Regarding the editorial from the Association of Professors of Medicine, it is hardly surprising that a group composed of the current chairpersons of departments of medicine is not thrilled with proposals to downsize their domains. However, it is unreasonable to depict an organizational structure created in a medical environment that no longer exists as a visionary model ideally suited to current challenges.

Nothing is sacred or immutable about the organization of medicine or academic medical centers; structural organizations in this complex industry should reflect current internal needs and external forces. That the traditional department of medicine is increasingly regarded as an anachronism merely reflects the failure of the organizational structure and its leadership to cope with conflicts between divisional specialties over monetary and manpower resource allocations and over resident time allocations in training programs. Accordingly, many believe that smaller departments of medicine, unencumbered by the demands of specialties whose practice structure and postgraduate training needs have become far removed from those of general internal medicine, would more successfully focus on training and research pertinent to general internal medicine.

Most would agree that existing and looming challenges in health care reimbursement, clinical resource allocations, and clinical teaching require an organizational structure for academic medical centers that will better coordinate the goals and activities of all current clinical departments. Whether the diverse specialties of internal medicine are recognized within this larger structure as discrete entities or as elements of a traditional department is not important. Given the current failure of leadership through the traditional structure, however, it seems unlikely that it is suited to the task of meeting the challenges that now face us.