We appreciate the interest in our study and are pleased that it has generated discussion about internists' procedural skills. Drs. Farnan and Arora are concerned that the change in the ABIM requirements doesn't consider the need for residents to perform procedures competently and safely during training. Resident credentialing is a process for certifying residents who can do procedures independently while in training. Gabryel and Brierley (1) reviewed this topic and described its use in hospitals in New York State. The competency of residents in procedural skills remains an important issue even though Medicare requirements for direct supervision have limited the procedures that residents do independently. More information is needed about the procedures done during training by residents and their teachers.

Drs. Luh and Karnath propose that one cause of the decline in the number of procedures that internists do is that board certification in emergency medicine is now restricted to those trained in emergency medicine residencies. They point out that internal medicine residents have lost a major source of procedure experience to the emergency medicine residents. Our study provides no data on these questions, but we think that training opportunities in procedures for internal medicine residents have likely been lost because of the growth of many specialty-oriented residencies and fellowships.

Dr. LaCombe suggests that the declining popularity of general internal medicine is linked to the decrease in procedures done by general internists and the resulting loss of practice revenue. He contrasts the procedures done in the United States with those in Canada and suggests that U.S. internists do fewer procedures because they lack the opportunity to learn them as residents. Bodenheimer and colleagues (2) discuss this idea in their recent paper on the income gap between specialists and primary care physicians. They point out that the relative value scale rewards specialists disproportionately because of the number of procedures they do. Would general internists do more procedures if they learned to do more of them in residency and if higher reimbursements made it worthwhile? This would be a great area for study. Incidentally, according to a recent survey, Canadian internal medicine residency graduates also have difficulty finding adequate opportunities for learning some procedures in training (3).

Mr. Metkus asks whether a nonresponse bias could account for the differences between the 1986 and the 2004 surveys. Both city size and hospital size affected the number of procedures done in both surveys. The methods used in the 2 surveys were nearly identical, however, and a breakdown of the respondents and results by city size and hospital size in the 1986 survey (see Figure 2 of the 1986 survey [4]) and the 2004 survey (see Table 2 of the 2004 survey) shows that not only is the percentage in each subgroup quite similar, so is the decline in the number of procedures done within each subgroup. To estimate the maximum potential effect of such a bias, we reanalyzed the 2004 data with the rural sample completely excluded: The mean number of procedures done in practice decreased only from 8.5 to 8.0, which is still quite a contrast to the 16.0 procedures done in the 1986 survey.