RSS Feeds
United We Stand
- Robert M. Glickman, MD;
- James P. Nolan, MD;
- Arthur H. Rubenstein, MD;
- J. Claude Bennett, MD;
- John D. Stobo, MD;
- Maurice A. Mufson, MD; and
- James Terwilliger, MD
- Association of Professors of Medicine, Washington, DC. Requests for Reprints: James Terwilliger, Executive Director, Association of Professors of Medicine, 1001 Connecticut Avenue, Suite 700, Washington, DC 20036.
In recent decades, departments of medicine have grown enormously. More recently, however, there have been suggestions that certain subspecialties (that is, cardiology and oncology) reconfigure as categorical disease centers with an eventual weakening of ties to departments of medicine. Recent trends in health care make such a change undesirable. More and more, general internists will direct and coordinate the care of patients, and fragmentation of departments of medicine will make this task more difficult. The need to practice and teach cost-effective medicine and analyze patterns of care will require a closer working relationship between general internists and specialists. To accomplish these goals, a unified, rather than a fragmented, department of medicine is required.
At the very time when internal medicine and its subspecialties are being asked to act in unison to cope with a rapidly changing health care environment, one increasingly hears of efforts to fragment internal medicine. At some institutions, separate categorical centers (for example, cardiology and oncology) are being formed, often with separate hospital beds, training programs, and finances. The role of a department of medicine as the home for internal medicine and its sub-specialties is being questioned. In this editorial, we examine the implications of fragmentation and conclude that it would be an unwise course for internal medicine.
In every academic medical center, one can find faculty who wistfully recall earlier days, when departments of medicine were administered by a single departmental secretary, the faculty all had contiguous offices, and departmental budgets were a small fraction of today's. Integration was easier then.
In recent decades, however, centripetal forces have grown. Departments of medicine have been transformed because of the dramatic growth of subspecialty medicine, which followed the development of new knowledge leading to improved ways of caring for patients. Departments of medicine have grown to become the largest in most medical schools, whether measured in space, faculty numbers, hospital beds, or budget. This growth was based on achievement and is well earned. It was, however, made possible by generous funding for patient care and research, which could foster such aggressive growth.
The current economic climate threatens to stall this momentum and has created new tensions within departments of medicine. Constrained reimbursement for clinical activities has now for the first time limited the growth of even successful elements of the department. Reductions in clinical revenues have placed economic pressures on departments of medicine by calling attention to wide differences in clinical earnings among procedural and nonprocedural divisions and raising questions about the support of less wealthy elements of the department by the more financially successful elements. At the same time, centers and institutes that were developed to accommodate highly specialized programs sequester resources that formerly were shared across the department. These programs often require flexible approaches to governance, academic appointments, assignment of space, and the utilization of revenues. Many institutions have dealt successfully with these challenges, but others have found them a source of unrest.
The impetus to change the traditional organization of departments of medicine comes most strongly from categorical or disease- or system-related programs, such as those in cardiovascular disease, oncology, and gastroenterology. For the past few years certain division chiefs of cardiology have had growing interest in separating from departments of medicine and establishing their own departments. They have argued that this would enhance training in their subspecialty and that their faculty have had disproportionately greater responsibilities with insufficient recognition of their contributions. However, another important issue is income, a portion of which is reallocated by the department to support teaching as well as less financially viable divisions. Whatever the merits of these adjustments, the rapid introduction of managed care threatens to turn this situation completely around rapidly. With health system reform, there will probably be more generalists, fewer patients referred to specialists, as well as a lower level of reimbursement for their services. Experience in Los Angeles and Minneapolis, which have large managed care systems, supports this prediction. The future will require integrated clinical arrangements involving faculty not only in departments of medicine but also other clinical departments. The relationship with the academic center hospital will be interactive, flexible, and respectful of all of the constituents' needs. Precisely these considerations, in our opinion, make the unity of departments of medicine more critical than ever.
Clinical Care
Fundamental changes in health care reimbursement have forced changes in the way medicine is practiced. The pressure by third-party insurers to provide comprehensive and coordinated medical services for their subscribers demands that generalists, subspecialists, and hospitals be organized in an efficient and cooperative fashion. It will be less likely, in the years ahead, that an individual patient can directly and independently choose individual subspecialty physicians. Rather, primary care physicians will be called on to coordinate care, direct subspecialty referrals, and remain the stable link in a complex system. An organizational structure such as a department of medicine has the breadth and strength needed to balance these competing needs and requirements, which will only become more complex in the years ahead.
Multidisciplinary, disease-oriented programs and centers that offer new opportunities for innovative, specialized care compete successfully for patients and attract and retain outstanding physicians who can provide state-of-the-art care. Most successful medical centers have developed such multidisciplinary programs. It would be an error, however, to fundamentally reorganize the structure of departments of medicine to accommodate these specific programs. No one can predict with certainty changing rates of diseases, technologic advances, or the interdependence of subspecialties brought about by new approaches to care. For example, consider how clinical practice and reimbursement have been altered by changing medical practice. The changing economics of renal dialysis, the reassessment of the role of biliary lithotripsy, or the advent of laparoscopic surgery are examples of changing areas of clinical practice that have had major effects. Technologically advanced subspecialty programs would be severely compromised without the participation of nonprocedural disciplines. It is precisely the depth and diversity of departments of medicine that promote the needed integration and coordination. It would be unwise to risk overdependence on a limited number of subspecialty programs and centers at the expense of the broader clinical expertise traditionally included in departments of medicine.
Research
Research used to be carried out successfully along traditional subspecialty lines, without much need for other kinds of scholars. Now research requires the participation of scholars in many disciplines. For example, investigation into the causes of inflammatory bowel disease involves specialists in infectious disease, immunology, and genetics, in addition to gastroenterologists. Departments of medicine can accommodate cross-disciplinary research, which would be more difficult to accomplish in multiple, smaller administrative units.
It is also desirable to have research programs that represent the full range of clinically relevant perspectives, from molecular biology to health services research. This can best be fostered in departments of medicine because of their breadth and diversity. As noted by Braunwald [1], this critical evaluation of health care practices is more likely to be carried out in the intellectual environment of a department of medicine than in a more narrowly focused disease-oriented center.
Teaching
As patterns of care become more complex, teaching physicians becomes more challenging. The Balkanization of care along strict subspecialty lines is as undesirable for education as it is for patient care and research. With increasing specialization, the traditional core of knowledge and skill for all internists is being questioned but is, in reality, more critical than ever [2]. First, internal medicine training is necessary to provide the generalists America needs. Second, a basic understanding of internal medicine as a whole is an essential foundation for subspecialists. As the information base of medicine expands, the training period for subspecialists may need to be extended. It is therefore incumbent on medical educators to continually refine training programs that will preserve the essential components of internal medicine training for those destined to receive further subspecialty training. Third, as clinical medicine changes, understanding the interplay between general and subspecialty medicine is essential. With limited financial resources for medical care there will be pressure for physicians to be more cost-effective in ordering diagnostic tests and consultations and this requires excellent communication, mutual knowledge, and colleagueship among generalists and the subspecialists. We must be able to teach students, housestaff, and fellows these concepts. These complex teaching missions are a major responsibility of departments of medicine.
The rapidly changing environment, competing demands for general and subspecialty care and training, and economic pressures make the unity of departments of medicine more essential than ever. The challenge of modern departments of medicine is to provide a setting where the balanced ecology of medicine can be preserved. If they are successful in reconciling competing interests, they will retain a flexible ability to deliver care, conduct research, and train future physicians in yet undefined ways. Departments of medicine must be institutional leaders willing to shape new approaches to patient care, research, and training. In so doing, they must also support collective needs of other departments as well as the hospital and medical school.
Only by remaining intact can departments of medicine help the nation adapt to challenges of health care. The Association of Professors of Medicine, representing the leadership of departments of medicine of the nation's medical schools, embraces this challenge and will facilitate the required dialogue, study, and implementation.
- Copyright 2004 by the American College of Physicians
