Former general internist here. I obviously have opinions about the assertion that generalists provide no incremental value. The model you posit, wherein a generalist oversees a panel of NP’s and PA’s is already common. Many primary care problems can be handled in this way. No disagreement. But there is a host of multi-systemic disorders that most mid-level practitioners would never recognize. And do you think most subspecialists are interested, aside from the occasional rheumatologist, in comprehensive management of the protean manifestations of most of these types of disorders. This coordination of care for complex disorders has to be done by someone. And for the sake of the patient I hope it’s someone with a solid command of pathology, physiology, pharmacology and so forth. And maybe someone with the time and empathy to talk to actual humans. If you think coordination of care is handing out referrals, that’s a massively reductionist view.

What you are talking about is ideal state. My experience is literally its always "here's the referal" if i talk about anything specific and the standard host of anti biotics and standard z pac style medicines dont clear it up. Always.

Now my view might be biased because i have been given Kaiser as my provider and i know they have incentives in their system that arent the norm. But its always a specialist referral. Ear problems that the anti biotic didnt solve? ENT referral! (the ENT laughed and said the general medicine doctor made the problem actively worse with the multiple types of anti biotics proscribed sense it was a fungal infection in the ears). Skin issue? Here's the dermatologist referral! Shortness of breath after working out? Here's the pulmonology referal if you want it. Your knee hurts? Here's the rheumatology referral.

I am legit curious what medical service the doctor would provide. You mention "multi-systemic disorders that most mid-level practitioners would never recognize" do you have an example of that?