Correspondence
The Structure of Departments of Medicine
N Engl J Med 1994; 331:946-948October 6, 1994
- Article
To the Editor:
In the Sounding Board section of the May 19th issue of the Journal,1,2 two sides of a well-rehearsed argument were presented. That the large departments of internal medicine lost control of some of the major organ specialties in the past couple of decades is not in doubt. Departments of neurologic and cardiovascular sciences in particular have almost completely separated in many universities. This trend may have worried the heads of departments of internal medicine for reasons of both principle and power. An outside observer will have noticed two simultaneous trends. Although the individual organ-based specialties have declared their independence, internal medicine has taken on new areas. Many internal-medicine departments have concentrated on areas that transcend the divisions based on organ systems, such as hypertension, genetics, health care delivery, and molecular biology.
The arguments presented by Myerburg1 and Nolan2 are cogent and coherent, but all too familiar. Neither suggested that the existing trends may be either inevitable or predictable. The practice of medicine broke off from the natural sciences several hundred years ago, the subspecialties of medicine and surgery divided in the last century, and obstetrics, psychiatry, and more latterly, ophthalmology, pediatrics, and gerontology have branched off more recently. On each occasion, what was left after the separation was modified, became a coherent entity, and maintained an important role. At each point, however, I have no doubt that the arguments presented against the latest subdivision were similar to those we now hear. The main argument hinges on the need to train generalists. If the need is there, the evolving departments will have the expertise to train them. There may be a period of relative lack before the demand becomes so great that a supply is produced, but perhaps we should design departments or rotations specifically for these training needs rather than enforce a historical solution on a changing medical community.
It is also essential for other clinical and research reasons to maintain some generalist departments. We should not assume, however, that the old and cumbersome department of internal medicine is necessarily always the best model. Where a generalist approach is essential, in fields such as primary health care delivery or genetic or multisystem diseases and in the application of newer molecular biologic techniques, there will be departments that provide this expertise and training. These departments can create and use collaborative links with organ-based subspecialty departments and as a result be more productive. This may well be preferable to forcing a single department to house all staff no matter how disparate their research interests.
The advantage of such a realignment would be that the individual organ-based specialty departments and the new kinds of internal-medicine departments that arise will be large enough to allow a critical mass of research, but narrow enough in interests that members of the department know and are interested in one another's areas.
The risk of enforcing the old model and keeping the escaping subspecialty groups under control is that the resulting department will be so large that it is impossible to manage or will have so few people researching any one area that there is no interaction between people of like minds and interests.
2 ReferencesAndrew Coats, D.M.
National Heart and Lung Institute, London SW3 6LY, United Kingdom1
Myerburg RJ . Departments of medical specialties -- a solution for the divergent missions of internal medicine? N Engl J Med 1994;330:1453-1456
Full Text | Web of Science | Medline2
Nolan JP . We should resist efforts to split internal medicine. N Engl J Med 1994;330:1456-1457
Full Text | Web of Science | Medline
To the Editor:
In his new order of internal medicine Dr. Myerburg has left no room for me, a subspecialist rheumatologist in full-time private practice. I would not expect to be included, and was not, in the Valhalla of procedure-intensive subspecialties (“cardiology, oncology and hematology, gastroenterology, nephrology, and pulmonary medicine”) that he envisions as sharing the leadership role with a department of primary care medicine. He does allow that “research-oriented divisions of . . . rheumatology could blend into either department.” But that leaves a loyal internist like me without a home in internal medicine, and I wonder how many of my “research-oriented” rheumatology colleagues will be welcomed into Valhalla -- that is, until the change from profit center to cost center for these units, which Dr. Nolan predicts in his article, indeed occurs.
Dr. Nolan reports that “a recent analysis estimated that there will be a deficit of 100,000 generalist physicians and a surplus of 100,000 specialists.” What analysis? The only reference is to an editorial written by a journal editor in cooperation with an admittedly wise and prescient, but currently not fully employed, politician1. And when this reference is reviewed, one discovers that the reference for the analysis is yet another editorial written by the same journal editor three years previously. I would have expected more science and data from the president of the Association of Professors of Medicine. But the data just are not there, and I fear it has become a case of something becoming an accepted truth if one repeats it often enough. (And for those who cite the European model as a paragon, a recent review finds percentages much like those in the United States2.) To make things worse, Dr. Nolan gives away the farm by stating that “specialists are perceived to have a major responsibility for the excessive cost of medical care.” For this Nolan gives no reference, but others have, and it is always the one as yet incomplete study by Greenfield et al.3
I continue to be appalled by the inability of the academic leadership of internal medicine to speak out against these two major misrepresentations.
3 ReferencesHerbert Kaplan, M.D.
American College of Rheumatology, 4545 E. Ninth Ave., Denver, CO 802201
Lundberg GD ,Lamm RD . Solving our primary care crisis by retraining specialists to gain specific primary care competencies. JAMA 1993;270:380-381
CrossRef | Web of Science | Medline2
Whitcomb M. Medical education/physician work force issues: England, France and Germany. Health professions analysis and research report. Washington, D.C.: Bureau of Health Professions, November 1993.
3
Greenfield S ,Nelson EC ,Zubkoff M , et al. Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA 1992;267:1624-1630
CrossRef | Web of Science | Medline
To the Editor:
Dr. Nolan, in his rebuttal to Dr. Myerburg's proposal for the formation of separate academic departments of medical specialties, referred to the 1960s model of separate departments of clinical medicine and specialty medicine at the University of Connecticut. The intent of that nearly 30-year-old experiment, begun before the era of primary care, was to attract clinician-teachers to an academic role as generalists, a role seen as important to teaching and, even then, being left as the specialties flowered1,2. Now, well into the era of primary care, subspecialties continue to flourish while departments of medicine, inattentive to the role of the general internist as clinician-teacher, remain unable to develop programs in primary care that respond to national needs3. Dr. Myerburg's call for a dramatic reorganization of departments of medicine makes a review of the Connecticut model timely.
The University of Connecticut Health Center's Department of Clinical Medicine and Health Care was designed in 1967. Its general internists, attracted to the academic role of clinician and teacher, were paired with faculty involved in health care research, epidemiology, ethics, and prevention. They taught medical students and residents and practiced in the university hospital and ambulatory settings according to the model of the British firm,2 while faculty in the medical specialties acted as consultant-teachers and investigators in their respective fields. As the health center grew, it became difficult to recruit new members to the department of medical specialties. The more traditional departments of medicine and community medicine were formed in 1972.
Dr. Myerburg's proposal and the formation of a national association of subspecialty professors apart from the traditional leadership of the Association of Professors of Medicine present a major challenge to university departments of medicine. They must not miss the opportunity this challenge presents to address their responsibility for leadership in primary care.
3 ReferencesJames E.C. Walker, M.D.
University of Connecticut Health Center, Farmington, CT 06030-52151
Walker JEC ,Murawski BJ ,Thorn GW . An experimental program in ambulatory medical care. N Engl J Med 1964;271:63-68
Full Text | Web of Science | Medline2
Walker JEC . Clinical medicine and the specialty of? Arch Environ Health 1967;15:670-673
Medline3
Petersdorf RG ,Goitein L . The future of internal medicine. Ann Intern Med 1993;119:1130-1137
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Dr. Coats, viewing the debate from a distance and in historical perspective, sees change as inevitable because of the evolution of science, medicine, and society. I do not necessarily agree with his deterministic conclusion, but drastic change may be inevitable if leadership fails to recognize problems and to address them meaningfully. Dr. Coats also expresses concern about managing large and unfocused departments. In fact, it is an axiom of management that conflicting missions within an organizational unit exert a destructive influence on function. Successful diversification within an organization is jeopardized if the mix of missions is not in harmony,1 a principle supporting Dr. Coats's suggestion that we strive to avoid forced coexistence of functions that fit poorly together.
Dr. Walker suggests that we revisit the Connecticut model. Even though stresses between general internal medicine and the medical subspecialties long preceded the original Connecticut experiment, the timing of that experiment was wrong. The distinction between the role of the traditional academic general internist and the emerging new roles for generalists in academic medicine did not exist in 1967. The traditional internist, defined by Osler as a pluralist and distinguished from the generalist,2 has a clearly defined academic mission and a central role in education and clinical investigation in conjunction with subspecialists. Today, this vanishing breed has to be contrasted with the primary care generalist in the academic medical center, whose activities are heavily dominated by health care delivery services and who is hard pressed to maintain other academic activities because of the time demands and nature of the service3. It was largely the missions related to this role to which I referred and which support Dr. Walker's suggestion. I do not question the need for primary care generalists in contemporary academic medical centers; the issues I raise relate to their organization and management.
My comments address problems in academic medical centers, but I am sensitive to Dr. Kaplan's concern for practicing subspecialists -- particularly those in the smaller subspecialties -- whose areas of expertise are being threatened by the same forces that are being felt in academic centers. I do not believe that society will abandon its demand for subspecialty care for specialized medical problems, and health care planners and political strategists would be wise to consider the wishes and predictable reactions of society in models for health care reform.
3 ReferencesRobert J. Myerburg, M.D.
University of Miami School of Medicine, Miami, FL 331011
Drucker PF. Management: tasks, responsibilities, practices. New York: Harper & Row, 1985:709-10.
2
Osler W. Internal medicine as a vocation. In: Aequanimitas: with other addresses to medical students, nurses and practitioners of medicine. 3rd ed. Philadelphia: Blakiston, 1932:133-45.
3
Fogelman AM ,Adams WS . Impact of managed care on departments of internal medicine. Am J Med 1994;96:i-v
Web of Science | Medline
Author/Editor Response
I appreciate Dr. Walker's further elaboration of the nearly 30-year-old experiment at the University of Connecticut to make general internal medicine more attractive as an academic discipline. Although divisions of general internal medicine have been greatly strengthened in the past decade, I agree that a major challenge to departments of medicine is to continue to build these divisions to complement and integrate with already strong subspecialty groups.
Dr. Coats would go further than Dr. Myerburg, arguing that the individual specialties in internal medicine will inevitably form their own organ-based departments to produce a critical mass for research and facilitate shared interests. Such a model has evolved in the United Kingdom, with primary care physicians limited to community practice and consultant specialists limited to practice in hospitals. As I pointed out in my article, the tradition of the internist in this country has been as a physician with skills encompassing a continuum from primary to tertiary care. I disagree that a realignment of the present structure of departments of medicine is either desirable or inevitable.
Dr. Kaplan is correct that data regarding work-force projections for generalist and specialist needs are not rigorously scientific. If one believes that managed-care organizations will dominate the marketplace by the turn of the century, there is compelling evidence that these providers have drastically reduced their need for medical and surgical specialists1. Furthermore, both federal bodies examining projected work-force needs have emphasized the substantial excess of certain specialists2,3. It may well be that with more refined studies, some subspecialties of internal medicine will prove to be undersupplied, whereas others will be oversupplied. Certainly, further studies by a national commission will be necessary for an accurate determination of the data Dr. Kaplan seeks. As to whether specialists are responsible for the escalating health care costs, the perception is that they clearly play a part4. Although Dr. Kaplan may chide us for a lack of scientific data on these issues, both work-force planning and cost containment will need to move forward while detailed studies are being performed.
4 ReferencesJames P. Nolan, M.D.
State University of New York at Buffalo, Buffalo, NY 142151
Wennberg JE ,Goodman DC ,Nease RF ,Keller RB . Finding equilibrium in U.S. physician supply. Health Aff (Millwood) 1993;12:Suppl:89-103
CrossRef | Web of Science | Medline2
Reforming graduate medical education. In: Physician Payment Review Commission. 1993 Annual report to Congress. Washington, D.C.: Physician Payment Review Commission, 1993:55-84.
3
Council on Graduate Medical Education. Improving access to health care through physician workforce reform: directors for the 21st century. Rockville, Md.: Department of Health and Human Services, 1992.
4
Schroeder SA ,Sandy LG . Specialty distribution of U.S. physicians -- the invisible driver of health care costs. N Engl J Med 1993;328:961-963
Full Text | Web of Science | Medline
