The position paper by the ACP Task Force on Physician Supply sought to examine the current and future roles of the ideal general internist in light of recent trends showing decreasing interest in careers in general internal medicine and ambiguity about the role of the general internist in a rapidly changing health care environment. The paper discussed characteristics shared by all internists, including subspecialists. It also suggested redressing imbalances between the shortages of primary care physicians and the oversupply of subspecialists. However, the paper did not, and was not intended to, address the roles of subspecialists in the future. Although the Task Force rejected the option that all future general internists become fully trained subspecialists who would then provide some primary care, it did not, as Dr. Santella suggests, reject the option of future subspecialists continuing to provide some primary care, as many do now. Similarly, the task force was optimistic that general internal medicine practices will survive outside the realm of academic medical centers.

We acknowledged in our paper that "there is a continuum of practice styles along a spectrum bounded at the one end by the pure general internist and at the other by the purely consultative or procedure-based subspecialist." We considered the "internal medicine specialist" to be included within the term "generalist." The general internist has the skills to meet the patient's needs for comprehensive first contact and continuing care. Currently, the demand for general internists far exceeds the supply.

The Task Force agrees with Drs. Steinmann and Kahn that the breadth and depth of knowledge obtained through education and training in internal medicine is one of the most important common attributes shared by all internists. Further, we agree that this knowledge base is essential for diagnosis and treatment decision making and that it is one of the most distinguishing features that best enables general internists to perform the traditional role of managing patients with complex illnesses that involve multiple organ systems, as well as the increasingly important roles of resource and clinical information managers.

As Dr. Sugar notes, it may be nearly impossible for the general internist to be equally expert both in hospital and office settings; however, we contend that the general internist can, and should, be characterized as expert in these settings. Managed care is influencing the ways that physicians practice, and some managed care organizations may seek general internists solely for inpatient care. Nevertheless, there will be a continuing role for general internists in office practice, even in a managed care environment, because managed care organizations must also be responsive to patient needs and demands.

Traditional internal medicine training programs must be retooled, curriculum changes are needed, increased emphasis should be given to obtaining procedural skills, and training should be more flexible. The Task Force recognized that general internists of the future may need flexible training programs that will enable them to tailor their training to obtain specific skills that are especially needed in particular community practice environments. The general internist of the future should have a generalist outlook but may also need special skills that respond to particular demands in the local practice environment. Areas of special expertise might be in the traditional, organ system-based subspecialties or could be in areas such as geriatrics, adolescent medicine, substance abuse, or other areas not directly related to organ-based subspecialties. Thus, in a large group or multispecialty practice, one general internist might serve as the local expert on medical problems during pregnancy, another might have a special interest in sports medicine, while a third might have special expertise on geriatric patients.