Subspecialization in internal medicine: a historical review, an analysis, and proposals for change

The recent decline in the production of primary care physicians has been associated with a decrease in the production of general internists and an increase in the number of medical subspecialists. A significant majority of entering internal medicine residents anticipate entering a medical subspecialty. This transition in the development of medical manpower, perceived by some as inappropriate, is analyzed in light of historical trends in the evolution of internal medicine and its subspecialties, and in conjunction with the roles played by the American Board of Internal Medicine and the National Institutes of Health. Evidence is presented that the creation of virtually independent subspecialty departments may have been detrimental to the education of physicians and not productive of the physician scientists they are assumed to create. Current recommendations for reform are reviewed and a new proposal is presented, suggesting increasing the length of the medical residency from 3 to 4 years, incorporating subspecialty training in one or more fields into the third year of the residency, removing "duration of training" as a requirement for board eligibility in a subspecialty, transferring the certification of technical competence in a procedure to local institutions, and creating investigational units in basic disciplines within the department of internal medicine that would serve as a resource for all the subspecialty divisions.