I am Program Director of an internal medicine residency program consisting of 27 residents in a community hospital-based, university-affiliated setting. During the past few years, the percentage of graduates entering primary care has decreased from 80% or more to 50%, with the remainder entering subspecialty fellowships. Consequently, I instituted a fourth year of training similar to that suggested by Dr. Fogelman [1], consisting of teaching and administrative responsibilities and an extensive training period in one or two subspecialties. We aimed for proficiency in such procedures as gastroscopy. With the number of procedures done for certification equivalent to that of a fellowship program, much time would be spent with a generalist in an ambulatory, private practice setting.

I have offered the position for the past 2 years and have been unable to fill it. The generalists in our area are in such great demand that the starting salary is four times that of the fourth-year position. Because financial rewards appear to drive residents to select future practice opportunities, I would need to double or triple the current resident salary to fill the position. Hospital finances preclude this. If such a public outcry and need for generalists exists, this fourth year will need to be subsidized by a third party.