in a 13% to 15% increase in primary care contacts [14]. Developed countries that provide universal coverage are typically built on a base of 50% or more general practitioners. Managed care incentives will stimulate competition for well-trained generalists [15-17].

Conversely, the new environment will increase pressure to maintain a leaner supply of nonprimary care specialists [18]. Overspecialization, combined with fee-for-service, abundant technology, and unrestrained patient self-referral are potent, cost-generating ingredients [19, 20]. Increasing service volume and intensity, as much as one third of which may be of marginal or no benefit, accounts for one half of the noninflationary growth in medical expenditures [12] and may be the most important part of the cost differential between the United States and other developed countries [21]. Closed-panel or staff-model managed care organizations control service volume in part by maintaining an aggregate physician-to-population ratio that is 25% less than the current national supply and a more balanced generalist:specialist mix [15, 22]. Compared with this model, the supply of certain medical subspecialists, such as cardiologists, gastroenterologists, and pulmonologists, may exceed present demand by as much as 200% [23].

Many internists trained for subspecialty careers primarily practice as generalist physicians. In the more disciplined health care system of tomorrow, it may be inefficient and more costly to employ narrowly trained subspecialists to deliver comprehensive primary care services. Given the subspecialty surplus, managed care organizations are considering how to retrain subspecialists as generalists (Testimony of Group Health Association of America to the Council on Graduate Medical Education, October 1992).

The March toward Subspecialization

It is widely acknowledged that the overspecialized U.S. physician workforce and its training pipeline do not match well with health care needs. Today, only one third of all physicians in the United States are general internists, general pediatricians, and family physicians; and only one sixth of all students choose generalist careers. Changing the nation's physician mix to 50% generalists would improve primary care access, save an estimated $5 billion dollars a year in physician income [24], and billions more in marginal tests and procedures avoided [21]. Despite concerns of a physician surplus, the physician-to-population ratio is projected to increase by 20% in the next 25 years, driven by the continued surge in service-intensive, nonprimary care specialists, and subspecialists [3].

Internal medicine's dramatic growth and inexorable march toward subspecialization during the last two decades is a major contributor to the physician surplus and specialty imbalance we face today [25]. Between 1978 and 1988, the adult population increased by 25%, whereas the overall internal medicine population increased almost five times that amount. During the last 20 years, the number of internal medicine subspecialists has grown by 205%, or almost three times faster than the number of general internists. Fewer than 60% of internists are self-designated generalists and only one fourth of internal medicine residency graduates do not subspecialize [26].

The road toward subspecialization was built with good intention. In the 1960s, concerns about access to primary care prompted federal incentives to expand medical schools and train more physicians. However, the combination of large increases in federal funding for biomedical research and generous reimbursement for procedural medicine fueled the growth of high-paying, subspecialty-trained practitioners and faculty [27]. In the 1970s, Congress substituted more targeted approaches to produce a majority of generalist physicians. However, in a necessary final compromise, legislation defined primary care output as the percentage of internists, pediatricians, and family physicians in the "first" year of residency training, before residents elect to subspecialize. Consequently, medical schools immediately exceeded the 50% generalist goal, eliminating incentive to change.

In the late 1970s, residency programs in primary care internal medicine were established to graduate more general internists. Funded through the Health Resources and Services Administration, these primary care "tracks" provided more office-based training in gynecology, dermatology, orthopedics, otolaryngology, ophthalmology, psychiatry, and preventive and occupational medicine than traditional programs and twice the amount of continuity-of-care experience [28]. In the 1980s, this $10 million program ran up against a reconfigured and multibillion dollar hospital-based Medicare graduate medical education financing system that provided significant disincentives against ambulatory, primary care training. Despite concerns of an impending physician surplus, national workforce analytic and planning efforts virtually disappeared during the laissez faire, anti-planning mentality of the 1980s. Although federal oversight was eliminated, the main economic engines driving academic health centers and physicians down the road to subspecialization remained [29].

Today, medical students and residents view the world of internal medicine through inpatient- and subspecialty-tinted glasses. Students receive little preclinical exposure to the psychosocial, person-centered, health-oriented aspects of medical generalism [30]. Only 15% of the required third-year internal medicine clerkship is spent in the outpatient setting [31]. One third of all medical schools do not require any internal medicine outpatient experience. Although 17% of full-time allopathic faculty are internists, the minority are generalists and few are department chairs [3].

Internal medicine residency training, like the third-year clerkship, primarily advertises subspecialization. Internal medicine residents spend, on average, more than 75% of their time in the hospital, often in intensive care settings and with highly specialized aspects of medical care. The limited outpatient experience has been criticized as mainly hospital-based and specialty-oriented, poorly supervised, and lacking in continuity of care [32]. As a result, the resident's patient profile may bear little resemblance to that seen in generalist practice.

Furthermore, traditional internal medicine residency programs provide little exposure to managed care. Only 24% of internal medicine residencies have any contracts with health maintenance organizations (HMOs) and only one fifth have more than 20% managed care enrollees in their practice. Only 5% of all internal medicine programs that do have managed care contracts have their residents serving as the primary care provider [33]. In a survey of HMOs, 4% thought that internal medicine graduates were "well prepared" and 75% thought they were "poorly prepared" for managed care [17].

Primary care residency tracks graduate more generalists than do traditional programs and have produced an important cohort of general internist faculty leaders [34]. However, they have their limitations. Most training still takes place in the inpatient setting, and office-based, continuity-focused, and managed care experiences are limited. Furthermore, the self-designated "primary care internal medicine" programs listed separately in the National Resident Matching Program may not emphasize more continuity-of-care or office-based training or graduate more generalists. Most importantly, these tracks remain the exception rather than the rule [35]. Their most important attributes have not yet found their way into the Special Requirements for Internal Medicine Training [36]. The Requirements only call for 10% continuity-of-care experience and an unspecified amount of training in common office-based generalist competencies.

The absence of a national physician workforce strategy combined with powerful medical education financing and health care reimbursement disincentives reinforces the march of the medical education system, including internal medicine, toward subspecialization [29]. The Health Resources and Services Administration provides some $150 million to train generalists and to encourage primary care for the underserved. The federal government funds some $40 million in primary care research that supports generalist faculty. Critics point out that these expenditures are dwarfed by some $4 billion dollars of biomedical research funding through the National Institutes of Health and more than $5 billion from the Health Care Financing Administration for graduate medical education, which, directly or indirectly, provides significantly more potent incentives to produce hospital-based subspecialists [3-5, 29]. The traditional fee-for-service indemnity system, combined with mounting administrative and regulatory burdens, presents even more formidable barriers for general internist faculty and practitioners.

Without an unequivocal national policy direction, such critical outcomes as the aggregate physician supply, demographic composition, specialty mix, and geographic distribution are little scrutinized. Academic health centers located in cities or rural states with primary care shortages and subspecialist surpluses produce more anesthesiologists, radiologists, gastroenterologists, and cardiologists than general internists, general pediatricians, and family physicians. Conversely, primary care-oriented academic health centers find themselves swimming upstream against a medical education marketplace that rewards specialization. It should come as no surprise that fewer graduates are choosing generalist careers and that many residents and practicing physicians feel ill-equipped in the primary care and managed care competencies demanded by the health care system (Table 1).

Medical Education: Changing Course

Policymakers have realized that implementing minor course corrections in the medical marketplace will not halt the march toward subspecialization, especially in the short run. The Council on Graduate Medical Education, the Physician Payment Review Commission, and the Pew Health Professions Commission suggest similar sweeping changes in national physician workforce policy to train fewer physicians and more generalists anticipated with health care reform [3-5]. First, they recommend that Congress limit the total number of filled first year resident positions to 110% or less of the number of U.S. medical school graduates, a 20% reduction from today's level. They propose that at least 50% each resident cohort should complete primary care training programs and enter generalist practice. Second, they recommend that positions and funding be allocated to attain these national goals. Third, fundamental changes in graduate medical education financing policy are suggested that consolidate Medicare direct and indirect graduate medical education into a single education pool; require all private payers to contribute explicitly to this pool; eliminate disincentives for ambulatory and primary care training; and allow payments to the teaching hospital, residency program, medical school, or consortia of such entities. Finally, they call for a national advisory committee to monitor progress and recommend future adjustments in workforce goals and policy.

These recommendations are built on several important principles. Federal financing of physician training is a public good. However, the public should finance only the physician supply and mix needed by the American people. That determination should be driven by an analysis of national physician supply and requirements rather than by individual hospital service needs. Finally, quality is as important an outcome as numbers and specialty mix. Generalist physician training must emphasize more ambulatory, primary, and managed care practice competencies.

The journey toward medical generalism has begun. In the recent health professions reauthorization bill, Congress reallocated almost $50 million in existing low-interest-rate loans to reward financially eligible students committed to general internal medicine, general pediatrics, preventive medicine, and family practice careers and to reward schools that produce more primary care physicians. Congress also redirected primary care training dollars to reward internal medicine residency programs with a demonstrated track record in producing more generalists and practitioners for underserved communities. Similar outcomes-based funding strategies are being proposed at the state level. Managed care organizations have become more involved in medical education. Academic health centers and teaching hospitals are reversing direction to be compatible with physician resource needs and to survive and prosper in the health care system.

The Effects of Federated Council for Internal Medicine's 50% Goal

Despite today's changing environment, internal medicine's road toward medical generalism may appear formidable. The generalist:specialist ratio will be balanced, in part, on the back of internal medicine because it constitutes one third of all filled first-year residency positions. Given the goal of constraining physician supply growth, increases in generalist production must be accompanied by similar decreases in the number of nonprimary care specialists and subspecialists trained. Even if one half of all internal medicine residency graduates did remain generalists, its contribution to the pool of generalists needed may be more modest than expected.

This is illustrated by examining three scenarios for a cohort of allopathic residents. Figure 1 shows the specialty choices made by 1987 allopathic medical school graduates (that is, not osteopathic or international medical graduates), the latest cohort from which data are available [37, 38]. In the first postgraduate year (PGY-1), 55% of all residents chose categorical internal medicine, pediatric medicine, or family medicine residency positions. Internal medicine composes 60% of these potential generalist positions. However, in the fourth year of training (PGY-4), more than one half the potential generalist pool entered subspecialty training, leaving only 26% of all the residents in a generalist pathway. General internists constitute about 40% of this total pool of generalist graduates. Only 30% of the PGY-1 internal medicine resident cohort decided not to subspecialize.

View larger version (27K): [in this window] [in a new window]   Figure 1. Specialty mix of U.S. resident cohort. Allopathic medical school graduates, 1987.

What if the Federated Council for Internal Medicine's goal that 50% of internal medicine graduates become generalists were attained? How would it affect the overall goal that 50% of all residency graduates each year enter generalist practice? Figure 2 simulates this scenario. Although 20% more internal medicine residents would choose generalist careers compared with the 1987 cohort, general internists would contribute only 32% of the larger total generalist pool needed. As illustrated, the remaining two thirds of the generalist pool could be attained by doubling the percentage output of both family physician and general pediatric residency graduates. Even if 20% more general pediatricians forgo subspecialty training compared with those depicted in Figure 1, attaining a 50% PGY-4 generalist pool results in a 17% reduction in filled, nonprimary care PGY-1 positions. This is largely because internal medicine still occupies one third of all PGY-1 positions and still loses 50% of its potential generalist cohort to subspecialty training.

View larger version (29K): [in this window] [in a new window]   Figure 2. Specialty mix of U.S. resident cohort given FCIM's 50% goal.

On the other hand, what if a higher proportion of residents in categorical internal medicine programs remained generalists? Figure 3 shows, for example, that if 75% of the same cohort of internal medicine residents did not pursue subspecialty training, general internists would compose almost one half of the total generalist pool. Because far fewer internal medicine and pediatric residents enter subspecialty training in this simulation, more PGY-1 nonprimary care slots can be filled. Overall, 80% of PGY-1 internal medicine, family medicine, and pediatric residents in this scenario remain generalists compared with 47% in the 1987 cohort.

View larger version (25K): [in this window] [in a new window]   Figure 3. Specialty mix of U.S. resident cohort given 75% GIM goal.

The numeric impact of these changes in residency mix depends on how many first-year resident positions are being filled. Given the 1991 fill rate, the 3% reduction in PGY-1 categorical internal medicine positions in Figure 3 would translate into 200 fewer positions. However, limiting the number of filled PGY-1 residency slots to 110% of the number of United States medical graduates would eliminate some 4000 currently filled positions. Given internal medicine's share of PGY-1 slots, this would translate into the reduction of some 1300 additional filled internal medicine positions. Ultimately, the number of internal medicine subspecialty positions that should be filled based on health care needs may determine the percentage of general internists produced in each class.

More refined workforce projections that factor in the contribution and behavior of osteopathic and international medical graduates are needed but are limited by fragmented and incomplete data bases linking medical school, residency, and practice. Yet, this exercise illustrates the kinds of decisions that must take place if the United States is to move toward a more rational system of physician workforce oversight. Others have recognized the sober calculations that lie beyond the Federated Council for Internal Medicine's 50% goal. In a presentation to the Association of American Medical Colleges, Dr. Petersdorf offered a plan to double the number of general internists, which would eliminate 600 internal medicine fellowship positions [39]. Given physician supply and need, such proposals may be in the interest of medical subspecialists and the public [40].

As critical as these goals are, matching physician resources to health care needs through changes in residency mix is a slow process. Even if the goal of graduating a majority of practicing generalists was attained by the year 2000, it would take until well past 2030 to achieve a 50:50 mix of practicing generalists and specialists. Setting a higher residency output (for example, 75% of all residency graduates choose generalist careers) as illustrated may be prudent but unattainable, at least without more academic and professional leadership and supportive federal policy. Given this reality, retraining existing subspecialists may be an attractive strategy and a new growth field for academic medicine.

Internal Medicine and the Road Ahead

Goals aside, the fundamental question becomes how does the internal medicine community produce more and better trained generalists? During the past year, the internal medicine community has been productively engaged in charting a new course toward medical generalism [41, 42]. It appears that substantial course corrections in the undergraduate, graduate, and practice environment, as well as in public policy, may be necessary.

Many recommend that the road to medical generalism must begin with a substantial and positive medical school environment that better advertises the rewards of community-based, general internal medicine practice [43, 44]. Student exposure to internal medicine may best take place outside the hospital in ambulatory sites where most medical care is practiced. Accelerated programs combining 3 years of medical school and 3 years of residency training program may be a viable strategy to reduce debt burden and produce more generalists [45]. Medical schools will need to recruit and train more community-based general internist faculty role models and find new ambulatory training sites.

Fundamental changes in residency training may be necessary to prepare general internists for managed care practice. Some recommend that educational objectives and schedules could be built around faculty-resident group practices that replicate the outpatient, continuity-of-care emphasis of a generalist [46]. Except for certain inpatient (for example, coronary care units) and outpatient (for example, emergency medicine) rotations to garner specific competencies, scheduling could protect the resident's group practice responsibilities. In this scenario, residents could serve as primary care physicians to managed care enrollees.

An office-based, continuity-of-care-oriented internal medicine training program may not be the best way to train the hospital-based medical subspecialist. However, the traditional highly specialized, hospital-based internal medicine residency program with its skewed inpatient mix may not be the best way to train the general internist or anyone below the fellowship level. Some internal medicine leaders have advocated different residency pathways to generalist and subspecialist practice if the traditional program does not emphasize primary and managed care practice [47].

General internal medicine constitutes a broad and definable scope of competencies that cannot perpetually be defined by one's residency certificate or by simple self-reporting. The longer one is in practice, the more clinical competence is related to one's practice profile and continuing education activities. Yet, some still respond to public concerns about the shortage of generalist physicians by including, in their calculations, all certificates issued to internal medicine residency graduates, even if they subsequently decided to subspecialize.

Ultimately, a competency-based classification of a "generalist" physician is needed for quality and accounting purposes [3]. This common standard could be applied to the content of residency training and the initial certification examination, then to continuing education and recertification requirements. The American Board of Internal Medicine's movement to time-limited certification and recertification would allow for the development of a specific general internal medicine examination and continuing education requirements for competency and classification [48]. Such a system could allow for a pathway to be developed to retrain and recertify a medical subspecialist as a general internist [49].

The road to general internal medicine benefits from strong Departments of Family Medicine and Divisions of General Pediatrics, and vice versa [50]. Although some point out the differences [51], general internists have much in common with their primary care colleagues, particularly family physicians [52]. During the past few years, important interspecialty relationships have been built. From a common concern to revitalize student interest in generalism, the Primary Care Organizations Consortium was formed. The Primary Care Organizations Consortium serves a vital role of enhancing generalist physician communication, collaboration, and advocacy [53]. Recently, the Consortium was awarded a contract to implement and evaluate an interdisciplinary-run, undergraduate primary care clerkship.

Ultimately, fundamental changes in medical education financing and health care reimbursement policy are needed to remove the substantial barriers that block the road to medical generalism. Member organizations of the Federated Council for Internal Medicine have endorsed a number of these directions. The $10 billion federal and almost $3 billion state funding that flows into the medical education system for research and training represents a sizable public trust. The medical education system will produce more generalists and fewer specialists given sufficient public resolve and effective public policy [54].

Challenges on the Road Ahead

Public expectations and political promises for a system that provides high quality and affordable health care to all citizens will inevitably move the medical education system down the road toward medical generalism. The real questions are how quickly will the nation proceed and will the medical education community lead the way?

In his plenary address at the 1992 annual meeting of the Association of American Medical Colleges, Dr. Schroeder outlined the possible responses of academic medicine to this new direction and challenged them to assume a constructive role in the journey^[56]. Reaching the destination will require fundamental changes in the way the medical education system is organized, financed, and evaluated. As Schroeder points out, barriers in the road may be placed by those who deny the problem exists, abdicate the primary care role to nonphysician primary care providers, maintain that only small course corrections are necessary, or simply look to others to solve the problem. He warned that if progress is too slow, these barriers may only invite more unwanted government intervention.

My daughter concluded that Alice would have a much better chance of reaching her destination if she knew where she wanted to go and what it would take to get there. The same applies to the nation and its new directions for the medical education system, as well as to the internal medicine community and its journey toward medical generalism.

The views expressed in this article are strictly those of the author. No official endorsement by the Department of Health and Human Services or any of its components is intended or should be inferred.