Deployment of academic subspecialists in the emerging era of primary care

While the next generation of physicians promises to provide an expanding pool of highly qualified primary care internists, academic departments of internal medicine are currently confronting the apparent conflict of a maldistribution of subspecialists to generalists with growing pressures to deliver comprehensive care. The dilemma is compounded by the rigid compartmentalization and segregation of subspecialty sections and by the widespread assumption that subspecialists can provide only consultative rather than primary care. One solution is to reorganize narrowly focused and fragmented subspecialty clinics into multispecialty group practices or firms. Subspecialists can deliver comprehensive care to patients whose predominant medical problems lie within their areas of expertise in a multispecialty firm setting that provides immediate access to subspecialists in other fields, as well as general internists, and encourages the liberal use of informal consultations. Since it is unlikely that nonacademic managed care ambulatory practices will ever be able to generate sufficient excess clinical revenues to subsidize the academic missions of an internal medicine department, and since trainees must be exposed to realistic clinic practice settings, education and clinical research should be fully integrated into the organization of an academic multispecialty practice plan. The mandate for primary care can be exploited to actually facilitate the academic enterprise by promoting the cross-fertilization of ideas among the various disciplines.