Dr. LaCombe's article [1] was most meaningful. I was impressed by its passion, eloquence, and timeliness. As a general internist with 5 years of post-medical school training and 37 years of practice experience, I heartily endorse his position. However, although his approach to medical care may work in Norway, Maine, I fear it will have tough sledding elsewhere.

Having been exposed to Drs. Dock and Snapper and others, I opted for the specialty with great anticipation. In the early years of my practice, I was able to manage almost all of the cases that came my way, with good results and grateful patient response. Unfortunately, with the passage of time and the evolution of "subspecialists," such activity became progressively more difficult.

In New York City, the ever-increasing numbers of department heads and hospital directors limited the privileges extended to the general internist. When I hospitalized a patient, frequently the medical resident's first question was, "Which cardiologist (or pulmonologist or gastroenterologist, and so forth) should I call?"

Eventually, general internists at my hospitals were formally excluded from any role in patient management in the critical care units. On the other side, communications from malpractice insurance carriers constantly emphasized the need for protective consultation.

Although the type of physician Dr. LaCombe and I both admire and seek to emulate may still function in isolated areas, I fear the survival of such physicians is impossible in urban areas.