Correspondence
The Affliction of Internal Medicine
N Engl J Med 1993; 329:212July 15, 1993
- Article
To the Editor:
Dr. Kassirer (March 4 issue)1 suggests that the need for primary care internists could be satisfied if the edentulous Federated Council for Internal Medicine (FCIM) would take a strong, enforceable stand. Historically, the FCIM was convened to discuss issues of mutual interest. Although its discussions have traditionally been candid and comprehensive, its record is more akin to whispering with one voice, because the issues have not always been clear and have not always had a direct, simultaneous effect on each of the organizations that make up the council. What seems to have changed dramatically in the past year is that all the organizations now recognize the importance of their collective voice, their collective wisdom, and their collective strength.
Through a variety of forces, fundamental changes in internal medicine are now under way. A national goal of 50 percent of medical school graduates' entering generalist specialties has been endorsed by the FCIM2 and eloquently defended by Petersdorf3. Achieving this goal will mean that the proportion entering both internal-medicine subspecialties and nongeneralist specialties and subspecialties must decrease. The real questions are, How many of these trained specialists and subspecialists does the nation really need? and Who will determine the number of training positions? The issue extends beyond internal medicine itself and therefore requires a far more extensive public or social solution than is possible within internal medicine. Academic medicine as a whole will change in fundamental ways to meet these demands. It must enhance generalism and increase the production of generalists while at the same time preserving the values and qualities that come through the scholarly pursuits of the other specialties and subspecialties, which are essential to our teaching hospitals and medical schools. A physician work-force commission must be established to set limits on the number and mixture of training slots overall, before we can train the number of generalists required. Substantial improvements must be made to ensure more equitable reimbursement as regards time and effort spent in the care of patients by generalists if a permanent shift in personnel is to occur, as was recently pointed out by Levinsky4.
A comprehensive, enforceable approach to the physician work-force problem is required, and as Dr. Kassirer suggested, the recent reports of the Committee on Graduate Medical Education, the Physician Payment Review Commission, and the Macy Foundation Conference outline workable mechanisms5-7. I do not believe that medicine can solve this problem without specific federal legislation. The forces are too strong and too entrenched to be overcome by logic or moral suasion.
7 ReferencesJ. Claude Bennett, M.D.
Chairman, Federated Council for Internal Medicine, Philadelphia, PA 191041
Kassirer JP . Primary care and the affliction of internal medicine. N Engl J Med 1993;328:648-651
Full Text | Web of Science | Medline2
Federated Council for Internal Medicine
CrossRef | Web of Science | Medline3
Petersdorf RG. The doctor is in. Presidential address: 103rd Annual Meeting, Association of American Medical Colleges, New Orleans, La., November 8, 1992. Washington, D.C.: Association of American Medical Colleges, 1992.
4
Levinsky NG . Recruiting for primary care. N Engl J Med 1993;328:656-660
Full Text | Web of Science | Medline5
Third report of the Council on Graduate Medical Education, October 1992. Washington, D.C.: Department of Health and Human Services, 1992.
6
Report of the Physician Payment Review Commission, April 15, 1993. Washington, D.C.: The Commission, 1993.
7
Morris TQ, Sirica CM, eds. Taking charge of graduate medical education -- to meet the nation's needs in the 21st century. New York: Josiah Macy, Jr., Foundation, 1993.
