A recent editorial from the Association of Professors of Medicine [1] stated that "certain division chiefs of cardiology have had growing interest in separating from departments of medicine". Far from being a minority opinion, this course was favored by 56 (60%) of 93 cardiology division chiefs in a poll we recently did [2]. The reason was that chairs of medicine often expect disproportionate clinical care, teaching, and research responsibilities of cardiologists, on whom they rely heavily for financial support. The lumping of resource needs with those of less active medical subspecialties has led to some friction. In addition, cardiology programs are often not represented on key institutional policymaking or executive committees [3].

The editorial states that although cardiologists may have "had disproportionately greater responsibilities with insufficient recognition of their contributions," health system reform may make it difficult or impossible to reallocate resources. The record shows, however, that many cardiovascular programs can provide "integrated clinical arrangements" as well as an "interactive, flexible" system in a self-sufficient manner, and have provided leadership to hospitals in entering managed-care arrangements.

The editorial argues that because disease prevalence and demand for specialized procedures fluctuates, a multifaceted department is needed. Yet, because of the aging population, cardiovascular disease will remain a leading cause of morbidity and mortality in developed nations, and successful therapeutic approaches such as complex pharmacotherapy, bypass surgery, coronary angioplasty, and antiarrhythmic devices will continue to evolve. In addition, cardiovascular research often extends beyond the department of medicine with links to cardiovascular surgery, anesthesiology, physiology, pharmacology, and molecular biology. The editorial decries the fact that "at some institutions, separate categorical centers. are being formed, often with separate hospital beds, training programs, and finances," but such arrangements have immensely enhanced the quality of patient care, teaching, and research in Europe and the United States, and have brought prestige and visibility to their parent institutions.

The authors suggest that "the training period for subspecialists may need to be extended" to accommodate the need for greater knowledge. However, the board requirements in the cardiovascular diseases have just increased from 2 to 3 years of training, and expertise in angioplasty, electrophysiology, and other specialized clinical areas requires a fourth year of training. These changes may necessitate a reduction in the medical residency [4] for those entering the cardiovascular subspecialties.

Despite their differences, cardiology and medicine share many goals and can work together to modernize their structure and function, especially to provide balanced education for generalists and specialists. Traditionally, medicine has depended on cardiology and other clinically active subspecialties for financial and other support. It is unclear how the vacuum created by separation of subspecialty groups into independent departments would be filled. Departments of medicine would be likely to focus on revitalizing primary care [5]. It behooves both cardiology and medicine to communicate and find solutions by capitalizing on common interests to achieve constructive change.