The Physician Work Force: Does the Marketplace Set National Policy?

Policymakers now believe that a larger role for generalists would help cure this country's health care ills, especially high costs, insufficient preventive care, and limited access to care. This belief stems from several sources [1]: the proportion of generalists in successful managed care plans in this country [2] and in other countries, where the health and satisfaction of the people are higher, and the costs are lower, than in the United States [3]; evidence that the cost of care for similar patients is higher when those patients are treated by specialists rather than generalists [4]; and dispassionate examination of the kinds of services needed by most of the people most of the time.

The generally accepted target is a physician work force that is not much larger than the present one but that comprises at least 50% generalists [5]. The number of physicians in the United States—there is now 1 physician for every 420 persons—will increase if the number of medical schools, the number of medical students, and the rate at which physicians from other countries enter U.S. practices remain the same. To control the total number of physicians, some expert groups have recommended placing a cap on the number of residencies offered—for example, 110% of U.S. medical graduates [5].

If the number of physicians remains about the same and the proportion of generalists increases, then the number of specialists must decrease. The internal medicine community has voiced its commitment to …