As general internists practicing in a rural area, we feel that the position paper [1] on the development and need for well-trained general internists does not address the fundamental issues. First, the definition of a general internist is unclear. Is it what an internist is supposed to be, what an internist is perceived to be, or what an internist does in daily practice? The latter varies by region and community. An internist in a suburb in the Northeast is partly defined by what subspecialists do. Board certification in cardiology may be required to read hospital electrocardiograms or to do stress tests. This requirement may not apply in a rural setting. Additionally, training programs promote different concepts of internal medicine by offering "primary care," "traditional," and "categorical" tracks. Our first priority should be to identify and implement the tenets of primary care that define internal medicine.

In a rural setting, general internists are held in high esteem because they practice all aspects of internal medicine, from family counseling and patient education to ventilator management. When care is not fragmented or divided among many physicians, health care delivery becomes more efficient. Patients become secure, and trust develops between patient and physician. A positive environment is created, providing a good model for residents and students.

The position paper [1] refers to "overwhelming service obligations" blunting the "satisfaction and excitement of internal medicine". The implication is that service requirements are noneducational. The concept of "service" is fundamental to internal medicine and must be taught by example and made a central part of the formal curriculum. We exist because patients exist, and every patient encounter sharpens our clinical skills. Without the underlying concept of service, academics and education become hollow and self-serving.

Therefore, we propose these solutions:

1. Clarify and standardize the definition of a general internist, especially with respect to subspecialty areas where adequate competency and expertise are shown.

2. Educate the educators to train general internists for the real world.

The problems of esteem and reimbursement and the decline in the residency match and in the public's perception of internal medicine will not be solved until we get back to basics.