Quo vadis? A dilemma.

In the United States, where are we going with the explosion of medical knowledge, technology, and innovative therapy that is acknowledged worldwide? The journey has been rapid, comprehensive, and, in some areas of medicine, spectacular. In the process, we have focused our medical progeny on specialization and sub-specialization. Meanwhile, there has been scant focus on producing the muchneeded and now disappearing broad-based internists and family physicians. This is clearly the product of medical educators, who are almost all specialists and sub-specialists. As such, they fail to provide specific role models for medical students and residency fellows in training with an interest in broad-based internal medicine and family medicine. The current medical education scheme unfortunately has thus contributed to the wholesale increase in the cost of medical care. Corrective action would require the development of a large cadre of broad-based internists and family physicians, who, in turn, need the attraction of proper reimbursement by medical insurers to offset the huge debt of medical school education that currently drives many graduates into high paying specialty areas. Medical insurance providers should properly pay doctors for the time and expertise involved in taking a comprehensive medical history and performing a complete physical exam. This could obviate the standard use of frequently unneeded, repeated CT scans, at great expense and with significant radiation exposure concerns. Moreover, there is an opportunity for significant cost savings by reducing the unnecessary tests and procedures on which many sub-specialists rely. Multi-page medical history forms completed by patients, as a doctor timesaver, easily miss important clues that are evident in oneon-one interviews (e.g., when patients are hesitant or uncertain in giving answers). Furthermore, as a time saver, physicals are frequently limited only to a patient’s chief complaint, rendering it insufficient. And because all specialties in medicine and surgery are now increasingly segmented into sub-specialties, most patients now have four or five doctors, rather than a single doctor to coordinate patient care. It has been estimated that the average debt of graduating medical students has risen to $200,000. This requires them to train for and join high-paying medical specialty practices, rather than going into the lower-paying field of primary care. In addition, a relatively new concept, medical homes, will require a larger cadre of broad-based internists and family physicians. These physicians will provide constant and continuous primary care and arrange for specialist services. Already in some areas of the United States, the shortage of primary care physicians is being remedied, in part, by nurse practitioners who provide such care. The factors noted here will only further increase the current deficit in the numbers of family physicians and broad-based internists. Primary care physicians are on the lowest rung of the ladder of stature and payment in the medical world. This is unfortunate and unwise, given the important role that these physicians can play in maintaining high-quality, costeffective medical care. Indeed, Braunwald [1] has compared specialists and sub-specialists to the virtuosi of an M. Malach (&) Department of Medicine, New York University Medical Center, 455 North End Avenue, Apt. 912, New York, NY, USA e-mail: mmmdmacp1@gmail.com