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Internal Medicine and Training Subspecialists

TO THE EDITOR: Dr. Weiner's editorial [1] on the article by Langdon and colleagues [2] was thoughtful in its laudatory reflection. However, I must take exception to his statement that a related issue that also appears to have been sidestepped is a delineation of the exact role the Board (and other internal medicine groups) should have in the downsizing process. As the total number of training slots decreases, exactly how should accreditation be used to ensure that only the best programs remain within each subspecialty? I fear that Dr. Weiner has missed the point. The American Board of Internal Medicine and other certification boards have a single, critical function: to ensure that certified specialists and subspecialists meet certain criteria of excellence in the areas of medical knowledge and skill (within the limitations imposed by a tough examination). They should never be called on to become the instruments of downsizing teaching programs. The only role they should play is an indirect one, by indicating the success of specific programs in generating board-certified graduates. To do more would represent a dreadful conflict of interest and would be counterproductive to the mission of the boards. As Langdon and colleagues state, the primary interest of the American Board of Internal Medicine is the quality of training of internists; ways to finance graduate medical education are beyond the Board's purview. So it should remain. It is painfully evident, however, that unless the U.S. Congress has sufficient wisdom to create fire-walled funding, the enlightened program envisioned by the Task Force will never come to fruition. This would jeopardize the entire structure of basic research, clinical investigation, and teachingthe total contemporary medical enterprisein the foreseeable future. One could expand this dream to suggest that necessary revenue could be derived from insurers and managed care organizations; from a levy on medical licenses and relicensure; or from a surtax on cigarettes, alcohol, handguns, and ammunition. This revenue could ensure the survival and growth of this carefully and painstakingly wrought intellectual treasure. I have faith that many capable and visionary legislators will appreciate the enormous stakes involved. I believe that after all the tumult and shouting die, they will do the right thing.