Contrary to the views of Dr. Hood and Dr. Goldsmith that new departments should be created, the Association of Professors of Medicine believes that a symbiotic relationship between the core (general internal medicine) and the exterior (the subspecialties) best prepares medical students and residents in internal medicine for a career in practice, teaching, or research.

Both general internal medicine and the subspecialties would lose if a breakup of departments occurred. Generalists would be deprived of exposure to, and knowledge from, the cardiologist, gastroenterologist, and so forth, thus impairing their abilities to make broad-based and informed clinical decisions. The subspecialists would lose the foundation of their field—general internal medicine—limiting their ability to treat the patient and his or her condition in an integrated fashion, leading to the further proliferation of super-specialized care. The whole of the department would suffer from the compartmentalization of clinical and investigative efforts, which would detract from the ability of departments to support their teaching and research missions. Both the generalist and subspecialist will need to rely on and profit from each other's knowledge and skills if internal medicine is to succeed in an environment increasingly dominated by managed care.

The Association of Professors of Medicine is taking steps to address the current exigencies. The organization has established a task force on managed care to look at both educational and clinical practice issues; a course on developing and improving the management and leadership skills of department chairs is being planned with a premier business school; and the organization will expand its membership to include other leaders in the academic internal medicine community outside the medical school departments.

Departments of medicine and their parent medical schools operate and are structured heterogeneously. Nevertheless, the Association of Professors of Medicine is advocating steps to help department chairs provide the leadership Dr. Goldsmith states is lacking, both at the association and department levels. We agree with Dr. Goldsmith that traditional structures and practices of departments of medicine need to be intensely scrutinized in light of contemporary health system imperatives. The chairs of these departments and their national organization are rising to this challenge.