Journal of General Internal Medicine

, Volume 9, Supplement 1, pp S7–S13 | Cite as

The generalist health care workforce

Issues and goals
  • Steven A. Wartman
  • Modena Wilson
  • Norman Kahn


The generalist health care workforce in the United States is best characterized as those practitioners who deliver primary care services. These include most family physicians, general internists, general pediatricians, nurse practitioners, osteopathic family physicians, and physician assistants. Based on a variety of factors, including health care needs, managed care/HMO hiring practices, international comparisons, and health care costs, the case for increasing the amount and proportion of generalist providers is compelling. Projections strongly suggest a worsening shortfall of generalists if no change is made. Changing the career choices of medical students to promote generalism, even significantly, will take 20 years or more to have a meaningful impact. Therefore, retraining specialist physicians in oversupply to practice as generalists is an important option to consider. To best meet the nation’s health care needs, three issues need to be addressed in the context of health care reform: the creation of a “system” of generalist care that integrates into a coherent and collaborative framework the scopes of practice of the various generalist disciplines; the pursuit of a workable short-term model to convert specialist physicians into generalist physicians, led jointly by family medicine, general internal medicine, and general pediatrics; and a significant change in the medical education process to produce an ample supply of well-trained generalists.

Key words

generalism health care reform physician supply primary care 


  1. 1.
    Healthy People 2000. National health promotion and disease prevention objectives. Washington, DC: DHHS, 1990.Google Scholar
  2. 2.
    Schappert SM. National ambulatory medical care survey: 1991. Advance data from vital and health statistics; number 230. Hyattsville, MD: National Center for Health Statistics, 1992.Google Scholar
  3. 3.
    Alpert JJ, Charney E. The education of physicians for primary care. Washington, DC: DHEW, 1973.Google Scholar
  4. 4.
    Institute of Medicine. A manpower policy for primary health care: report of a study. Washington, DC: National Academy of Sciences, 1978.Google Scholar
  5. 5.
    Gamliel S, Mullan F, Politzer R, Stambler H. Availability of primary care health personnel. Arch Intern Med. 1992;152:268–73.PubMedCrossRefGoogle Scholar
  6. 6.
    Council on Graduate Medical Education. Third Report of the Council. Washington, DC: DHHS, 1992.Google Scholar
  7. 7.
    Physician Payment Review Commission. Annual Report to Congress, 1993. Washington, DC: Physician Payment Review Commission.Google Scholar
  8. 8.
    Pruessner HT, Hensel WA, Rasco TL. The scientific basis of generalist medicine. Acad Med. 1992;647:232–5.CrossRefGoogle Scholar
  9. 9.
    Barondess JA. The future of generalism. Ann Intern Med. 1993;119:133–60.Google Scholar
  10. 10.
    American Academy of Family Physicians. Physician Career Change Education. Kansas City, MO: AAFP, 1993.Google Scholar
  11. 11.
    American College of Physicians. Report of the ACP Task Force on Physician Supply. 8/27/93 Draft. Philadelphia, ACP, 1993.Google Scholar
  12. 12.
    Greenwald H, Peterson ML, Garrison LP, et al. Interspecialty variation in office-based care. Med Care. 1984;22:14–29.PubMedCrossRefGoogle Scholar
  13. 13.
    Noren J, Frazier T, Altman I, DeLozier MS. Ambulatory medical care: a comparison of internists and family—general practitioners. N Engl J Med. 1980;302:11–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Geographic variation in expenditures for physicians’ services in the United States. N Engl J Med. 1993;328:621–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care. JAMA. 1992;267:1624–30.PubMedCrossRefGoogle Scholar
  16. 16.
    Kravitz RL, Greenfield S, Rogers W, et al. Differences in the mix of patients among medical specialties and systems of care. JAMA. 1992;267:1617–23.PubMedCrossRefGoogle Scholar
  17. 17.
    Ambulatory Pediatric Association. Guidelines for training in general/ambulatory pediatrics. Preamble. McLean, VA: APA, 1984.Google Scholar
  18. 18.
    Ambulatory Pediatric Association. Essential elements of retraining or career development in primary care. McLean, VA: APA, 1993.Google Scholar
  19. 19.
    Starfield B, Hoekelman RA, McCormick M, et al. Who provides health care to children and adolescents in the United States? Pediatrics. 1984;74:991–7.PubMedGoogle Scholar
  20. 20.
    Starfield B, Hoekelman RA, McCormick M, et al. Styles of care provided to children in the United States: a comparison by physician specialty. J Fam Pract. 1985;21:133–8.PubMedGoogle Scholar
  21. 21.
    Meyer CT, Price A. The crisis in osteopathic medicine. Acad Med. 1992;67:810–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Career change education; a strategy for producing generalists. Division of Medicine Overview Statement. Division of Medicine, BHPr, HRSA, DHHS, Washington, DC, May 1993.Google Scholar
  23. 23.
    Cummings M. The pull towards the vacuum: osteopathic medical education in the 1980s. J Am Osteo Assoc. 1990;90:353–62.Google Scholar
  24. 24.
    Schultz PR, McGlone FB. Primary health care provided to the elderly by a nurse practitioner/physician team: analysis of cost effectiveness. J Am Geriatr Soc. 1977;25:443–6.PubMedGoogle Scholar
  25. 25.
    Sharpe TR, Banahan BF. Evaluation of the use of rural health clinics: attitudes and behaviors of primary care physicians in service areas of nurse practitioner clinics. Public Health Rep. 1982;97:566–71.PubMedGoogle Scholar
  26. 26.
    Goksel D, Harrison CJ, Morrison RE, Miller ST. Description of nurse practitioner inpatient services in a public teaching hospital. J Gen Intern Med. 1993;8:29–30.PubMedCrossRefGoogle Scholar
  27. 27.
    Brown SA, Grimes DE. Nurse practitioners and certified nurse-midwives: a meta-analysis of studies on nurses in primary care roles. Washington, DC: American Nurses Publishing, 1993.Google Scholar
  28. 28.
    Sox HC. Quality of patient care by nurse practitioners and physician’s assistants: a ten-year perspective. Ann Intern Med. 1979;91:459–68.PubMedGoogle Scholar
  29. 29.
    Edmunds MW. Evaluation of nurse practitioner effectiveness: an overview of the literature. Eval Health Prof. 1978;1(spring):69–82.PubMedCrossRefGoogle Scholar
  30. 30.
    American Academy of Physician Assistants. Physician Assistants: Partners in Medicine. Alexandria, VA: AAPA, 1991.Google Scholar
  31. 31.
    Rivo ML, Jackson DM, Clare L. Comparing physician workforce reform recommendations. JAMA. 1993;270:1083–4.PubMedCrossRefGoogle Scholar
  32. 32.
    Kindig DA, Cultice JM, Mullan F. The elusive generalist physician. JAMA. 1993;270:1069–73.PubMedCrossRefGoogle Scholar
  33. 33.
    Morgan WA. Using state board of nursing data to estimate the number of nurse practitioners in the United States. Nurse Practitioner. 1993;18:65–74.PubMedCrossRefGoogle Scholar
  34. 34.
    Ad Hoc Advisory Group on Physician Assistants. Definition of the PA Council on Graduate Medical Education. Draft 10/17/93.Google Scholar
  35. 35.
    Feil EC, Welch G, Fisher ES. Why estimates of physician supply and requirements disagree. JAMA. 1993;269:2659–63.PubMedCrossRefGoogle Scholar
  36. 36.
    Association of American Medical Colleges. AAMC Policy on the generalist physician. Acad. Med. 1993;68:1–6.Google Scholar
  37. 37.
    Cohen JJ. The country needs more generalist physicians! American ABIM News Update. 1993:summer/fall.Google Scholar
  38. 38.
    Council on Graduate Medical Education. First report of the Council. Vol. I. Washington, DC: DHHS, 1988.Google Scholar
  39. 39.
    Koop CE. A general and primary solution for American health care problems. Acad Med. 1993;68:46–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Relman AS. Reforming the health care system. N Engl J Med. 1990;323:991–2.PubMedCrossRefGoogle Scholar
  41. 41.
    Supplying physicians for future needs: The report of the Task Force on Physician Supply. Washington, DC: Association of American Medical Colleges, 1990.Google Scholar
  42. 42.
    Altman SH. The mix of physician manpower and its effect on U.S. health care system: the U.S. versus other industrialized nations. The National Primary Care Conference: Proceedings. Volume I: 293–316. Washington, DC: DHHS, 1993.Google Scholar
  43. 43.
    President’s health care reform plan: American Health Security Act of 1993. Washington, DC: Bureau of National Affairs, September 13, 1993.Google Scholar
  44. 44.
    Friedman E. Changing the system. JAMA. 1993;269:2437–42.PubMedCrossRefGoogle Scholar
  45. 45.
    Wennberg JE, Goodman DC, Nease RF, Keller RB. Finding equilibrium in U.S. physician supply. Health Aff. 1993;12:89–103.CrossRefGoogle Scholar
  46. 46.
    Luke R, Terwilliger J, Ibrahim T. Beyond the 50% solution. Ann Intern Med. 1993;95:83–5.Google Scholar
  47. 47.
    Spong FW. Subspecialist internists as PCPs (primary care providers). Presented at the meeting: Career Change Education: A Strategy for Producing Generalists. Sponsored by Division of Medicine, BHPr, HRSA, Rockville, MD, June 1993.Google Scholar
  48. 48.
    Moore GT. Let’s provide primary care to all uninsured Americans—now! JAMA. 1991;265:2108–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Schroeder SA. The troubled profession: is medicine’s glass half full or half empty? Ann Intern Med. 1992;116:583–92.PubMedGoogle Scholar
  50. 50.
    Grumbach K, Lee PR. How many physicians can we afford? JAMA. 1991;265:2369–72.PubMedCrossRefGoogle Scholar
  51. 51.
    Rivo ML, Satcher D. Improving access to health care through physician workforce reform. JAMA. 1993;270:1074–8.PubMedCrossRefGoogle Scholar
  52. 52.
    McGinnis JM, Richmond JB, Brandt EN, Windom RE, Mason JO. Health progress in the United States. JAMA. 1992;268:2545–52.PubMedCrossRefGoogle Scholar
  53. 53.
    Starfield B, Simpson L. Primary care as part of US health services reform. JAMA. 1993;269:3136–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Tarlov AR. How many physicians is enough? JAMA. 1990;263:571–2.PubMedCrossRefGoogle Scholar
  55. 55.
    Council on Graduate Medical Education. Fourth Report. Executive Summary (draft dated 8/30/93). Washington, DC: DHHS, 1993.Google Scholar
  56. 56.
    Kassebaum DG, Szenas PL. Specialty preferences of 1993 medical school graduates. Acad Med. 1993;68:866–9.PubMedCrossRefGoogle Scholar
  57. 57.
    Kahn NB, Jackson SJ, Schmittling G, Ostergaard D, Graham R. Results of the 1993 national resident matching program. Fam Med. 1993;25:511–6.PubMedGoogle Scholar
  58. 58.
    Aiken LH, Lewis CE, Craig J, Mendenhall RC, Blendon RJ, Rogers DE. The contribution of specialists to the delivery of primary care: a new perspective. N Engl J Med. 1979;300:1363–70.PubMedCrossRefGoogle Scholar
  59. 59.
    Franks P, Clancy C, Nutting P. Gatekeeping revisited: protecting patients from overtreatment. N Engl J Med. 1992;327:424–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Lundberg GD, Lamm RD. Solving our primary care crisis by retraining specialists to gain specific primary care competencies. JAMA. 1993;270:380–1.PubMedCrossRefGoogle Scholar
  61. 61.
    Rodney WM. Retraining of physicians for primary care: a case report from family medicine 1987–1993. Presented at the meeting: Career Change Education: A Strategy for Producing Generalists. Sponsored by Division of Medicine, BHPr, HRSA, Rockville, MD, June 1993.Google Scholar
  62. 62.
    Geyman JP. Training primary care physicians for the 21st century: alternative scenarios for competitive vs. generic approaches. JAMA. 1986;255:2631–5.PubMedCrossRefGoogle Scholar
  63. 63.
    Colwill JM. Education for the primary physician: a time for reconsideration? JAMA. 1986;255:2643–4.PubMedCrossRefGoogle Scholar
  64. 64.
    Strelnick AH, Bateman WB, Jones C, et al. Graduate primary care training: a collaborative alternative for family practice, internal medicine, and pediatrics. Ann Intern Med. 1988;109:324–34.PubMedGoogle Scholar
  65. 65.
    Nursing’s agenda for health care reform. American Nurses Foundation. Kansas City, MO: American Nurses Publishing, 1992.Google Scholar
  66. 66.
    O’Neil EH. Health professions education for the future: schools in service to the nation. San Francisco: Pew Health Professions Commission, 1993.Google Scholar
  67. 67.
    Whitcomb ME, Desgroseilliers JP. Primary care medicine in Canada. N Engl J Med. 1992;326:1469–72.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 1994

Authors and Affiliations

  • Steven A. Wartman
    • 1
  • Modena Wilson
    • 2
  • Norman Kahn
    • 3
  1. 1.the Department of Internal MedicineMount Sinai Medical Center of Greater Miami and the University of MiamiMiami
  2. 2.the Department of PediatricsThe Johns Hopkins School of MedicineBaltimore
  3. 3.the Division of EducationAmerican Academy of Family PhysiciansKansas City

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