Health system reform and the generalist physician.

The quality of primary care services is central to reforming the health care system of the United States. The well-trained generalist is essential in a delivery system that emphasizes high-quality, cost-effective care. Several analyses estimate that within a few years the United States will have 100,000-150,000 too many specialists, and some estimates show a shortage of perhaps 35,000 generalists. Residents and residency programs in nongeneralist areas continue to increase, and two-thirds of graduates enter careers as specialists. Academic medical centers must assume major responsibility for changing their programs to produce the types of practitioners that U.S. society needs. Among the changes recommended or directed by advisory bodies and professional organizations are establishing a workforce commission to set long-term goals, limiting the number of first-year residency positions and allocating them to generalist and nongeneralist specialties, establishing a national payment system to support residency training, setting up transition payments to teaching hospitals that reduce their number of residency positions, and initiatives to graduate more minority and generalist physicians, improve geographic distribution, and expand the capacity for primary-care teaching.