The push toward generalism: a view from surgery.

Recent proposals for health care reform center on restructuring the physician workforce in favor of more "generalists." These plans are based on several assumptions that have been neither clearly argued nor proved. Despite this, each of the plans enunciated thus far dictate that primary care physicians comprise at least 50% of the nation's physician workforce. Such a mandate has enormous repercussions for medical education. This paper takes issue with several assumptions underlying these reform initiatives, particularly the assumption that primary care does not include surgery. Because of the primary nature of surgical care, the prevalence of surgical diseases, the projected shortage of physicians entering general surgery, and the fact that surgical care is most effectively and efficiently provided by general surgeons, general surgery should not be handicapped as it would under present reform proposals. We recommend that the assumptions underlying plans to restructure the nation's physician workforce be tested, and that any reform enacted be based on rational criteria linked to the projected prevalence of disease in the nation as well as a determination of which practitioners care for those diseases most effectively and efficiently. We further recommend that medical students' time in surgical activities be increased rather than decreased, that general surgeons increase their activity in medical school curricular development and teaching, and that surgeons become involved more actively in the graduate training of primary care physicians.