In the November 2005 issue of the GME E-letter, we wrote, "The apparently inexorable trend toward greater specialization and subspecialization begs the question, 'Whose needs are being served?' To what degree is this trend being driven by our patients' need for more highly specialized knowledge and skills to achieve better clinical care? Or to what degree is it the product of professional desires? For mastery? For controllable lifestyle? For income?
"Some doctors assert that this trend is being driven by a desire to evade the onerous duties of front-line patient care — in ERs, ORs, clinics, or inpatient units. But I'm not sure how much lifestyle issues are the real problem. To what degree are we all responsible for letting our profession be minced into smaller and smaller pieces?"
Following are edited versions of the comments received, with identifying information removed.
Why specialization?
Much of primary care medicine can be performed more efficiently, more cheaply and as thoroughly by nurse practitioners and other advanced nursing personnel. With the impending physician shortage, why train MDs to do these tasks?
We have recently survived a period in which specialists were demonized, and primary care providers lionized, in the name of public policy. During the early and mid-'90s, the specialty of anesthesiology was particularly vilified, and anesthesiologists were made out to be all sorts of bad. Anesthesiology residencies saw a plummeting interest, with a nadir in the mid- to late '90s (at our medical school, one of the senior faculty told the incoming class that those few students still interested in anesthesiology would never find jobs!). Thus followed a national anesthesiologist shortage.
During this shortage, operating room productivity slowed, and surgeons were stymied and operating into the night, as OR capacity dwindled. Patients had surgeries cancelled, and waiting lists grew. Anesthesiologists were working impossible hours to facilitate what patient care we could. This reduced the opportunity for conducting research and extending the knowledge of the field.
We are just coming out of this period, and our speciality is in a growth phase again. In our institution, this results in more opportuntities for patients to receive top-notch operative care, including growth in pain-relieving regional anesthesia. Our pain management service census has grown fivefold in the last 8 years; we have developed considerably more methods to alleviate suffering as a result of this increased demand. Our intensive care units are staffed with highly qualified specialists, providing more efficient and effective round-the-clock care to the sickest patients in the system.
All of this is possible because of specialization. When we were damned for being specialists, our colleagues and patients suffered. Medical knowledge continues to grow, and it is not possible to be a "Jack of all trades, master of none" as in the past. To best serve our patients, we have increased our depth and breadth of understanding and capabilities within our field, sacrificing some breadth outside.
During this phase of the growth of our specialty, death related primarily to anesthetic mishap has decreased from about 1:1000 surgeries in the early 20th Century, to something closer to 1:100,000 at the beginning of the 21st Century. We are facilitating surgical and perioperative care in patients who would never have survived their hospital stay years ago, and this is a direct result of the pursuit of excellence in our specialty.
Please do not damn the specialists again. Doing so harms patients.
Prior to Flexner, physicians basically did everything: surgery, pediatrics, internal medicine, etc. But medicine at that time was technologically infantile, and even some of today's advancements that we take for granted—for example, blood transfusion—did not exist prior to the 1900s. After Flexner, medical student education became more standardized, more rigorous, and more scientific based. As a result, more research was performed and more advancements made, making it impossible for one physician to "know it all" or to "do it all." The general practitioner could no longer keep up with the technological or knowledge advances in general surgery, for example, so physicians specifically trained in surgery were preferred because outcomes were better. The same for pathology, to cite another example. A physician could not continue to master developments in the realm of pathology and remain a master in surgery.
In addition to the advancements in knowledge, I would guess that superior outcomes by specialty-trained physicians were recognized by the public and by insurance companies (and the government?), helping to push further subspecialization. My guess is that the tipping point toward increased subspecialization was achieved somewhere in the late 1920s to early 1930s, when many of the first specialty societies and boards were established (it would interesting from a medical history standpoint to review the political and causative reasons for specialty board/society formation).
From a more "selfish" standpoint, I imagine that some of the drive toward specialization was also based on the personal interests of physicians who would then "limit" themselves to practice in those areas that they enjoyed doing.
Ken Ludmerer alludes to some of the forces affecting increased specialization in Time to Heal (pages 98-99 and 180-187) but my sense is that it was a more complicated process then he discusses.
I am a family medicine residency program director at an academic health science center. I give my life to serving God and my patients as a physician/healer. I work every day in an environment where I have to fight to get my patients the medical care they need. I work in a medical education system in which students and learners struggle to remember why they went into medicine…as medical education drifts farther and farther from actual patient care and morphs into sophisticated “technician” work. Rarely do I see this benefiting my patients or my learners.
When will we learn from history and from experience globally that patient care is improved, outcomes are improved, and cost is lowered when basic primary medical care is delivered by trained generalist physicians? I strongly believe that EVERYONE IN THE WORLD DESERVES A FAMILY DOCTOR. Will we provide a system which ensures this need is met?
When will we return to the roots of our profession as a covenant relationship to serve by doing what our patients need us to do? When will we take back the responsibility to train the doctors that our nation and world need? The world does not need more rich self-centered technologists who protect their cushy lifestyles. Patients do not need more emergency rooms to fill their blood pressure prescriptions and provide their mental health. Our patients do not need more cosmetic help to look better. They need basic prevention to FEEL better, basic medical care to GET better, and quality-driven systems of integrated full-spectrum primary care to LIVE better.
We would not have our current problems with teaching medical professionalism if we remembered what profession we were called to. I do not believe as a profession that we are called to be narrow-minded technicians caring for a single condition in a single organ-system. No matter what our specialty, we are called to be PEOPLE who provide hope, bring healing, and enhance health for PEOPLE in need. This is the root of professionalism.
Like many complex issues this is not either/or but many shades of gray. A "both/and" explanation is more accurate. Some of this excessive specialization is clearly lifestyle and getting out of the “heavy lifting” of primary care, particularly since the obvious economic disparities between primary care and subspecialty care have not been addressed. This economic disparity remains a huge indictment of our collective professionalism and unquestionably drives distorted career choices.
However, there is also a need for focused and specialized expertise in certain clinical situations where concentration on a limited but highly technical skill benefits properly selected patients and is associated with better outcomes. Part of the problem is that we collectively have not been very disciplined or vigorous about insisting on demonstrable patient benefit before breaking off new subspecialties. In fact, the decisions are frequently political-, lifestyle-, and reimbursement-driven rather than patient centered.
There is no question at least in surgery that it is being driven by the increase in knowledge and the explosion in technology. It is impossible for any single surgeon to span the depths of pathology that defined most of the specialties in years past. My biggest concern is that with these significant changes our medical institutions and organizations are not responding quickly enough and in fact are resisting the changes, thereby creating confusion in the training of surgeons and subjecting many patients to care that is less than optimal.
The tone of your invitation is that specialization is bad, which is poor form.
I agree that there is a great need for excellent primary care physicians. When I am caring for a patient, I much appreciate when the PCP is an excellent provider.
So, what are the barriers to encouraging providers becoming primary care providers? Although some enter subspecialty medicine due to perceived economic benefits, I think many (hopefully most) enter because it is more interesting. Certainly in rheumatology that is true, as there are no monetary rewards to doing subspecialty training (see the analysis by R. Meenan in early '90s).
So the real question is, "How does one make doing primary care rewarding/enticing?" I do not view this a fault of the subspecialties that they might be more interesting!
Your musings about the "apparently inexorable trend toward greater specialization" remind me of several questions we had from students at a careers in family medicine panel we organized for Primary Care Week. It's a fallacy that seems to be growing stronger every year—the need to subspecialize in order to "keep one's options open." So students who otherwise might have made great family docs go into internal medicine wanting to keep their options open, then end up becoming gastroenterologists and spending most of their days doing routine colonoscopy after routine colonoscopy on faceless patients over 50 who family physicians actually know well and see for more interesting issues.
Bless the GI docs and other subspecialists for doing their mind-numbing part, but what a shame to think that so many students are making career decisions because someone (other than us) told them that primary care is passe and the only challenges in medicine come from studying one tiny slice of it.
The impact of the medical knowledge base contributes substantially to this phenomenon. The work needed to master my field of general internal medicine (and I use the word "master" with some sarcasm) is astounding . . . and I'm in academics, with lots of extra time allocated for study. I can't imagine how a family physician in clinical practice can hope to achieve this.
My area of research focus is deep vein thrombosis. Believe it or not, I experience much less anxiety over my DVT patients (despite the inherent risks of anticoagulation therapy) than I do my general internal medicine patients. This is because I have a confidence in my knowledge base of venous thrombIism, which I find elusive in internal medicine as a whole. I can relate to those who seek to specialize in a very tight field. It allows one to avoid the anxiety of uncertainty.
I believe the GME community (and our specialty societies) need to focus on creating an increasingly standardized and accessible summary body of knowledge to guide the primary physician in best practices. The commercial product UpToDate, and the American College of Physicians' PIER, perhaps come closest to fulfilling this need at present—but fall short of making information available on a patient-by-patient basis. Such a body of knowledge might even generate a chart note (based on active medical problems) which would directly provide reminders for specific interventions.
Secondly, and a little more colorfully, I'm going to scream if I read one more editorial that says, "Perhaps if students search their hearts for why they went into medicine, they'll realize that primary care fits their picture of what being a doctor is all about." This is a polite way of saying, "If students weren't such greedy capitalists, we'd have enough primary care doctors and we wouldn't have to do anything to change the inequitable nature of the health care system." Students realize that the structure and remuneration of primary care indicates that the field is not deemed valuable by the profession and by society, and so they seek careers in fields that are. I don't think it's largely the money...I think it's the respect. Pay and call schedules are simply measures of the value with which the field is regarded. Why would highly intelligent, capable students not seek to garner the highest esteem possible?
Until the fundamental brokenness of the E/M coding system is repaired, it seems unlikely that we will have hordes of medical students clamoring for training in primary care—no matter how much we tell them they should. It is wrong that, for example, performing an automated radial kerotomy for 35 minutes garners fees 50-75 times that of managing a patient with eight active major medical problems during a 35-minute visit. Until the profession and the payment system value evaluation and management as much as performing procedures, selling students—especially those highly accomplished students with their choice of specialties—on primary care will be a difficult challenge.
PS. I would like to point out that I'm not bitter, and that I very much enjoy my field. Also, as an academic I am not highly paid (on a physician scale), nor would improved E/M compensation impact me very much—so I'm not selfishly advocating changes in how specialties are compensated. I simply think the system is unfair.
There are large generational differences that those of us who have been in the profession more than 5 years fail to understand fully . . . and are maybe even unwilling to recognize or accept. Call it lifestyle, or balance, income needs/desires, student loan balances, or whatever you will, it appears that medical students are choosing their specialty with very different criteria than in the past.
I have been educating family medicine residents for 13 years. The good news for my program is that we are still able to attract highly compentent U.S. grads for our six spots a year despite the dramatic decrease in applicants. The bad news is that while the number of residents has remained the same, the number of patients has increased and the number of hours that residents are both allowed to and willing to work has decreased. Often the "buck" (insert here lab value, x-ray report, follow-up arrangements) is passed—"She admitted him; he followed him in the hospital; she saw him in clinic. . . ." Dear heavens! Will someone take responsibility and care that out there is a worried, possibly very sick, person depending on a physician?!
I walked into the physician lounge in our community hospital 2 weeks ago and introduced myself to a medical student waiting for his preceptor. He had overheard me on the phone and asked immediately after my introduction, "Are you an attending?" To my affirmative that I was the associate director of the family medicine residency, he blurted, "Do you work more than 40 hours a week?" Do I even want this person in my residency program? He is considering dermatology and anesthesiology—stable hours, high
pay, no call or weekends.
And then I pause. . . . I do work more than 40 hours a week, sometimes twice that much. I take call, see patients in the hospital, deliver babies . . . and I don't make even half of what the interventionist specialties do. Why wouldn't I choose an easier path? I'd love to have more time at home with my kids and get more sleep. Yet, I would choose the specialty of family medicine all over again—I choose it from my heart.
At times I feel resentful, judgmental, frustrated, and confused over this generation of medical students/residents. I need help understanding them so I can realistically design an educational program for the needs of the future. We are training new physicians in an old model. Are we attracting the right folks into medical school in the first place? How does the educational process shape them, discourage them, encourage them? What are their goals, dreams, and desires—and why? These are just some of the critical questions we must ask for the sake of our profession and the health care of our patients.
Specialization is here to stay. Hippocrates set fractures. Now, even family practitioners don't do that.
You state that in 1964, there were 21 specialties in the Green Book. Now there are 121.
In 1964, having leukemia or chronic kidney failure meant that you would soon die. Now, in 2005, we specialists can cure leukemia, and with dialysis and transplant, we can give you years of productive life. Neonatal care costs a lot of money, too. But the Harvard economist David Cutler has shown clearly that this and other expensive medical care is in fact cost beneficial.
In 1964, a heart attack could kill or make its victim a cripple, forcing him to stop work, removing a productive worker from society. Now, specialty care reverses myocardial ischemia, prevents death, and keeps many productive middle aged workers at work.
Specialty care is a good thing.
Specialization is driven by the information explosion as much as anything. It is increasingly difficult to keep up with a subspecialty in neurology such as stroke or headache, much less keep up with all of medicine. Add to that the problem that cognitive physicians are the lowest paid physicians, and anyone with a procedure that makes money, no matter how loosely the criteria are applied for its use, makes a lot of money. I believe that these factors are driving the decisions of our "brightest and best."
Being a family physician who now sees patients 1 day a week at a community health center and doing public health education and research the rest of the week, I may not be the best person to respond to your question. Having said that, I can share my own personal decision making. I liked "managing" and "coordinating" patient care, so I became a family physician. I got my MPH and did a fellowship in minority health policy because I wanted to become better at managing, coordinating, and advocating for my patient's care. I then wanted to help others manage, coordinate and advocate for their patient's care, so I began teaching and doing research. Since academic excellence depends on specialization, I focus on community-oriented primary care.
I think most physicians want to be effective and that drives people to look for ways to accomplish this. the cynic in me has seen too many of my peers select specialties based on lifestyle and pay. Having $400,000 of educational loans to pay back between my wife and I, I can't fault folks who think they need to specialize to make ends meet. Ego is another common trait among physicians, and people want to be respected, so they choose "cool" or "exciting" specialties. Far too often I hear my students complain that the deans or faculty mentors push them away from primary care specialties because of the low salaries.
Having put my two cents in about people's motives, I think the political and financial institutions that create incentives generally drive the workforce. If there wasn't money or power in this, no one would do it. Doctors are just ordinary people who happen to be a bit more educated. As the pharmaceutical industry knows well, doctors are suckers for incentives.
So, who is served by specialization? Those that specialize and the health care industry execs. Certainly, not the patients. Just look at our infant mortality rate, life expectancy, and health care disparities.
I am an infectious diseases fellow. I selected this route as an extension of my role as an internist, choosing a subspecialty that keeps me in every organ system and allows work in the clinic, hospital, laboratory, field, and conference room. It was a simple matter of following academic interest coupled with a desire for flexibility in setting, and anchored in general and hospitalist internal medicine.
As a parent, I am likely to attempt a daddy track in the next few years, but this I think would be just as likely if I were a generalist or a subspecialist. I suspect that most GME applicants are savvy enough to understand that the preconceived notions of how one behaves as an "-ist" are irrelevant to our adult choices.
I agree that it is amazing to look at the growth in the number of program requirements that are published in the Green Book.
As a surgery program director, one of the satisfying things is observing a new intern come into the program who can barely tie a knot and has no operative skills and over the course of 5 years develop into a mature and competent surgeon. I really do not know how we do it. How does a person who has some book knowledge learn when and when not to operate on a wide variety of diseases, learn the technical aspects of surgery so that he/she can do complex cases in their practices, learn critical care so that they can care for patients with multisystem trauma or organ failure in 5 short years?
When I think about this, I wonder if 5 years is enough time to adequately train a general surgeon. Do most need more time? This brings up the question, "What is the real purpose of a residency, whether general surgery or other specialties?" I believe that the faculty and the residents are in a program to learn the specialty. Some of the additional requirements have nothing to do with specialty training. Specifically, some of the core competencies require additional work and effort and in order to satisfy the requirements and may take time away from, or emphasis away from, the specifics of the specialty.
While I support the concept that physicians must incorporate these competencies into their practices, I believe that adding them to residency training may not be the appropriate time or place. We should be screening for individuals who have these character traits before they enter the medical profession. These should be emphasized in undergraduate training (as a part of a pre-med curriculum) and in medical school. They can be reinforced in a residency, but the primary emphasis of a residency should be on “patient care” and “medical knowledge” as it relates to the specialty training.
From my perspective, it would seem that program requirements are being added as a reaction to public influence. Yes, we should be responsive to the public’s concerns, but we as a medical profession should make sure that our response is not placing the primary purpose of a residency at risk. I have no doubt that we can educate and train our residents better, but I still contend that the primary focus and what a program should be judged on is: "Are the residents receiving good training and education in the specialty?" Or another way of putting it is, "Is the program’s finished product a good physician who provides excellent care to his/her patients after leaving the training program?"
In addition to the important issues you raised is the increasingly condescending approach taken by hospitals toward physicians. Hospital administrators increasingly view themselves as the bosses and treat physicians as employees, creating more and more requirements and paperwork without any good reason. I believe hospital administrators are contributing to the desire of physicians to stay away from hospitals and work in environments over which they have more control.
Normally, I would simply delete the usually irrelevant e-mails from your office, but your missive on the supposed "mincing" of our profession is so disingenuous and so profoundly divulges your complete lack of understanding of GME that I can't help but reply.
The painfully obvious reason for the proliferation of specialties is the exact same reason that health care is so expensive in this country: Health care technology has exploded, and our country's appetite for this technology has kept pace. When a child falls off the monkey bars at the local playground and has a temporary loss of consciousness, her parents will dutifully take that child to the local ER for a CT or MRI of the head.
Closer to my home, fully 50% of the patients referred to our university rheumatology division for treatment of rheumatoid arthritis are incorrectly diagnosed. This is not to insult the referring physicians, but to point out that the remarkable technologies now available for treatment of rheumatoid arthritis require a commensurate level of technical competence to correctly use. If our society wants this technology, it will need to deal with the increasing specialization in medicine required to use this technology appropriately.
Although some component of the specialization trend may be due to lifestyle issues, specialization has been going on in medicine and multiple other sectors for the entire history of mankind. It is a natural process. To try and halt it is a waste of time. Instead, we should seek to understand it and manage it the best we can for the greater good.
Front-line patient care is specialized, as much as subspecialty care (more accurately proceduralists). As a physician whose father recently had a PCI, I searched for a cardiologist whose entire practice was catheterization. Why would I trust my father's health to a cardiologist who only performs the occasional PCI? Many studies (not all of them are medical studies) show that people who do the same tasks frequently have better success. The old adage "practice makes perfect" is clearly true in procedural care.
As an emergency medicine physician, I would argue that specialization in all categories of medicine is a good thing for the public—especially in the field of emergency medicine. Clearly, physicians who specialize in one facet of medical care have extra knowledge in that area. Physicians trained in emergency medicine are very good at picking out "sick" from "non-sick" patients. In fact, I train my residents in this skill every single day. After a few years of experience, my residents clearly understand how to make quick decisions on the level of illness of patients at the triage desk. As a corollary, residents from other services (i.e., Internal medicine, surgery, OB/GYN, pediatrics) do not possess this knowledge and skill base.
In matters of emergency and critical care, seconds and minutes are precious commodities. I, for one, would not want to be treated by a non-emergency-medicine-trained physician if I had a bona-fide emergent/critical condition. However, if I had to find out the best ways to control diabetes for a patient, I would never look to an emergency medicine physician . . . we simply do not have (or want) that expertise.
From time to time, I am able to watch those "real life" TV shows. Those medical broadcasts are illuminating—when non-EM physicians perform resuscitations, I cringe at the mistakes that I often see. This supports personal experience that I've had. During my educational experience, I was witness to the filming of a "trauma" show. The trauma team took over the level 1 resuscitations during the filming periods. It was embarrassing to watch them fumble through the ATLS algorithm. Why did the trauma team have trouble with ATLS? It was because in this hospital the Emergency Department usually handled the first stages of trauma care. The trauma "specialists" were not used to performing the ABCs appropriately. A colleague of mine said it most eloquently: "Don't they know that this is being broadcast on public TV? Why would anyone want to demonstrate how they are committing malpractice?"
Indeed, specialty care is a good thing because specialists routinely perform procedures that nonspecialists do not.
Specialization is undoubtedly a reflection of many things. I am an "MS doctor" who sees only patients with MS and related diseases. For me, this allows me to stay on top of a very complex, chronic disease and provide comprehensive care. To many of my patients, I am the first person they call with ANY problem. The "primary care doctors" frequently know little if anything about MS, as they need to deal with hundreds of problems, and usually have little if any neurology training. For the patient, this gives them a doctor, really a team of professionals, who understand their complex disease and can help them with it. Usually, once they see us, they don't even wish to return to their general neurologist, much less a PCP, for their MS needs. Thus, I think caring for chronic illnesses is one example of evolving specialization which suits everyone's needs well. There are many other examples.
The evolving complexity of medicine is pushing us toward this. And to be clear, those who lament the loss of a long-term patient-doctor relationship with all this specialization insult those of us who have incredibly rich, long-term relationships with our patients while we provide specialty care. I doubt any PCP knows his/her patients any better than I know mine.
Why make the question and answer of increasing subspecialization so difficult?
This is the natural evolution of exponentially growing knowledge. The larger the database, the more need for categorization and subcategorization.
An interesting observation that is self-damning as well. Yes, there are more subspecialties, but for every new subspecialty the ACGME has added 5 new pages of requirements. The process of accreditation is becoming overly burdesome. If you guys figure out why this degree of bureaucracy needs to exists in the ACGME it won't be hard to figure out the answer to your own question.
Many of the "new" subspecialties are carve outs from previously established specialties. We now have bariatric specialties, and surgical oncology specialties that didn't exist before. Now throw in very questionable specialties like geriatrics and the numbers add up. (Is there really that much difference in taking care of a 65 year old and a 66 year old that we need a new specialty? I really doubt it.)
Then you have the new mandated specialties—there used to be pulmonary and we took care of the critically ill. Now there is a seperate critical care fellowship. Not to be outdone the anesthesiologists now have "critical care fellowships" in spite of having never rotated on a medical subspecialty rotation. The surgeons of course can do things better than all us dumb fleas so they also have "critical care fellowships" (after all, every surgeon is born with 3 years of knowledge that the dumb medical resident toils 3 years learning) so they can operate all day and run an ICU with critical patient from the OR.
You ask where and why all these new subspecialties came from and why the program requirements are so lengthy—it's because the ACGME will approve anything as a subspecialty. I'm waiting for the GI specialist who only does colonoscopies and refers out for the EGD. After all we have hepatologists now. Not long ago when I was a resident the GI attending knew liver disease. Now ask one of them to come out of the EGD lab to see someone in the hospital with liver disease and you would think you'd asked them to kiss their sister.
The process of super specializing training does a disservice to the fellows who don't get the breadth of exposure they did in the past unless they stick around at miserable pay rates to be a hepatologist, or finish a third year to get critical care training. Perhaps that's one of the answers: Cheap help is hard to get, so let's make a new fellowship out of something we already were training them to do, then we get them another year or 2 to do the night call and cover the holidays cheaply. You ask why the explosion—you allowed it to happen.
As a practicing pediatric orthopedic surgeon, and chief medical officer of an academic medical center, I have been very involved in the crisis brought on by subspecialization and the creation of specialty hospitals that allow surgeons to practice outside the community hospitals and thereby avoid call. Although my specialty is pediatric orthopedics, I took general trauma call for 27 years. Several observations:
- Specialization and subspecialization allow us to provide very highly specialized care, which in many cases is very desirable. We are headed for a disaster unless we figure out a way to have a sufficient workforce to provide more routine care.
- A big part of the problem is lifestyle and you can't change that by dictum. Money however, speaks. If the CPT coding system rewarded the things we need to see done you would be able to attract more people. If you get paid $18,000 for a 2 level elective cervical spine fusion and $800 to fix a broken hip or $2,000 to take care of a trauma victim in the middle of the night, which would you chose?
- Specialties need to develop core competencies that must be mastered and maintained if you wish to practice that specialty. We have residents that are perfectly capable of fixing fractures who after a year of fellowship suddenly claim they don't have the skill to do so. Require that these competencies be part of initial board certification and of recertification until a certain amount of time has elapsed.
- You can't mandate ethics either, but medical students need to be taught that there are certain responsibilities that come with the turf. Some have suggested making call coverage a condition of licensure. I think that would be hard to enforce. There are MDs who do research or a variety of things that make them incapable of taking competent call.
Your observations and questions have been on the minds of the primary educators for several years now. Attempts to obtain real scientific evidence as to student choices have had mixed results…but students do acknowledge that prestige and lifestyle are better in the subspecialties (the Arizona study, Future of Family Medicine quantitative data, etc.). However, the problem is real and must be addressed. Both international data (Starfield) and national research (Health Affairs, spring 2004) confirm the obvious: a health care system is only as good (in efficiency and quality) as its primary care infrastructure.
If one looks at the medical model of care in our country, it is easy to see why we are where we are. We study organs, not organisms (hepatology); we emphasize knowing a disease rather than the patient with a disease (diabetology/chronic disease management programs); we pay billions for molecular research and an amount equal to about one percent of that for patient/practice-based systems research (NIH vs Title VII); the payors value (pay for) face-to-face care rather than population health care (patient management fees, group visits, e-communication, and other patient-preferred varieties of care), which engenders hamster wheel office care—and loss of relationships—while encouraging the new, and often expensive and often unnecessary, technologies—proceduralists over cognitive physicians. We treat diseases, we don't keep people healthy; and, finally, we have not valued (at least enough to demand it) an integrated health information network where doctors, hospitals, and other community providers can communicate with each other about our patients, find real-time information technology decision support, and analyze our practices for quality improvement and safety.
There is no question that most of us have benefited from many scientific advances, and my comments should not be interpreted as antiresearch. I just believe that we have not applied the philosophy of moderation, of recognizing the need to value primary care and help support its necessary changes in infrastructure to become that great primary care foundation our system needs.
As I talk to students around the country, I bring up these ideas and ask a simple question: ”Who is going to take care of the people?”
Everyone keeps adding more and more requirements. For example, the core competencies. Some are simply a restatement of tried and true needs such as medical knowledge. But "systems-based practice" is an area that has not been heard of until late. I know the medical system is complex, and sometimes coordination of a patients care is indeed time-consuming and does require specified knowledge. But why do we need to define it and measure mastery? It looks good on paper to say we teach and measure this. However, does this ensure that our graduates can indeed make better referrals or navigate the system with more ease?
The same is true of the core competency of professionalism. As program director I know a professional when I see one, and for 50 years we have produced physicians who are professionals. What need is driving the quantification of a qualitative measure?
Yes, the people at the ACGME are well-educated, and some changes are improving training. Some changes are also needed because medicine is ever-evolving and we need to keep pace. What is missing is the broad view. We are getting so caught up in the minutiae that we lose sight of the big picture. This causes all of us to jump through hoops for no purpose other than to prove we can.
Every change should meet the standard of improving patient care. If we cannot prove a measure leads to enhanced patient outcomes then we should not initiate it. Let our leaders focus on this instead of on every educational measure thought up by some PhD or other.
Regarding subspecialization, we live in a world where everyone expects to go to the best and brightest and get the best care. In our major cities physicians are commodities. Subspecialization is often the route to attracting a patient base. How else can one compete against the 50 other similarly trained doctors in your neighborhood? The fact that organized medicine recognizes another new specialty does not create the need but it validates and encourages it. This is a commentary on our society that expects instant cures for a lifetime of obesity, smoking and living to excess. Until that changes the Green Book will forever keep growing.
From the recent data on medical residents' preference of subspecialty fellowships over primary care, and my observations of candidates for GI fellowships, it is clear that primary care internal medicine is no longer desirable. It may be due to multiple factors well known to my primary care faculty colleagues: increasing requirements as in P4P, reduced reimbursements, longer hours (while housestaff have duty hour limits), liability pressures, HMO pressures, increasing knowledge base, unfunded mandates, etc. This is certainly a crisis and the leaders in internal medicine and family medicine are well aware of most of the issues. The subspecialists and primary care providers must find common ground to look for solutions to this crisis.
Driving specialization is the patient's need for better clinical care through the doctor's mastery of comprehensive specialized knowledge and skills. The "frontline" of patient care involves most specialties, and most doctors do not consider their duties onerous.
There is no question that the wave of specialization in medicine over the last 100 years has provided incredible advances in medical care. "Letting our profession become minced into smaller and smaller pieces" puts a negative connotation on these advances made possible through specialization.
Many of your premises appear to me to be naive and incorrect.
This is an interesting question. I think there are many forces at work to cause increasing specialization, including physician factors, market factors, and patient factors. Physician factors include the tendency of compulsive people to become doctors in the first place. The compulsive studier is more likely to get into medical school. Then we make them memorize a zillion factoids to enhance their compulsivity. If they don't get it right on the test, medical students who have excelled in the past (under lesser workloads) become anxious because they are unable to master the material they are presented. Those who are unable to control their anxiety have to select finite fields where mastery is at least a possibility, rather than general fields where one can never say that they get it all. Lifestyle issues are important, but in my experience with medical students and residents, it is anxiety aversion that is more important deciding factor.
The market issues are about payment for thinking rather than doing, and for caring rather than for curing. As a neurologist I am compensated less for doing a difficult history and examining a patient than a procedure-oriented person is for doing a procedure that takes the same amount of time. I could save the system unnecessary MRIs and tests if I do this, but the system does not value it. The system can "see" the repaired limb or heart, but cannot understand the details of knowledge, skill in patient assessment, and the holistic approach I use in patient diagnosis and management. And I didn't "fix" the patient, which is the purpose of medicine anyway, isnt it? Why then did I not spend the same number of years to train to become a general surgeon or orthopedist? I ask myself that fairly often.
Patient expectations are also a problem. Of course each patient feels that they are the only one their doctor is looking after. So the person who has to put it all together and interpret the specialist's recommendations to the patient, the generalist, is left holding the bag of scut handed down from a bevy of specialists. The generalist is expected to know everything about a given patient, that is, everything about all the specialties too. And once again, the generalist is not rewarded financially for thoughtful care and handling all the day-to-day and night-to-night issues. Meanwhile, the specialists are told not to see patients often in follow-up because they don't get paid as much on an hourly or RVU basis for follow-ups as they do for new patients. So the generalist is again left with unresolved specialist issues, and the patient is left half cared for.
I think that superspecialization can be good when it involves rare or delicate procedures or disorders. So saying, I believe that superspecialists belong only in tertiary care centers and academic health centers so that their special knowledge and skill can be used by a large number of people. I also think that the technology advances need to be sorted out in an academic setting before going into the community, so that patient need drives the technology, and not the other way around.
As an example, intravascular therapy for carotid stenosis was not on our menu at my institution until this year—now we must decide who gets this new technology and who should have operative or medical therapy. Hopefully we base our decision on evidence, and not on marketing from the stent developer or interventional radiologist, so it avoids the "if you build it they will come" mentality.
On the heels of your question comes testimony to Congress, delivered by Dr. Vineet Arora.
I'm sure there are many reasons for specialization, but certainly the economic one is very compelling. Until Congress and insurers begin to place more value on primary care physicians, the growth toward specialization will not be halted.
We can look at these issues from the following perspectives: Patient, population, and physician.
1. Procedures
There are benefits to the patients when someone does only certain procedures and become an expert in them. That person's expertise, however, is not readily available to all who might need that procedure. The physician gets reimbursed well and may even ask for more than the reimbursement rate if his expertise is desired by the patient
- Patient benefit: yes
- Population benefit: no
- Physician benefit: yes
2. Too many physicians in sub- and sub-subspecialties
- Patient benefit: no (fewer primary care physicians for coordinating fragmented care)
- Population benefit: no
- Physician benefit: yes
3. Less primary care
- Patient and Population benefit: no (less access)
- Physician benefit: no (increased workload and poor reimbursement)
4. Hospital medicine being chosen over ambulatory practice (because of higher salary, more manageable work hours)
- Patient and Population benefit: yes
- Physician benefit: yes
5. Ambulatory primary care practice—low reimbursement for physicians, with ongoing Medicare cuts. So physicians specialize to avoid this. Who suffers? The patient and the population.
To address these issues in GME, we need work at national levels through the AMA, ACGME, and other specialty professional organizations. Perhaps specialty practice could be mandatory prior to sub-subspecialization. Finding solutions to these issues may help us address the lack of basic health care for the 40 million uninsured and underinsured while providing specialized training.
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