Virtually every analysis and review, including those by government agencies, foundations, and professional organizations, have concluded that there are not enough practicing generalist physicians and too many highly specialized physicians for a rational health care system. Internal medicine is a crucial part of physician manpower, with more than one fifth of the country's practicing physicians and one quarter of the residents in training.

It is difficult to estimate just how many of the various categories of physicians are needed, but the one third of American physicians who are general internists, family practitioners, or general pediatricians is a much smaller proportion than that in other developed countries, such as Canada and Germany (50%) and Great Britain (> 70%).

The United States has set a national goal of 50% of physicians in generalist disciplines, and the federal advisory Council on Graduate Medical Education recommends that this be approached by having 50% of all residency graduates enter practice as generalists [1]. Recently, the Federated Council for Internal Medicine stated its goal that 50% of graduates of internal medicine residency programs should enter the practice of general internal medicine [2]. These proposals are not new, but it is an important consensus for internal medicine at a critical time.

This issue of Annals includes two articles addressing the issue of internal medicine manpower. The first examines the implications of the national consensus that 50% of physicians be generalists [3]. Rivo estimates that with 50% of graduates of residency programs entering primary care practices, and family practice residents making up half of this group, increasing to 50% the graduates of internal medicine programs who enter general internal medicine practices would add a relatively small increment to the total group of graduates entering generalist practices. Increasing the proportion to 75% could not be accomplished in the near future. Internal medicine residency programs are not particularly attractive to U.S. medical graduates; fill rates in the National Residency Matching Program have declined for the eighth consecutive year to 53.1% in 1993.

Such projections point out the futility of depending solely on changes in rates of production of generalists over the near term. Although it is important to reverse the trend away from generalist trainees, urgent manpower needs would not be approached in this way during the next several years. If health system reform occurs, it will be hampered by the scarcity of generalists.

Internal medicine subspecialists provide an important part of primary care [4], which is likely to increase as changes in delivery systems limit the patient encounters and reimbursements of subspecialists. It is generally believed that subspecialists use more resources and generate more costs than do primary care physicians for similar patients. This belief, not firmly established, is suggested by the recent results of the Medical Outcomes Study comparing cardiologists and endocrinologists with generalists [5]. It is reasonable to expect that in increasingly managed health care settings, subspecialists, like generalists, will conform to guided standards of care. Updating subspecialists in general internal medicine can be facilitated by innovative continuing medical education and by the American Board of Internal Medicine's recertification procedure, which will include an extensive self-evaluation process followed by the opportunity to be recertified in general internal medicine as well as in the subspecialty. Internists practicing as both generalists and subspecialists could increase substantially the availability of primary care to adults during the next several years.

In another article in this issue of Annals [6], Barondess reminds us that primary care is not the only care that generalists provide. He argues that generalists should be able to provide care in a broader range of situations; they should be responsible for inpatients and provide some of the tertiary care now given by subspecialists.

Barondess and others would extend the basic training of internists to 4 years so that they could have more ambulatory care experience, learn to do more in subspecialty areas and thus need fewer referrals and consultations. Such training would be highly desirable but it is difficult to accept lengthening the training time for general internists, with its negative implications for cost and attractiveness, when there has not been full assessment of the need for extensive time spent now on inpatient services in 3-year programs and better use of the fourth year of medical school. It should be possible to restructure general internal medicine residency training within 3 postgraduate years.

Definitions of the role and privileges of the general internist, including procedures and consultations, are key to changes in education and credentialing and to manpower projections. The procedures performed by general internists vary considerably with training, time in practice, location, and the sizes of their hospitals [7]. The roles of general internists as consultants probably differ according to a spectrum of similar factors.

Both Rivo and Barondess review how we came to our present specialty mix. Important influences include expanding knowledge bases and new technologies causing the growth of subspecialties; research and patient care funding generated by subspecialty activities; fellowship and residency programs driven by hospital needs; inappropriate residency curricula and faculty composition; students' and residents' experiences with inpatient, subspecialty-dominated internal medicine; and practice settings beset with increasingly stifling regulations combined with inadequate reimbursements for generalists. These forces have been interrelated and powerful. All must be addressed if changes are to be effective and sustained.

Unlike other nations with health plans, the United States has had no effective national oversight system to deal with manpower in the health professions. Accurate manpower information has not been regularly produced. When information has been available, its implications could not be translated readily into action because there has been no effective mechanism to do so; organizations and agencies responding largely to their own important but fragmented missions have been setting the manpower agenda. The role of the Accreditation Council for Graduate Medical Education's Residency Review Committee for Internal Medicine in controlling residency and fellowship positions is perceived to be limited by concerns about constraint of trade. The leadership organizations of internal medicine and the Accreditation Council for Graduate Medical Education, in their present forms, cannot be expected to carry out alone the changes that must be made. Agreement is widespread that a new national body is needed, empowered to set physician work force policy, using control over public and possibly private funding for graduate medical education as a lever.

A national policy regarding internal medicine's work force carries the potential for harm as well as for good. Internal medicine is the nation's largest actual and potential source of generalists. Inappropriate policies could have negative effects on the physician work force and on the cost and quality of care. In addition, poor graduate medical education policy could damage internal medicine's education, research, and development missions.

National manpower policies must be guided by concerted internal medicine leadership. The Federated Council for Internal Medicine is a promising organization in this regard. More leadership from subspecialty representatives and organizations is needed as well.

America's internal medicine subspecialties have been the source of many of medicine's most extraordinary and valuable scientific, technologic, and patient care developments. Their abilities to do so must not be weakened by careening policy changes. Subspecialties are under great pressures to reduce the number of trainees, to provide hospital care with fewer people, to give up procedures to generalists, to conform to managed care systems, to accept reduced incomes, and probably to spend more time in primary care. In addition, institutional and economic pressures are testing linkages of subspecialty divisions to departments of medicine in hospitals and medical schools [8]. There is a strong need for an integrated internal medicine discipline, particularly at this time of redefinition and change.

Substantial changes in the nation's physicians work force cannot be accomplished overnight. We must approach them with a rational sense of urgency and pay attention to the variety of powerful forces that have caused the present distorted situation, and avoid unstable and potentially harmful policies. For internal medicine, the challenges and responsibilities are enormous but they can be managed.