Increasing subspecialisation, driven by new knowledge, experience and technology, challenges the relevance of a broad discipline like general internal medicine. However, these same influences are also responsible for the worldwide renaissance of generalism in clinical practice.1 With an ageing population, an increasing prevalence of chronic disease, rising costs of healthcare, greater consumer expectations, and more awareness of the risks and errors of clinical practice, our society needs general internal medicine to provide integrated, cost-effective and high quality specialist medical care. This need is even greater for people with complex, multisystem problems, who account for most acute hospital admissions.

Here, we outline the fields pioneered by generalists and now common to many clinical disciplines.

Evidence-based medicine (EBM). The EBM movement encourages consistent and judicious integration of best available research evidence with clinical expertise and patient values in making clinical decisions.2 EBM has spawned whole new fields of study of the design, conduct and reporting of clinical trials, and the searching, appraisal, synthesis and dissemination of published research.

Quality improvement. Within the past decade, the magnitude of clinical error and suboptimal care has become apparent.3 This has created new disciplines of health service research and quality improvement. These aim to study and enhance the appropriateness, effectiveness, safety and efficiency of healthcare delivery. Concepts such as peer-review, physician profiling, performance indicators, clinical audit, and practice guidelines are now accepted as credible tools for promoting a "systems-based" approach to improving care.

Outcomes management. Since publication of Ellwood's sentinel paper in 1994,4 the "outcomes movement" has focused attention on scientific methods for determining the impact of modern medicine on patients' quality of life and functional status, as well as on adverse events and survival. Although many benefits have accrued from advances in high-technology, specialised medicine, more could be achieved if common chronic diseases were managed optimally within a continuum of care which spans hospital and ambulatory practice, and integrates acute care with health maintenance. Physicians in general internal medicine, with their broad knowledge and experience, are in an ideal position to lead disease-management initiatives, especially in communities away from major urban centres.

Interdisciplinary care. Healthcare teams have become the dominant units of care delivery. They comprise a diversity of professionals, including specialists, but have one inherent weakness: fragmentation of care among "too many chiefs". For patients with multiple problems who are vulnerable to the effects of polypharmacy and overly invasive interventions, the coordinating and temporising role of a general physician to prioritise goals of management and appreciate patients' needs and preferences is mandatory for providing compassionate, cost-effective care. The establishment in many hospitals of acute medical assessment and intervention units run by general physicians, and appointment of those with procedural skills and subspecialty interests, are examples of this integrative approach to care. In primary care, more general physicians are needed to meet general practitioners' demand for specialists who can provide "whole-patient" care.

Links with other disciplines. With advances in surgical and anaesthetic techniques, more older patients with multiple comorbidities are undergoing elective and emergency surgery. General physicians play prominent roles in preoperative assessment and perioperative management. Many general physicians have contributed to advances in clinical pharmacology, emergency and intensive care medicine, palliative medicine, geriatrics, occupational health, rehabilitation and obstetric medicine.

Other contributions to care. Because of their skills in diagnosis and management of common medical conditions, general physicians undertake much of the undergraduate and postgraduate teaching in teaching hospitals. Most directors and visiting consultants of medical departments of community public hospitals (> 150 beds) are general physicians. Many possess procedural skills (echocardiography and endoscopy) otherwise unavailable to patients in many parts of regional Australia.

The future. The broader interests, skills and vision of physicians in general internal medicine complement the necessarily deeper, focused expertise of subspecialists. In the future, such physicians will be forging new alliances with patients, general practitioners, geriatricians, subspecialists, healthcare funders and policy makers in researching, delivering and teaching better practice. Newer models of specialist care, such as "hospitalism", regional disease management programs, hospital-in-the-home programs, multidisciplinary care teams and outreach services, will have the active participation of general physicians.5 The discipline of general internal medicine will continue to play its part in assisting specialist medical care to meet the challenges of the 21st century.