Blackwell Publishing, Ltd.
Larson et al., The Future of General Internal Medicine
The Future of General Internal Medicine
Report and Recommendations from the Society of General Internal Medicine
(SGIM) Task Force on the Domain of General Internal Medicine
Eric B. Larson, MD, MPH, Stephan D. Fihn, MD, MPH, Lynne M. Kirk, MD, Wendy Levinson, MD,
Ronald V. Loge, MD, Eileen Reynolds, MD, Lewis Sandy, MD, MBA, Steven Schroeder, MD,
Neil Wenger, MD, MPH, Mark Williams, MD
The Society of General Internal Medicine asked a task force
to redefine the domain of general internal medicine. The task
force believes that the chaos and dysfunction that character-
ize today’s medical care, and the challenges facing general
internal medicine, should spur innovation. These are our
recommendations: while remaining true to its core values
and competencies, general internal medicine should stay both
broad and deep—ranging from uncomplicated primary care to
continuous care of patients with multiple, complex, chronic
diseases. Postgraduate and continuing education should
develop mastery. Wherever they practice, general internists
should be able to lead teams and be responsible for the care
their teams give, embrace changes in information systems,
and aim to provide most of the care their patients require. Cur-
rent financing of physician services, especially fee-for-service,
must be changed to recognize the value of services performed
outside the traditional face-to-face visit and give practitioners
incentives to improve quality and efficiency, and provide com-
prehensive, ongoing care. General internal medicine residency
training should be reformed to provide both broad and deep
medical knowledge, as well as mastery of informatics, man-
agement, and team leadership. General internal medicine
residents should have options to tailor their final 1 to 2 years
to fit their practice goals, often earning a certificate of added
qualification (CAQ) in special generalist fields. Research will
expand to include practice and operations management, devel-
oping more effective shared decision making and transparent
medical records, and promoting the close personal connection
that both doctors and patients want. We believe these changes
constitute a paradigm shift that can benefit patients and the
public and reenergize general internal medicine.
payment; hospitalist; geriatrics.
J GEN INTERN MED 2004; 19:69–77.
primary care; medical education; physician
research in primary care and general internal medicine. The
primary care movement of the 1970s reestablished general
internal medicine, which grew until the early 1990s;
now many question our field’s future.
Practitioners remain committed to providing high-
quality primary medical and hospital care and ongoing
personal relationships with patients across a broad age
group, especially the growing number of seniors, chronically
ill adults, and people with multiple diseases. However, many
practitioners struggle with low reimbursement, increasing
administrative burdens, and demands for brief (5-minute)
visits that frustrate doctors and patients.
cation rates to U.S. medical schools show medicine is less
Anecdotes suggest that debt-laden students
entering medical school interested in generalist disciplines,
including general internal medicine and especially family
medicine, are discouraged by the fields’ uncertain financial
—turning instead to ancillary specialties such as
anesthesiology, pathology, radiology, and higher paying
subspecialties like orthopedics, ophthalmology, cardiology,
Like practicing general internists in the community
reporting increasing role strain,
internists now face rising demands for productivity, brief
visits, and administrative burdens.
internists have increasingly been pressed into clinical
service as academic clinical enterprises have expanded.
For patients, the health care environment is rapidly
changing, and access to primary care is declining especially
he Society of General Internal Medicine (SGIM) is
dedicated to improving patient care, education, and
many academic general
Received from the Group Health Center for Health Studies (EBL),
Seattle, Wash; University of Washington Harborview Medical
Center (SDF), Seattle, Wash; University of Texas Southwestern
(LMK), Dallas, Tex; University of Toronto (WL), Toronto, Ontario,
Canada; The Southwestern Montana Clinic (RVL), Dillon, Mont;
Beth Israel Deaconess Medical Center (ER), Boston, Mass;
United Health Care (LS), Minneapolis, Minn; University of
California (SS), San Francisco, Calif; UCLA Medical Center (NW),
Los Angeles, Calif; and Emory University (MW), Atlanta, Ga.
The longer version of this report is available at http://
Members of SGIM Task Force on the Domain of General
Internal Medicine: Eric B. Larson, MD, MPH—Chair; Ronald V.
Loge, MD; Eileen Reynolds, MD; Wendy Levinson, MD; Lynne
M. Kirk, MD; Mark Williams, MD; Neil Wenger, MD, MPH; Steven
Schroeder, MD; Stephan D. Fihn, MD, MPH—Special Con-
sultant; Lewis Sandy, MD, MBA—Special Consultant; Martin
Shapiro, MD, PhD—SGIM President (2002–03); Judy Ann Bigby,
MD-SGIM President (2003–04).
Address correspondence and requests for reprints to Dr. Larson:
Director of Group Health Cooperative’s Center for Health
Studies, 1730 Minor Ave, Suite 1600, Seattle WA 98101–1448
Larson et al., The Future of General Internal Medicine
for the poor and disadvantaged minorities.
ence keeps making major strides in the effectiveness of
preventive, acute, and chronic care. However, the delivery
system is plagued by marked inefficiencies, a quality chasm
between the best possible care and routine everyday care,
previously undisclosed problems related to medical errors
and unsafe systems,
and more than 40 million uninsured
Americans lacking access to general medical care. Threats
of terrorism and global infectious diseases have exposed
Americans to the health care system’s insufficient prep-
aration for dramatic catastrophic events.
enough wealth seek “boutique” practitioners offering the care
that most insured people once expected as routine. Mean-
while, fewer generalists and specialists accept new Medicare
patients because of declining reimbursement rates.
THE CHAOS THAT CHARACTERIZES U.S. MEDICINE
FOR MANY PATIENTS AND DOCTORS TODAY
SHOULD SPUR INNOVATION
Rather than fear change and be paralyzed into living
with the chaos we know, we should see chaos as an oppor-
tunity to promote new solutions. We will serve patients
better by actively defining and pursuing a paradigm shift
in our field than by simply waiting to see what happens. It
is in this context that the SGIM established a task force
to examine the domain of general internal medicine, now
and in an uncertain future.
The task force started by reflecting on Francis
Peabody’s famous centering message—“The secret of the
care of the patient is in caring for the patient,”
first phrase of the SGIM’s mission statement, “to promote
improved patient care.” We then defined a paradigm shift,
which should drive where general internal medicine
develops, guided by what is best for patients and the public
at large. This shift has implications for clinical practice,
teaching, and research that lead to our recommendations.
As medicine advances and becomes more chaotic, gen-
eral internal medicine must adapt, while remaining true
to its strengths—its core values and competencies. These
time-honored core values, which patients appreciate,
have distinguished and sustained general internal medi-
cine (see Table 1).
Our field’s hallmark is expertise in caring for adult
patients, especially those with complex and chronic ill-
nesses. Most general internists provide high-value, com-
prehensive, and longitudinal patient care for both the
healthy and infirm and coordinate complex treatment
within a health care system. That longitudinal care can last
decades, through health and illness, as medical issues
come, go, and grow in number and complexity. It can be
delivered primarily to outpatients, with inpatient care
provided by hospitalists, who as general internists provide
the high-value, complex care our field values; or the same
general internist can act as both an outpatient and
hospitalist physician. Now, especially in mature practices,
older patients receive much of that care.
Some may dismiss lifelong care to individuals as
anachronistic; but patients seek and value such care in
their doctor–patient relationship.
on effective communication, with patients and other health
professionals alike. General internists value a close, at times
intimate, personal connection
as in the American College of Physicians (ACP)’s slogan,
“Doctors for Adults.”
Although not unique to general internal medicine,
strong emphases on quality outcomes and both primary
and secondary preventive services mark the field. General
internists have cultivated a commitment to evidence-based
practice—with scientific and intellectual rigor, adhering to
evidence-based medicine, and expecting to use and share
this knowledge. Like all professionals, general internists
place a high value on education, including lifelong learning.
Many also promote education for their colleagues, other
health professionals, and trainees. General internists also
place high value on educating their patients, as well as
the lay public in general. We are often the information
managers for our colleagues and patients.
Adaptability has been a hallmark of the specialty of
general internal medicine. This is demonstrated by a will-
ingness to take on the newer realms of clinical medicine
(e.g., refugee care and HIV care), therapeutics, communi-
cations, and diagnostic and information technologies.
Leadership is emerging as a core value in general
internal medicine. Internists appreciate that understanding
context is key to good outcomes—especially for patients, but
also for the institutions and societies where internists work.
Professionalism, a widely held value in medicine, is
particularly respected in general internal medicine and
draws many to the field.
Empathy and compassion, which
ground patient-centered medical care, have sustained
many internists during these troubled times.
Patient care depends
and are “adult-tricians”
ADAPTING TO A CHANGING ENVIRONMENT
The chaos of American medicine challenges many of
the traditional assumptions that general internal medicine
has cherished. Some are probably not worth defending,
while others are intrinsic to our specialty and will thrive
through the coming paradigm shift.
Ideally, the practice of general internal medicine
empowers patients to achieve better health outcomes,
while contributing to the public’s well-being. Our advocacy
for our field must always be grounded in our ultimate goals
of improving the medical care we provide and the health
of patients and the public—not any short-term gain for
individual doctors or medical institutions. It is challenging
to balance professional well-being with the interests of
patients and the public; but we dare not abandon these
aspirations. Generalists are needed to understand the
complex context in which we care for individual patients
and confront both our general and local health care
Volume 19, January 2004
environments. As Schroeder has written, if generalist care
is abandoned, it will need to be reinvented—again!
field should not stand still but needs to embrace new
models that coordinate and synthesize care.
Breadth and Depth
Breadth and depth are typically required of many
general internists. Our distinguishing identity is care of
older adults and patients with multiple, complex, chronic
As the principal practitioner for adults, general
internists must acquire skills “owned” by other specialties—
gynecology, dermatology, orthopedics, otolaryngology,
psychiatry, and internal medicine subspecialties.
Breadth and depth are especially valuable for an aging
public seeking maintenance of functional well-being from
practitioners who understand both simple and complex
management of common chronic diseases. General internists
have training in pathophysiology and therapeutics and
fascination with diseases of adults and the changes that
occur in the adult life cycle. Yet open questions remain: does
the marketplace value that understanding
objective evidence that it translates into better chronic
disease management and outcomes, including more sat-
and can general internal medicine have
multiple overlapping foci encompassing chronic disease
care, primary care, hospital care, and a commitment to
While breadth and depth constitute our field’s distin-
guishing features, they are perhaps its greatest challenge
for individual practitioners. Both breadth and depth are
relative and vary by where general internists practice and
patients receive care. General internists feel wearied by
rising expectations to work harder and do more care, adding
new skills while maintaining existing ones. Instead, today’s
systems of care need redesigning.
and is there
Several traditional assumptions that general internal
medicine has cherished are either invalid or irrelevant to
a new paradigm: first, we should acknowledge that we do
not enjoy absolute professional autonomy; in fact, we live in
an increasingly competitive, mercantile environment.
The practice of general internal medicine is not always
primary care. Some general internists do primary care
some of the time. Most family practice physicians do pri-
mary care most of the time. General internists do—and
should do—both “uncomplicated” and complex primary care.
Patients see both as essential, with uncomplicated care
often the first step in developing an ongoing doctor–patient
We should abandon our preoccupation of competing
with family medicine. There clearly are differences in
cherished values of general internal medicine and family
practice; but we must focus on what our patients value,
not on “tribal” professional distinctions.
Today the notion of a well-rounded generalist phys-
ician who can care independently for all types of patients,
referring only a small fraction of cases to specialists, seems
obsolete. Generalist physicians, working independently,
cannot deliver flawless care to all patients across a broad
spectrum of disease, when provided very limited time and
support. Instead, we must devise creative ways to manage
patients jointly with subspecialists.
ing in concert with specialists appear to provide the best
quality of care.
Patients are less interested in who
provides care than in its technical and humanistic quality.
Ultimately, in collaboration with specialists, and ever mind-
ful of public preferences, general internists must choose
which areas they will commit to master; where they will
maintain breadth, not depth; and where breadth and depth
vary by a practice’s context. Individual internists will aban-
don certain areas.
General internists occupy a unique niche in inter-
preting information and promoting self-management, with
an intellectual rigor that many patients value. Advances
in information systems, especially asynchronous, secure,
clinical e-mail and other real-time systems for efficient
information and data exchange, make collaboration and
communication easier than ever.
Health care demand and costs are increasing. As “baby
boomers” enter old age, they will have a huge impact on
health care. Communication technology will increasingly
affect practice and education and create more empowered
patients. Already competition and consumerism have led
to so-called tiered medical care, including “boutique
The growing diversity of cultural and ethnic groups in
our country challenges doctors’ communication skills and
cultural competence, especially for clinicians offering
history taking, doctor–patient relationships, and cognitive
skills as key services.
Professional satisfaction will be increasingly rooted in
Market and social forces challenge our
aspirations to apply mastery to patient care—especially
since our areas of mastery are typically cognitive, not pro-
cedural. Even the best generalist cannot have breadth
and depth in all areas of medicine. Rather, mastery in one
area should be superimposed on breadth and context in
others—to benefit our patients.
Training in practice management and team leadership
are critical yet lacking, so these skills develop haphazardly.
Internal medicine residents experience training and deliv-
ery models that differ widely from the actual practice of
most general internists.
Expectations about what general internal medicine
should do vary from one extreme of adding an endless array
Larson et al., The Future of General Internal Medicine
of tasks to restricting the field’s domain. New procedures
and skills are typically incorporated more quickly in
specialty practice, and reflect financial incentives of a
marketplace that favors new procedures.
Medicine’s workforce is changing dramatically.
current practice environment of general internal medicine
does not match the lifestyle expectations (time with family,
finances, personal autonomy) of students and physicians-
A VIEW TO THE FUTURE: OF WHAT KIND OF CARE IS
INTERNAL MEDICINE UNIQUELY CAPABLE?
Information, including real-time streaming data, is
increasingly moving from patient to doctor in some com-
mon databases. Such systems enhance two-way communi-
cation and connectivity but likely decrease physical visits.
As such systems move into community-oriented, primary
care settings, general internists (and family physicians)
may be the practitioners most attuned to what patients
want: information and care management, as participants
in the patient’s and family’s health care team.
Ideally, all Americans would have access not only to
care but also to better information about what services
accomplish and cost. By supporting excellence in medical
practice, an ideal system would lead to good outcomes
through shared information and well-designed structures.
Physicians would be paid for everything they do, including
nonoffice services (for example, phone and e-mail consul-
Payment would also be based on complexity and
conceivably also on meaningful measures of quality of care.
Point-of-service clinical information systems and decision
aids based on published literature would be available to
patients and families. A scenario with a view to the future
can be viewed at http://www.sgim.org/futureofGIM.pdf.
At its core, the domain of general internal medicine
will remain primary and principal care of adults—either
directly or as a member of a team. General internists will
keep seeking and filling voids as they become evident, to
meet patients’ rising expectations and demand for tech-
nical quality of care. Internal medicine will be dominated
by common chronic diseases
diabetes, arthritis, pulmonary diseases, neurodegenerative
disorders, and general therapeutics, especially drug
therapy. Competency in geriatrics will become increasingly
Chronic and complex disease management and
primary medical care—especially for preventive, patient-
activating, behavior change, and adherence- and health-
promoting services—will be increasingly evidence based.
General internal medicine will move to a system of
management designed to monitor and promote successful
outcomes. Practitioners must be both comprehensive and
efficient, monitoring outcomes of patients in their practice
regularly and routinely.
Doctors will work in systems and thus must have
mastery in systems thinking and development. Clinical skills
including heart disease,
will be valued and closely linked to communication skills.
The internist’s unique role will involve interpreting and
applying the knowledge stream and managing information
and knowledge as part of an ongoing personal and caring
relationship with patients, as well as educating colleagues
and team members.
Team members will change over time, but the internist,
patient, and family will remain constant. Team members
(e.g., cardiologists, other generalist physicians, nurses, case
managers, physician extenders, and others) will review data
online, usually asynchronously. General internal medicine
specialists will be able to provide the majority of care that
a particular patient with a chronic disease requires. To
accomplish this, they must be trained to achieve and main-
tain expertise in problems commonly found in adult medi-
cine (including those in the domain of other subspecialties)
and able to coordinate care across a health care system.
At the same time, general internists will communicate
closely with specialists who comanage patients with
complex diseases. Instead of providing parallel, often
uncoordinated services, all those involved in caring for a
patient will seamlessly coordinate for optimal quality and
As experts in chronic illness manage-
ment, general internists are well-suited to communicate
effectively with specialists and to integrate their recom-
mendations into an individual plan of care.
As demands rise for quality performance measures,
general internists should become the quality-accountable
physicians. This role will be challenging, given recent
evidence that spending more on care does not boost
access or quality,
and subsequent pressures to reduce
IMPLICATIONS FOR PRACTICE, TRAINING,
Supporting optimal patient care guides our vision for
the future of general internal medicine. That vision
includes team-based medicine practices designed to serve
patients better, support our field’s core values, and provide
more cost-effective service—over the long term and not just
driven by short-term profitability concerns. Practice organ-
ization should promote professional satisfaction, so doctors
are happier and student interest remains high.
In the future, we believe most general internists
(including those working in training programs) will belong
to teams; many will lead teams
autonomously. The team, comprising nurses, pharmacists,
social workers, other professionals, and other physician
specialists, will be organized based on characteristics of
people or populations served. It will be designed to pro-
vide primary and principal care, including care of people
with common chronic diseases. Use of the chronic care
model will become increasingly prevalent as a design
System supports are required for the team
rather than practicing
Volume 19, January 2004
to function well—both information infrastructure and
A more open, proactive system will emphasize patient
involvement in self-care and self-efficacy. Patients will be
more involved and more responsible for their own health
care—which will require additional flexibility.
cases, the team may be broadened to include nontradi-
tional health care providers, who can provide evidence-
based practices tailored to meet outcomes that patients
Current traditional fee-for-service financing does not
accommodate this model and will be a barrier to achieving
the best possible patient care.
develop and adopt new reimbursement systems designed
to promote this new model. We hope this report is the
first step in the path to a new model. Patients need a system
that will give physicians incentives, rather than penalizing
them, for providing cognitive services: a time-based metric
(similar to the legal profession), a salary system, patient
management fees, or capitation.
payment will encourage health professionals to work
closely together, as opposed to the present fee-for-service
system, which discourages collaboration. Barriers that
keep physicians from spending adequate time with patients
need to be removed, including current administrative bur-
dens and unreasonably rigid “brief-visit-only” scheduling.
Electronic records and secure clinical e-mail may help
reduce administrative burden and should further promote
Physicians will need to participate in, and welcome
openly, measurement designed to promote quality improve-
ment and more open information exchange. Patients
will likely feel much more confident as they experience
increased information sharing and better guidance from
physicians and the health care team.
At the national level, priorities need to change to
provide funds designated solely to develop a better infra-
structure for medicine and patient care across a continuum
involving many settings of care, across specialties, and
including procedures obtained in diverse settings. To
date, there are no effective systems designed to promote
physician self-care. Voluntary societies, large physician
groups, or nonprofit service groups would do well to fill
Much work is needed to
These approaches to
We believe that residency training programs should
train pluripotent generalists, capable of practicing in any
setting that they choose, and with a field of generalist
expertise related to a likely practice site. The internist prac-
ticing today and in the future needs a wide array of skills,
many of which are not mastered in current training pro-
grams, which focus on inpatient care in a traditional model.
Small primary care programs do address a wider range of
necessary knowledge and skills. However, few if any large
training programs have heeded the call, now almost 2
decades old, for training that is more relevant, more
ambulatory, more procedure based, and more applicable
to practice in the broad range of settings and populations
in which general internists work.
Inpatient training must be geared to modern prac-
Patients on the general medical service in our hos-
pitals are sicker, take more medications, stay fewer days,
and require more diagnostic and therapeutic decision
making than ever before. Now in addition to clear educa-
tional needs in the ambulatory arena, general internists
may require additional training (or, at least, not less train-
ing) in inpatient medicine, in chronic disease management
across the spectrum of inpatient and outpatient care.
General internists of the future will need to be trained with
attention to the integrative tasks of population-based
monitoring of process quality and outcomes. They will need
to learn about leadership skills and working in a team of
providers. As work hours of residents decline, as medical
knowledge expands, as medical care becomes more com-
plex, and as patients live longer with more chronic medical
illness, our residencies will be hard pressed to train general
internists competent in inpatient and outpatient settings,
in urban and rural environments, who are competent at
managing chronic illnesses and caring for older adults. In
addition to the obvious need for outstanding inpatient and
outpatient clinical medicine, we anticipate that programs
will need to incorporate the following: 1) longitudinal train-
ing directed to a specific population chosen by the resident
(e.g., HIV, geriatrics, women’s health, refugees), including
population-based quality measurement and improvement
techniques, and often across the spectrum of inpatient,
outpatient, subacute, and home care; 2) opportunities for
training in rural or community-based settings; 3) training
in geriatrics to include subacute, chronic, and home care;
4) enhanced training in communication skills (including
electronic) and in building and leading teams; 5) quality
monitoring and quality improvement techniques; 6) enhanced
opportunities for interested residents to gain skills in
performing procedures, including skin biopsy, endometrial
biopsy, casting, fine-needle aspiration, screening and other
endoscopy, and basic cardiology procedures; and 7) educa-
tion about information technology and medical informatics.
This task force believes that the current training sys-
tem is inadequate for the needs of the present and future
general internist. It is beyond the scope of this task force to
make specific recommendations about the curricula, content,
and length of residency training, but we are skeptical that so
much can be taught in our current 3-year programs.
Although internal medicine training has common and
uniform characteristics across various programs, the same
is not true for individual practices. Diversity of practice
sites, patient populations, geography, and health care sys-
tems demands different sets of skills. While all internists
generally will share core values and build on common skill
sets, many recently trained internists are unprepared for
their practice environment. Training programs that adapt
to career goals should produce internists with better
Larson et al., The Future of General Internal Medicine
preparation and skills for their work, raising the likelihood
of meeting the needs of their patients and achieving greater
career satisfaction. The interested reader can view 3 scenarios,
illustrating tailor-made mastery training for rural medicine
and for hospitalist medicine in private practice and aca-
demic settings, at http://www.sgim.org/futureofGIM.pdf.
Internal medicine training programs need radical
restructuring to accomplish what we have set forth. We
recommend that SGIM, with other academic and practice
organizations, convene a group of educators to review
current data on our residency programs’ successes and fail-
ures and to set concrete guidelines for the ideal training
program for the future general internist. The group should
establish a common base of breadth, depth, and mastery
for all general internists at each point in their training—
and determine what general internists will not be expected
to know or master. Instead of simply adding expectations
for everyone in the field, training must be tailored to the
various contexts in which general internists will practice.
Any new model of training should incorporate expected
levels of competence at graduation in each of the areas
necessary for future practice as a general internist. A few
extraordinary residents might take 2 or 3 years to attain
these levels and graduate, while others might take 4 years
or even longer.
We hope that as part of this process,
the convened group will work with the Accreditation Coun-
cil for Graduate Medical Education (ACGME) and American
Board of Internal Medicine (ABIM) to create tracks within
training programs for interested residents to qualify for cer-
tificates of added qualification (CAQs) as evidence of their
training. We hope that reinvigorated training will “raise the
bar” of general internal medicine
professional satisfaction and the attractiveness of the field.
Increased opportunities and flexibility to lengthen
the residency should let generalists in internal medicine
develop along different generalist tracks, including
hospital- and office-based and rural practitioners, geriatrics,
medicine–pediatrics, and other general areas of in-depth
mastery in internal medicine.
Previous proposals to restructure training programs
have been in vain, because large academic medical centers
receive significant financial rewards for inpatient, academic
rotations, and limiting training in ambulatory, community-
based, and rural sites off-campus. We predict some of the
most profound objections to our current proposal will come
from academic hospitals and departments—where turf may
be threatened, especially if community-based teaching
changes the flow of graduate medical education funding.
Medicare training dollars currently flow to hospitals, not
to educational directors or even directly to departments.
Replacing residents on inpatient wards with other pro-
viders or with attending-only services is necessary to liberate
time, but expensive to implement.
concept of the “best” teachers does not usually include
busy nonacademic practitioners as potentially some of the
most desirable mentors and trainees—yet many practicing
physicians are well-suited to teach the skills that the
generalist of the future will need.
The restructuring of training hinges not only on redis-
tributing graduate medical education funding, but also
on fee restructuring to reward physicians for the team
leadership, electronic communication, disease management,
and comprehensive—usually longitudinal—coordinated
care that future generalists will practice. To attract
students to our field, which is vital to our nation’s future
health, will likely require reimbursement reform. Internists
will need a payment system with incentives (as opposed to
today’s fee-for-service disincentives) to provide telephone
and electronic communications, avoid unnecessary pro-
cedures, and provide population-based supervision.
as mastery will enhance
Also, our current
Table 1. Core Values of General Internal Medicine
Core Value Attributes and
Expertise in adult
comprehensive, longitudinal care
Treating complex and chronic illnesses
Coordinating care in health systems
Commitment to quality outcomes
Commitment to preventive care
Expertise in geriatric medicine
Evidence-based practice of disease
prevention and health promotion
Using outstanding communication
Establishing personal, ongoing doctor–
Cultural sensitivity and competency
Breadth and depth of knowledge
Practice of evidence (science)-based
Commitment to lifelong learning
Educating patients, other
professionals, and trainees
New diseases, treatments,
technology, information technology,
cultural diversity, and
Commitment to quality, quality
improvement, public good
Commitment to excellence
Duty and service
Honor and integrity
Respect for others
* Italics indicate core values and competencies that particularly
distinguish general internal medicine.
Volume 19, January 2004
Although many students enter medical school with
career aspirations for primary care, the educational pro-
cess often derails those goals. This has led to a serious,
progressive decline in the number of medical school grad-
uates choosing primary care specialties, including internal
medicine. Without attention to the issues of career choice
for these potential future internists, all of the recommen-
dations in this report are rhetorical.
Over the past quarter century, academic generalists
have made important contributions to clinical research,
addressing a wide array of issues, especially those relevant
to routine practice.
Their work has emphasized seeing
whether medical interventions, such as tests or therapies,
truly benefit typical patients under usual clinical circum-
stances. Public investment in medical research has grown
dramatically during the past decade, as the National Insti-
tute of Health’s current $27.5 billion budget shows.
However, relatively little support is for research on effec-
tiveness and everyday clinical care.
conscientious clinicians try to apply existing technology
efficiently and effectively, the pipeline of new developments
promises hope for vastly improved patient well-being, while
posing a potentially overwhelming challenge.
A serious reconsideration of national research pri-
orities is needed. Concern has been growing that the mass-
ive investment in molecular biology and now gene therapy
research has not yet yielded the substantial benefits
expected in improved health for the American public.
People alive today, particularly those with multiple chronic
illnesses, need studies that help physicians apply existing
technologies to achieve the greatest benefit, while conserv-
ing precious health care resources. Depending on the prob-
lems studied, various methods are appropriate, including
traditional randomized trials, as well as nonrandomized,
quasi-experimental, and descriptive studies. Even a rela-
tively modest increase in support for such studies stands
to furnish enormous public benefit.
However, the research agenda should also follow
general internal medicine’s paradigm shift, testing the new
care models we propose and aiming to improve the practice
of our field and of medicine as a whole. Such studies should
not only evaluate single tests or limited interventions, because
improving chronic illness management usually involves
multifaceted interventions with coordination, comprehen-
siveness, and continuity, an activated patient, and systems
to support patients and providers.
studies have demonstrated impressive gains for patients
with depression, diabetes, asthma, and heart failure by re-
organizing care delivery to ensure better coordination, system
support, and active patient involvement.
showing the advantages of inpatient care provided by
hospitalists compared to traditional or usual hospital care
helped to establish the legitimacy of this new field.
Innovations aimed to improve other aspects of generalist
Thus, as today’s
care, especially involving patients with several other chronic
conditions, should be studied. Such studies will require
creativity in designing new, potentially effective modes of care
for chronic illness and imaginative methods of evaluation.
Researchers should also devote themselves to deter-
mining the depth, breadth, and special mastery areas of
general internal medicine. In what areas must all general
internists be competent? What areas are important in which
practice sites and settings? Are there areas of the field where
in-depth skills and knowledge are no longer relevant to the
patients for whom general internists care? We need
systematic research—engaging academic leaders, practi-
tioners, managers, and policy makers—to calibrate training
programs to reflect the current and likely future practice
It is also essential that research be conducted to assess
the quality of care delivered.
to measure and improve the quality of care using the
information in increasingly available electronic medical
We need to tell the public that these studies can
be conducted without compromising privacy, and that this
research is worthy of funding, with a goal of ever-improved
standards of care.
New methods are needed
Medicine today is in a state of chaos for doctors,
patients, and payers. We recommend that general internal
medicine move from confusion to innovation that is based
on our abiding goal to improve patient care. The domain
of general internists will continue to be primary and prin-
cipal care of adults. Skills that can distinguish general
internists and improve patient well-being include enhanc-
ing patient self-efficacy and managing information trans-
parently, increasingly in direct partnership with patients.
General internists should aspire to be skilled and knowl-
edgeable so they and their teams can provide most of their
patients’ general ongoing medical care, including for
common chronic diseases.
This paradigm shift will require major changes,
especially developing a new system for reimbursement,
overhauling the basic internal medicine residency, and
responding to opportunities that technologic changes
1. General internal medicine should remain true to its core
values and competencies, although market forces may tempt
the field to abandon them while adapting to chaos. Our field’s
strengths are critical to serving our patients’ needs, pro-
moting their well-being, and providing compassionate care.
2. The domain of our field should stay both broad and deep
—ranging from providing or supervising uncomplicated pri-
mary care to delivering continuous care to patients with mul-
tiple, complex, chronic diseases. As the principal provider
for adults, general internists need skills in gynecology,
Larson et al., The Future of General Internal Medicine
dermatology, orthopedics, otolaryngology, psychiatry, and
the internal medicine subspecialties.
3. General internal medicine should embrace changes in
information systems, especially those promising to enhance
partnership with patients, promote self-efficacy, increase
efficiency of care, reduce costs, and improve outcomes.
4. Postgraduate and continuing medical education should
develop mastery—a key element for both patient and pro-
fessional satisfaction. Mastery of our field should include
care delivery, practice management, information systems,
and team leadership skills, as well as the traditional
internal medicine knowledge and skill base.
5. General internists should usually work in teams and pro-
vide services through their own direct contact with patients,
traditional telephone communication (directly or through
staff), and more and more asynchronous communication
using e-mail and other new communication technologies.
Wherever they practice, general internists should lead and
be responsible for the care their team members give, aiming
to be able to provide most of the care their patients require.
6. Current financing of physician services, especially fee-
for-service, must be abandoned, reformed, or restructured
to include reimbursement for services provided outside
of traditional face-to-face visits. Physicians should be
reimbursed for time spent supervising long-term care,
managing teams, and providing services by phone and
e-mail. Alternatively, physicians could be paid a patient
management fee plus reimbursement for specific services
or a salary with incentives for productivity, quality,
and improved outcomes. We endorse the development of
reimbursement based on quality and outcomes.
7. General internal medicine residency training should be
reformed and reconstituted to provide both broad, in-depth
medical knowledge and mastery of additional skills in
informatics, management, and team leadership. General
internal medicine residents should have options to tailor the
final 1 to 2 years of their program to meet the special needs
of their anticipated practice and career goals, often earning
a certificate of added qualification (CAQ) or its equivalent
in special generalist fields. Subspecialists would typically
diverge from internal medicine residency after 2 or 3 years.
For this recommendation to be viable, reimbursement
reform is required.
8. General internal medicine educators and researchers
should emerge as leaders, promoting the changes in the
academic world that this new vision implies. They will need
the support of other academic leaders, especially depart-
ment chairmen. Skill development and research must
expand to let faculty gain the mastery and tools to teach
medical informatics, team leadership, and practice man-
agement. Research will expand to include practice and
operations management, developing more effective shared
decision making and transparent medical records, and
promoting the close personal connection that both doctors
and patients want. Research should continue not only to
document but also to improve the value of generalist,
comprehensive, and continuous care.
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