The Association of Subspecialty Professors was created in late 1993 with the help and support of subspecialty societies to serve as a platform to advocate and advance the training mission of subspecialty internal medicine [2]. Its council consists of representatives from training program committees of all major internal medicine subspecialty societies. At the FCIM Symposia, the most frequent question for the Association was, "How are subspecialty training programs going to respond to reform in graduate medical education?" This report represents part of that response.

It is hard to imagine what the practice of internal medicine would be like without easy access to subspecialists [3]. Subspecialty internal medicine in the last half of this century has emerged as the instrumental medium for organizing and disseminating an abundance of new medical knowledge. The academic subspecialties during this period have carried what amounts to the genetic code for biomedical research, patient care, and education. Although we all have a stake in what happens to this stream of information, the training habitat of subspecialty internal medicine has been the vector for transferring this medical knowledge to students, residents, and colleagues; a proving ground for new technology; and a test environment for innovation in treatment. The research funding of physician-scientists in subspecialty training programs has also provided major financial support for university departments of medicine. These contributions of subspecialty internal medicine make it difficult to accept the oft-heard notion that subspecialists are a disadvantage to the health care system [4-6]. Physicians involved with training programs in subspecialty internal medicine are genuinely concerned about this misperception.

Generalist, specialist, and academic internists each offer interactive professional choices in the service and care of patients. How many we want of each type of internist in the future is a challenge for our collective judgment [7, 8]. In the process of critically evaluating the internal medicine work force, however, we should not polarize or destroy departments of medicine. If we value and re-main committed to cultivating professional diversity in this new era of reflection, we can accomplish something sensible that enhances patient care. Of course, there are important distinctions between systems that create new knowledge and those that manage it; each component, however, has its special place, costs, and funding requirements. Determining the optimal composition of the physician work force in internal medicine depends, in the long term, on achieving a balance between cost-effective, high-quality patient care and continued research productivity and innovation. Achieving this balance should be the major determinant of subspecialization rates in the future.

Some General Observations about the Pressures To Decrease Subspecialty Internal Medicine

Numerous pressures are working to reduce the access of young residents in internal medicine to subspecialty training. We feel it is useful to comment on a few of the more important ones. In this regard, the opinion has been advanced that subspecialists, compared with generalists, cost health insurers too much money [4, 5]. If this is so, and the analyses have not been comprehensive [6], we must ask ourselves if we really want to limit patient access to subspecialists or if we just want to make subspecialty medicine more affordable? We all still have much to learn about the predictive value of health care outcomes research and about how to respond appropriately to the results of such research. With the limited information available today, almost any response seems premature. Where cost of service has become an issue, however, it might be more appropriate to bundle services or restructure payment schedules than to increase patient barriers to problem-solving encounters with knowledgeable experts.

It has also been suggested that internal medicine has too many subspecialists [9, 10]. Estimates of the percentage of internal medicine residents entering subspecialty training are as high as 75% [9] and as low as 55% [11]. The difference between the two numbers can be attributed to the variable rate of self-designation as a subspecialist by physicians who do not hold board certificates. The percentage of board-certified subspecialists among internists has actually remained stable for the past 16 years [11]. The question arises whether it is still appropriate to tally the self-designated subspecialists with the certified subspecialists rather than with the generalists. A formal training program in subspecialty internal medicine is the only route to board certification, and subspecialty program directors believe that only their trainees who achieve certificates are entitled to the designation of subspecialist. We believe that payer permissiveness about professional self-designation should be curtailed and that future subspecialty designation should be based on board certification.

An additional impetus to reduce the number of subspecialty trainees, and thereby perhaps create more generalists, has been the desire to attract primary care physicians to underserved rural and inner city areas. Practice circumstances and needs of the population in many health profession shortage areas, particularly rural, are different from populations serviced by managed care today. Developing new work force requirements for future health profession shortage areas cannot be determined simply by extrapolating demographic characteristics of work force use in current suburban health maintenance organizations. Needs of health profession shortage areas have not been met even though the size of the present work force of physicians has never been larger [7]; in fact, these underserved areas need generalists and subspecialists. It will take longer, however, to correct these deficiencies through legislative action on the distribution of residency and fellowship training positions in general medicine and the various subspecialties than to provide practice incentives and inducements to physicians who have finished their training.

What Is the Subspecialty Solution?

We have entered an era of tremendous uncertainty. Decisions about the physician work force that should be made by our profession are now being made by others. Several work-force bills in committee on Capitol Hill attempt to reduce the access of trainees to subspecialty medicine by limiting all training positions to 110% of graduating U.S. medical students or by forcing reductions in subspecialty training to 45% of total training positions. None of these changes will produce any noticeable shift in work force numbers until some time after 2025 when, if nothing is done, the U. S. population is expected to increase so that the physician/patient ratio will be not far from where we are now [7, 8]. The effect of work force mandates through legislative action is particularly difficult to predict when the amount of physician employment is being altered rapidly by the market forces of managed competition.

A growing sense from many quarters is that a physician work-force commission may be inevitable, if not this year, then soon. If so, we do not think the medical profession should stand on the sidelines and witness the creation of such a commission as an instrument of other outside special interest groups. Part of the definition of a profession is that it ought to regulate itself [12]. The responsibility for self-regulation should stem from our collective will, not the government's. Although we have some concern about establishing a physician work-force commission before a clear consensus exists about the long-term objectives, it would be appropriate to work toward characterizing the ultimate charge of such a commission. If medicine is to supervise its work force, however, a careful and realistic assessment should be made of training and employment opportunities for subspecialists using accurate, need-based models. What subspecialty mix is appropriate for the future health care environment is an urgent question that requires careful study. The answer is numerical but not easily determined. Considerable thought should be given to a calculation based on need without resorting to pernicious, across-the-board mandates that are capricious and inflexible and that may weaken our essential training institutions.

Recommendations from the Association of Subspecialty Professors

1. A physician work-force commission. Health care legislation pending before Congress proposes the formation of a national work-force board to make all future decisions about graduate medical education [13]. We believe such a commission should only include persons familiar with physician work-force issues. The issues and interactions that orchestrate the physician work force are complex. This commission is likely to be lobbied by many special interest groups using enormous pressure; the members of that commission must have life experiences that easily help distill important information. Our preference, if such a work-force commission comes to pass, is that it comprise knowledgeable physicians and educators in the field of medical training. The mission should be to regulate clinical training positions for all disciplines of medicine, with the ultimate goal of producing a work force that satisfies societal needs for efficient, cost-effective medical care without compromising research productivity, innovation, and professional development. This commission will need tort and anti-trust indemnification and organizational funding. Legal protections for this commission by legislative remedy or safe-harbor exemption from the Department of Justice are necessary to ensure a focused effort on reform free from frivolous litigation. It is most important that the commission establish a satisfactory mechanism for measuring the quality of training programs, so that any reductions in the number of training positions are made solely on the basis of quality considerations, not political or geographic considerations.

2. Need-based manpower modeling. The perceived abundance of selected groups of subspecialists in internal medicine does not mean that we have an oversupply of all subspecialists. Although no agreement exists yet on the optimal number of future trainees in each area, disciplines in which we are training too many subspecialists should be adjusted in favor of training more generalists. The likelihood of finding suitable employment at the conclusion of training will rapidly and appropriately modify future rates of entry into each subspecialty. To determine the optimal number of training positions, each subspecialty would benefit by developing need-based physician manpower models for its discipline. Because managed competition will emerge in various regions of the country to different degrees over many years, we suggest that work-force models consider various practice ratios of full capitation to discounted fee-for-service.

3. Payment for graduate medical education. The full direct and indirect costs of all phases of graduate medical education should be provided from a pool of dollars funded by all payers [14]. These funds should be allocated directly to qualified training programs certified by the Accreditation Council for Graduate Medical Education (ACGME).

4. Low-density physician areas. Replenishing health profession shortage areas should not be linked to reform in graduate medical education by restricting opportunities for subspecialty training. We live in a mobile society. Physician trainees move easily from one environment to another. Available evidence suggests that placing training centers in disadvantaged areas will not ensure that graduates will practice in those areas. Recruiting practitioners to health profession shortage areas can be accomplished best by strong incentives using a combination of education loan forgiveness plus physician income enhancement through location adjustments in reimbursement from all insurers.

5. Inpatient coverage for hospitals that lose physician training programs. Many hospitals have encouraged the creation of subspecialty training programs because they provide an affordable source of in-house medical care, and their presence in the health care environment makes the hospital safe for patients. If downsizing of the physician work force is mandated, it is unlikely that all subspecialty training programs will meet quality educational criteria. The hospital-based manpower lost will need to be replaced by a well-trained nonphysician work force. The direct and indirect costs of graduate medical education in 1992 were approximately 5.2 billion dollars [6]. We recommend that 1.5% should be set aside from all health insurance premiums to support either physician training, where it is ACGME-qualified, or nonphysician extenders as physician replacement personnel. Hospitals that continue to have subspecialty training programs could have the number of physician replacement personnel reduced or eliminated on a prorated basis. Adequate support of physician replacement personnel would encourage hospitals to economize in staffing their service work force.

6. Subspecialty physician-scientists. Fundamental research will continue to be applied to the bedside in the next two decades; it is expected that clinical investigators will continue to come from subspecialty training environments where such research is now carried out [15]. Programs with a strong and successful research mission will need special protections from general remedies applied by physician work force reform if they are to survive as functioning entities. These subspecialty research programs will also require a highly educated work force. Perhaps as many as 10% to 15% of new trainees in subspecialty internal medicine will need to prepare from the earliest stages of their career development to assume a pivotal role in this research enterprise. These trainees will be indispensable in transferring new technology from the research laboratory to the care of patients, and new health care systems that combine university and community hospitals into larger single entities will need to make available their collective patient populations for future clinical research. Placing essential biomedical research back on full hard-money support will also reverse the recent and dangerous trend to fund research programs with siphoned clinical dollars from medical school practice income. As suggested by Senators Harkin and Hatfield [16], funding derived from an additional 1% set aside from all health insurance premiums, apportioned between basic biomedical science and health care outcomes research, would be a constructive enhancement to the health care system.

7. Quality assurance in the training program environment. As discussed above, if congress eventually mandates a recalibration in the numbers of training positions to subspecialty internal medicine, the Association of Subspecialty Professors believes it should be done solely on the basis of the quality and merit of the training program. We believe that quality assessment should be determined by a new organization through which representatives of training program directors and members of the ACGME can jointly develop appropriate guidelines. This partnership would also be vulnerable to antitrust litigation and will need the same legal protections as the work force commission as well as organizational funding. Relevant data to consider in assessing the quality of training programs should include certification pass rates and other measures of outcome for graduates of each program.

8. Interactions between generalists and specialists. In the coming years, it will be extremely important to have continued dialogue among all parties interested in graduate medical education, including practitioners, educators, and physician-scientists (generalists and specialists). As greater emphasis is placed on the training of more generalists, we believe subspecialty educators will have an increased role as teachers of primary care physicians. We are particularly concerned about the recent trends of the U.S. government and insurance companies to make subspecialty care subordinate and less available, rather than more affordable. Such a move, in aggregate, may lower the quality and reliability of patient care in internal medicine. It is important for primary care physicians to build useful partnerships with subspecialty medicine to assure that advances in medical science and practice offered by subspecialty medicine are accessible to all patients served by managed competition.

Conclusions

The Association of Subspecialty Professors believes that all of internal medicine should speak with one mature voice if possible. Decisions made today about the physician work force in subspecialty internal medicine of tomorrow will have repercussions well into the next century. The complex judgments needed should be based on a cohesive profession that is intent and willing to draw responsible conclusions. We must charter a professional system that can be responsive to concerns about work force size and that can monitor and adjust physician distribution and mix in the marketplace of managed competition. The pendulum of this system must swing through an arc that incorporates the attributes of general internal medicine and subspecialty medicine in a manner that services patient care of the highest quality.