Training in subspecialty internal medicine on the chessboard of health care reform

Many reform-minded observers of the U.S. health care system have asked recently whether we are training too many subspecialists in internal medicine. Of course, the answer to this question may not be the same for all subspecialties or all manners of professional career, but any proposed answer has extended consequences for the entire health care system and the patients it serves. Some have even begun to advocate a firm ceiling on the numbers of subspecialty training positions in the future. Who, in fact, should be deciding such matters? These decisions are complex and not easily made by government, consumers, or insurance companies on their own, nor should they. These decisions are best made by a profession willing to examine and regulate itself where necessary. Recent legislative initiatives have made it abundantly clear that others are more than willing to act on our behalf, if we cannot. Whatever process is adopted for making such decisions, it needs to be fair, efficient, flexible, and responsive to unexpected demands in the future, including new practice economics, the availability of research funds, and medical innovation.