Challenges to generalism: views from the delivery system.

The declining interest in primary care among U.S. medical students is an ominous trend for the national health system. The medical school environment, the powerful financial incentives promoting specialism, and the practice environment itself have contributed to the decline of generalism. During a day-long meeting sponsored by the Robert Wood Johnson Foundation, representatives of group practices, HMOs, community health centers, and military medicine noted the universal shortage of primary care physicians, the fact that medical education does not prepare physicians for the realities of practice, the concern that "burnout" is a significant problem for retention and physician satisfaction, and the problem that the optimal design of primary care practice is not yet known. To reverse these trends, concerted action must take place within academic medicine, by public policy makers, and by the delivery system itself.