Preparing generalist physicians - The organizational and policy context

A combination of financial, regulatory, and professional factors have led to a gradual but pronounced decline in generalist training and practice in the United States. This trend is likely to undergo dramatic reversal, however, as reflected by the diverse range of health care reform proposals incorporating incentives to promote generalist education and primary care practice. Considerable consensus has been reached by a number of professional organizations and public policy groups regarding the broad details of reform of generalist physician training, but key areas of controversy remain with important implications for academic medical centers. In addition, the generalist professional organizations, particularly those of family practice, general internal medicine, and general pediatrics, are being challenged to reconcile historic differences in the definitions and training of generalist competence. In this, the call for "retraining subspecialists" will both offer an opportunity and entail a risk. Finally, academic medical centers will need new organizational structures that can combine the distinctive intellectual traditions and the expertise of the generalist medical disciplines to develop new approaches to the education and practice of primary care.