The article on the attractiveness of internal medicine [1] evoked many memories, not all of them fond, of my internal medicine training. Regrettably, after 20 years medical students still feel "humiliated" by "malignant attendings" and "journal jockeys." They also believe that internal medicine prolongs suffering and dying. I distinctly recall one of my fellow interns wondering why he found internal medicine so interesting and fascinating in the journals but so depressing in real hospital work.

McMurray and colleagues do a service by forcing us to re-examine long-standing practices. However, I do not agree that their findings represent a cohort effect or a decline in teaching effectiveness. In the 1970s and 1980s it was clear to me and the housestaff that those of us in patient care were held in less esteem than those teaching and doing research. Academic advancement has traditionally been based on research, to a lesser extent on teaching, and to a minimal extent on patient care It is no accident that medical school faculties and attitudes have perpetuated themselves.

For several years I have offered an outpatient internal medicine experience for students and residents in San Leandro, California. Preceptees work outside the artificial institutional setting with patients who have many medical and social problems. It is not unusual for them to be involved in the care of three generations of one family and to celebrate with their patients a 50th anniversary, a 90th birthday, or a birth of a child.

To continue to attract the brightest, most able, and most humane of our young physicians, internal medicine must make necessary attitudinal and organizational changes.