Journal of General Internal Medicine

, Volume 19, Issue 1, pp 69–77

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
  • Stephan D. Fihn
  • Lynne M. Kirk
  • Wendy Levinson
  • Ronald V. Loge
  • Eileen Reynolds
  • Lewis Sandy
  • Steven Schroeder
  • Neil Wenger
  • Mark Williams
Health Policy


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 characterize 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. Current 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 comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, 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, developing 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.

Key words

primary care medical education physician payment hospitalist geriatrics 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Grumbach K. Primary care in the United States—the best of times, the worst of times. N Engl J Med. 1999;341:2008–10.PubMedCrossRefGoogle Scholar
  2. 2.
    Moore G, Showstack J. Primary care medicine in crisis: toward reconstruction and renewal. Ann Intern Med. 2003;138:244–7.PubMedGoogle Scholar
  3. 3.
    Association of American Medical Colleges. Decline of medical school applicants continues in 2002: projections for 2003 indicate rebound. 2002 Press Release Accessed September 16, 2003.Google Scholar
  4. 4.
    Association of American Medical Colleges. Medical student graduation questionnaire: all schools summary. 2002 data report. Accessed September 16, 2003.Google Scholar
  5. 5.
    Newton DA, Grayson MS. Trends in career choice by US medical school graduates. JAMA. 2003;290:1179–82.PubMedCrossRefGoogle Scholar
  6. 6.
    Landon BE, Reschovsky J, Blumenthal D. Changes in career satisfaction among primary care and specialist physicians, 1997–2001. JAMA. 2003;289:442–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Shanafelt TD, Sloan JA, Habermann TM, Association of Professors of Medicine. The well-being of physicians. Am J Med. 2003;114:513–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressure, and physician job satisfaction: results from the physician worklife study. J Gen Intern Med. 2000;15:441–50.PubMedCrossRefGoogle Scholar
  9. 9.
    Schroeder SA. Primary care at a crossroads. Acad Med. 2002;77:767–73.PubMedCrossRefGoogle Scholar
  10. 10.
    Larson EB. General internal medicine at the crossroads of prosperity and despair: caring for patients with chronic diseases in an aging society. Ann Intern Med. 2001;134:997–1000.PubMedGoogle Scholar
  11. 11.
    Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contributions of major diseases to disparities in mortality. N Engl J Med. 2002;347:1585–92.PubMedCrossRefGoogle Scholar
  12. 12.
    Committee on Quality of Health Care in America Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001; also available at Scholar
  13. 13.
    Kohn LT, Corrigan JM, Donaldson MS, eds. Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999; also available at Scholar
  14. 14.
    Sandy LG. Homeostasis without reserve—the risk of health system collapse. N Engl J Med. 2002;347:1971–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Anderson GF. Physician, public, and policymaker perspectives on chronic conditions. Arch Intern Med. 2003;163:437–42.PubMedCrossRefGoogle Scholar
  16. 16.
    Peabody FW. The care of the patient. JAMA. 1927;88:877–82.Google Scholar
  17. 17.
    Haslam D. “Schools and hospitals” for “education and health”—general practice, not hospital care, accounts for most of health service. BMJ. 2003;326:235–6.CrossRefGoogle Scholar
  18. 18.
    Safran DG. Defining the future of primary care: what can we learn from patients? Ann Intern Med. 2003;138:248–55.PubMedGoogle Scholar
  19. 19.
    Zuger A. In an age of specialists one doctor is primary. New York Times. January 7, 2003.Google Scholar
  20. 20.
    Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15:122–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Eysenbach G. Infodemiology: the epidemiology of (mis) information. Am J Med. 2002;113:163–5.CrossRefGoogle Scholar
  22. 22.
    Reiser SJ, Banner RS. The charter on medical professionalism and the limits of medical power. Ann Intern Med. 2003;138:844–6.PubMedGoogle Scholar
  23. 23.
    Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med. 2002;17:243–52.PubMedCrossRefGoogle Scholar
  24. 24.
    Wagner EH, Austin BT, Davis CL, et al. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20:64–78.CrossRefGoogle Scholar
  25. 25.
    Showstack J, Lurie N, Larson EB, Rothman AA, Hassmiller S. Primary care: the next renaissance. Ann Intern Med. 2003;138:268–72.PubMedGoogle Scholar
  26. 26.
    Casolino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA. 2003;289:434–41.CrossRefGoogle Scholar
  27. 27.
    Lesser CS, Ginsburg PB. Health care cost and access problems intensify: initial findings from HSC’s recent site visits. Issue Brief: Findings from HSC. 2003;63:1–6.Google Scholar
  28. 28.
    Moore G, Showstack J. Primary care medicine in crisis: toward reconstruction and renewal. Ann Intern Med. 2003;138:244–7.PubMedGoogle Scholar
  29. 29.
    Reinertsen JL. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992–5.PubMedGoogle Scholar
  30. 30.
    Bodenheimer T, Wagner E, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model. JAMA. 2002;288:1775–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA. 2002;288:1909–14.PubMedCrossRefGoogle Scholar
  32. 32.
    Ayanian JZ, Guadagnoli E, McNeil BJ, Cleary CD. Treatment and outcomes of acute myocardial infarction among patients of cardiologists and generalist physicians. Arch Intern Med. 1997;157:2570–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Weingarten SR, Lloyd L, Chiou CF, Braunstein GD. Do subspecialists working outside of their specialty provide less efficient and lower-quality care to hospitalized patients than do primary care physicians? Arch Intern Med. 2002;162:527–32.PubMedCrossRefGoogle Scholar
  34. 34.
    Ayanian JZ, Landrum MB, Guadagnoli E, Gaccini P. Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction. N Engl J Med. 2002;347:1678–85.PubMedCrossRefGoogle Scholar
  35. 35.
    Sandy LG, Schroeder SA. Primary care in a new era: disillusion and dissolution? Ann Intern Med. 2003;138:262–7.PubMedGoogle Scholar
  36. 36.
    Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med. 2002;162:1577–84.PubMedCrossRefGoogle Scholar
  37. 37.
    Schroeder SA, Showstack JA, Gerbert B. Residency training in internal medicine: time for a change? Ann Intern Med. 1986;104:554–61.PubMedGoogle Scholar
  38. 38.
    Ginsberg PB. Payment and the future of primary care. Ann Intern Med. 2003;138:233–4.Google Scholar
  39. 39.
    McMurray JE, Linzer M, Konrad TR, et al. The work lives of women physicians: results from the Physician Work Life Study. The SGIM Career Satisfaction Study Group. J Gen Intern Med. 2000;15:372–80.PubMedGoogle Scholar
  40. 40.
    Frank E, McMurray JE, Linzer M, Elon L. Career satisfaction of US women physicians. Arch Intern Med. 1999;159:1417–26.PubMedCrossRefGoogle Scholar
  41. 41.
    Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable life-style on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Hoffman C, Rice D. Chronic Care in America: A 21st Century Challenge. Princeton, NJ: The Robert Wood Johnson Foundation; 1996.Google Scholar
  43. 43.
    Anderson G, Horvath J. Chronic Conditions: Making the Case for Ongoing Care. Baltimore, Md: Johns Hopkins University; 2002.Google Scholar
  44. 44.
    Mijka M. As Americans age, geriatricians go missing. JAMA. 2002;287:1792–3.CrossRefGoogle Scholar
  45. 45.
    Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273–87.PubMedGoogle Scholar
  46. 46.
    Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288–98.PubMedGoogle Scholar
  47. 47.
    Phelps CE. What’s enough, what’s too much? Ann Intern Med. 2003;138:348–9.PubMedGoogle Scholar
  48. 48.
    Wilensky G. The implications of regional variations in Medicare: what does it mean for Medicare? Ann Intern Med. 2003;138:350–1.PubMedGoogle Scholar
  49. 49.
    Halvorsen G. Kaiser Permanente. Ann Intern Med. 2003;138:232.Google Scholar
  50. 50.
    Romano M. Fever and chills: physician pay survey again shows wide disparities. Modern Healthcare. July 21, 2003; 29–31.Google Scholar
  51. 51.
    Thurow LC. Building wealth. Atlantic Monthly. 1999;283:57–69.Google Scholar
  52. 52.
    Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487–94.PubMedCrossRefGoogle Scholar
  53. 53.
    American College of Physicians Task Force on Physician Supply. The role of the general internist defined. Ann Intern Med. 1994;121:616–22.Google Scholar
  54. 54.
    Davidoff F. Advanced internal medicine (AIM). The training program in primary care internal medicine at the University of Connecticut School of Medicine. Conn Med. 1981;45:167–74.PubMedGoogle Scholar
  55. 55.
    Lenfant C. Shattuck lecture—clinical research to clinical practice—lost in translation? N Engl J Med. 2003;349:868–74.PubMedCrossRefGoogle Scholar
  56. 56.
    Sung NS, Crowley WF, Genel M, et al. Central challenges facing the national clinical research enterprise. JAMA. 2003;289:1278–87.PubMedCrossRefGoogle Scholar
  57. 57.
    Rosenberg RN. Translating biomedical research to the bedside: a national crisis and a call to action. JAMA. 2003;289:1305–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Hening S, Quon AS, Meyer R, Korn D. The Changing Landscape for Clinical Research. Washington, DC: Association of American Medical Colleges; 1999.Google Scholar
  59. 59.
    Ochs J. Providers, plans misinformed about vendor software capability. Manag Care. 2002;11:48–9.PubMedGoogle Scholar
  60. 60.
    Rothman AA, Wagner EH. Chronic illness management: what is the role of primary care? Ann Intern Med. 2003;138:256–61.PubMedGoogle Scholar
  61. 61.
    Horowitz CR, Goldberg HI, Wagner EH, et al. A randomized controlled trial of continuous quality improvement and academic detailing to implement clinical guidelines. J Qual Improv. 1996;22:734–50.Google Scholar
  62. 62.
    Goldberg HI, Wagner EH, Fihn SD, et al. A randomized controlled trial of academic detailing and continuous quality improvement techniques: increasing compliance with national guidelines for the primary care of hypertension and depression. Jt Comm J Qual Improv. 1998;24:130–42.PubMedGoogle Scholar
  63. 63.
    Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995;273:1026–31.PubMedCrossRefGoogle Scholar
  64. 64.
    Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996;53:924–32.PubMedGoogle Scholar
  65. 65.
    Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999;56:1109–15.PubMedCrossRefGoogle Scholar
  66. 66.
    Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212–20.PubMedCrossRefGoogle Scholar
  67. 67.
    Hedrick SC, Chaney EF, Felker F, et al. Effectiveness of collaborative care depression treatment in VA primary care. J Gen Intern Med. 2003;18:9–16.PubMedCrossRefGoogle Scholar
  68. 68.
    Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859–65.PubMedGoogle Scholar
  69. 69.
    Melzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866–74.Google Scholar
  70. 70.
    Kitahata MM, Koepsell TD, Deyo RA, et al. Physicians’ experience with the acquired immunodeficiency syndrome as a factor in patients’ survival. N Engl J Med. 1996;334:701–6.PubMedCrossRefGoogle Scholar
  71. 71.
    Indridason OS, Coffman CJ, Oddone EZ. Is specialty care associated with improved survival of patients with congestive heart failure? Am Heart J. 2003;145:300–9.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2004

Authors and Affiliations

  • Eric B. Larson
    • 10
  • Stephan D. Fihn
    • 1
  • Lynne M. Kirk
    • 2
  • Wendy Levinson
    • 3
  • Ronald V. Loge
    • 4
  • Eileen Reynolds
    • 5
  • Lewis Sandy
    • 6
  • Steven Schroeder
    • 7
  • Neil Wenger
    • 8
  • Mark Williams
    • 9
  1. 1.University of Washington Harborview Medical CenterSeattle
  2. 2.University of Texas SouthwesternDallas
  3. 3.University of TorontoTorontoCanada
  4. 4.The Southwestern Montana ClinicDillon
  5. 5.Beth Israel Deaconess Medical CenterBoston
  6. 6.United Health CareMinneapolis
  7. 7.University of CaliforniaSan Francisco
  8. 8.UCLA Medical CenterLos Angeles
  9. 9.Emory UniversityAtlanta
  10. 10.Group Health Cooperative’s Center for Health StudiesSeattle

Personalised recommendations