Alternative pathways for training the general internist and the medical subspecialist

Considerable attention is being directed from within the discipline of internal medicine to a perceived need for changes in the curriculum for postgraduate training of the internist. Much of this attention has been focused on the training required to properly prepare the general internist for the evolving system of health care. A proposal is presented to change the pattern of training of both the general internist and the medical subspecialist. After 2 years of core training, the general internist would enter 2 additional years of training that would include new material and additional experience in areas such as ambulatory and continuity care. After the core experience, the subspecialist would begin training in the subspecialty. The general internist would be certified as such, and the subspecialist would be certified only in the subspecialty. The proposal is based on the assumptions that 1) more general physicians are needed to meet the nation's health care needs; 2) more time will be required to properly train the general internist; 3) all of the additional and expanded training experiences for the generalist are not essential for training the subspecialist; and 4) the generalists of the future will not come from the ranks of subspecialists. The training needs of the general internist and the subspecialist should be viewed as separate, and curriculum changes should be considered without the restrictions of current patterns of training.