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President's Column

The ACP-ASIM merger: the best of two cultures

From the July/August 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.

By Harold C. Sox, FACP

July 1, 1998, marked a historic moment in internal medicine. The American College of Physicians and the American Society of Internal Medicine (ASIM), two large and vibrant organizations, became one. Internal medicine now speaks with a single voice.

The merger of ACP and ASIM required vision, courage, a willingness to seek middle ground and a great deal of hard work. Internal medicine owes an enormous debt to the negotiating teams led by Walter J. McDonald, FACP, Alan R. Nelson, FACP, William A. Reynolds, MACP, and Bernard M. Rosof, FACP, and to staff members from both organizations who are now implementing the merger in all of its myriad details.

An organization whose voice incorporates all of the perspectives of internal medicine will be more effective than two organizations. Already, this approach has borne fruit. In response to the crisis over HCFA's evaluation and management guidelines, a joint ACP-ASIM committee met during the past several months to craft a number of specific suggestions to improve the guidelines. AMA's evaluation and management guidelines work groups adopted most of this committee's suggestions.

Past differences

In the past, ACP and ASIM represented different organizational cultures. A look at the histories of the two organizations explains these differences. ACP was founded in 1915 with a mission to promote professional education, evidence-based clinical practice and public policy that protects the interests of patients. The forerunner of ASIM was the California Society of Internal Medicine, which was organized in the mid-1940s to deal with economic problems facing internists. Many other states followed suit. Those state societies joined forces in 1956 to form ASIM, which began operation in 1957.

At the time, the split in the ranks of internal medicine was amicable. As if to mark a deliberate division of responsibility for representing internal medicine, ACP disbanded a committee that it had formed to explore whether the College should negotiate with insurance companies over reimbursement rates. ACP agreed to pursue an agenda of scientific and public policy and physician education, while ASIM focused on legislation that affects the environment of practice.

That division of responsibility worked well until the government became more active in shaping the environment of medical practice. The different perspectives of the two organizations sometimes led to disagreement on specific issues. Government officials and legislators who asked organized internal medicine for help often received divided counsel, and internal medicine sometimes suffered.

Furthermore, with the passage of time, both organizations endeavored to become "full-service" organizations. As a result, ACP became more active in legislation relating to medical practice, while ASIM became more involved in the education arena.

Eventually, as the associations found fewer and fewer issues that divided them, the leaders of both groups began to question the need for two organizations with overlapping missions. Serious discussion about a merger began early in 1997 and proceeded remarkably quickly, culminating in approval of the final agreement earlier this year.

The path ahead

Although the pathway to the merger has been surprisingly smooth, the real uncertainties lie ahead of us. We speak of the merged organization as having the best aspects of both organizations. ACP has a matchless reputation in evidence-based practice, patient-focused health policy and medical education; ASIM has superb abilities in teaching practice management skills and bringing about legislation and regulation that protect the internist.

A full-service professional organization must have both of these skill sets. If we provide an environment in which the best of both of these organizations can thrive, ACP-ASIM will be more than the sum of its antecedents.

Some members, especially those who previously belonged to only one of the two organizations, are concerned that we will end up with considerably less than the sum of the two parts. This concern is natural and attends any major change, but I believe that these fears are largely groundless.

Will the policy focus of ASIM simply disappear? Not likely. The Regents have approved a new ACP-ASIM Medical Services Committee that will focus on the issues in which ASIM has excelled.

Can ACP-ASIM sustain ACP's hard-earned reputation for making the needs of the patient its first priority? And what will happen to this reputation as ACP-ASIM advocates vigorously for physicians' needs? Because there are very few policy issues in which the interests of the patient conflict with those of the physician, these questions will probably be less troublesome in practice than in theory. Nonetheless, we must be alert for potential conflicts in our dual advocacy roles and always place our patients' interests first when the two roles conflict.

Ultimately, an organization defines itself by what it does and how it allocates its resources. ACP-ASIM's Board of Regents decides which policies to advocate and how to distribute its resources. The Board establishes these policies by a majority vote. As long as the membership of the Board reflects a broad spectrum of expertise and perspective, the organization should maintain a desirable balance among its various missions and goals. ACP-ASIM needs to nurture future leaders who represent a broad spectrum of interests, and we must strive consciously for balance when selecting and electing leaders.

In this merger, two organizations with complementary strengths have come together. We must all think of ourselves as members of a new, full-service professional organization. All of the activities that we undertake are important to internists and to our patients. The history of our country shows that the essentials of a representational democracy—vigorous discussion, a vote and closing ranks after the vote—will serve us well as ACP-ASIM moves forward.

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