In 1897, over one hundred years ago, Sir William Osler, the greatest physician of modern times, was invited to lecture before the section on internal medicine of the New York Academy of Medicine. The title was “Internal Medicine as a Vocation.” There was, even in that early day, concern that general internal medicine was being neglected while the subspecialties were fragmenting it. Osler argued with eloquence that general internal medicine was the backbone of medical practice and every effort should be made to strengthen it and to maintain its position as the basic foundation for the education and training of physicians. Many of Osler's arguments for the importance of general internal medicine are as valid today as they were one hundred years ago. Some have lost their relevance in a period of great change in medical education, especially in the postgraduate years. Now, the general perception is that general internal medicine has become very unattractive to the current crop of medical students who are flocking to the subspecialties and the more lucrative procedure-oriented fields of practice. Whereas in the past internal medicine attracted the brightest and the best students with their Alpha Omega Alpha keys, even the best teaching hospitals are having difficulty in matching in internal medicine and find themselves accepting lower-ranking students and foreign medical graduates in order to meet their quotas. In addition, because most of those choosing a residency in internal medicine elect to become subspecialists, our country finds itself flooded with specialists who may end up examining each other and short of men and women providing primary care. The situation is so acute that it has been called a crisis in medicine and there are threats that government intervention and Draconian measures may be needed to correct the imbalance.

What went wrong and how can we fix it? Responding to Santayana's admonition that “those who cannot remember the past are condemned to repeat it,” let us review Osler's defense of the generalist in internal medicine.

Let us start with the definition of a “vocation.” The American Heritage Dictionary (1993) has two definitions of “vocation.”