Although the lack of a national policy on medical manpower has served U.S. medicine well in some ways, it also has created problems, the most important of which is the maldistribution of physicians in the various specialties, with too many specialists and not nearly enough generalists. The author explains why this imbalance is a problem and why it is receiving so much attention, describes three types of forces--economic, practice-related, and scientific--that favor the practice of specialty medicine, and demonstrates that the medical school experience itself may be a critical influence on students' career decisions. He then outlines possible ways to correct the imbalance, both outside and inside academic medicine; for the latter sphere, he proposes five detailed alternative scenarios of how corrective change might come about, which range from doing nothing to making a number of fundamental changes within academic medicine's institutions to having external financial pressures for change brought to bear by the states and the federal government. In conclusion, the author notes that some combination of these scenarios will occur, because spending for medical care in the United States is out of control and cannot be reduced unless the distribution of physicians by specialty is rebalanced to have a much greater percentage of generalists. His hope is that academic medicine will accept this challenge and bring about the best mix of physicians to meet the nation's needs.
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