U.S. Department of Defense


Date of this Version



Published in The American Journal of Medicine, Vol 120, No 12, December 2007.


It is the year 2025. During the past 20 years, internal medicine as a discipline continued to become less prestigious, less respected, and more fragmented. As fewer medical students chose internal medicine as a career, residency programs began to close. Those that remained open filled with fewer graduates of US medical schools but filled with more US citizens who graduated from international medical schools, more graduates of osteopathic medical schools, and more foreign graduates of international medical schools. Due to lack of adequate remuneration and a shift of primary care provision from generalist physicians to nurse practitioners and physician assistants, training in general internal medicine as a patient care specialty ceased. Generalist internal medicine careers have been replaced by tracks designed to foster health services research or academic careers; internal medicine training graduates subspecialty physicians.
Although the projected collapse of Medicare in 2019 was avoided, severe cuts in federal funding for undergraduate and graduate medical education programs forced medical schools and residency programs to compete for federal funds. As a result, medical school tuition became prohibitive, for-profit health care systems viewed medical education as a significant cost center and chose to limit the size of their residency programs, and community-based training programs could not withstand the financial pressures and closed. The result was a reduced supply of internists. Furthermore, compliance with the regulatory burden imposed by accrediting organizations—such as the Accreditation Council for Graduate Medical Education—drove individuals from sustained careers in education, further impacting the viability of training programs.