There is a growing schism between general internal medicine and the medical subspecialties. The latter are functioning increasingly as categorical disease centers, such as cardiac or cancer centers, which involve subspecialists from several departments. These new "horizontal" organizational units are though to enhance the effectiveness of patient care as well as the generation of resources, especially for research and training. However, subspecialists operating outside of the framework of training, accreditation, and standards established by internal medicine are at risk for being less effective in dealing with the "whole" patient. Further, the critical evaluation of clinical practices of subspecialists is greatly needed and is far more likely to be accomplished effectively within departments of internal medicine than in categorical disease centers. Therefore, although some strengthening of the new horizontal organizational units now seems appropriate, this processs must not be allowed to erode the important integrating structure provided by internal medicine.
