How Special is Too Special?

Scott Haig

The old man in the suit wasn't going to grade us and his stories weren't going to help us pass our board exams. It showed; the general surgery team fidgeted and rocked as he spoke to us at early Saturday morning "guest-attending rounds." He was a little stooped and white-haired, but no geezer. He wasn't one of our Ivy league professors of surgery, specialists in their elite yet narrow fields, but rather a 70-year-old doctor who had gone to our medical school before there was penicillin. He'd lived out his career someplace in Western New York - someplace where he was The Doctor.
Our guest had done it all: took out gallbladders and appendices, delivered babies, pulled teeth, set fractures, pinned hips, even opened skulls when the pressing blood threatened his patients' lives. The rest of the team was clearly a little bored with this Jack of all Trades. He noticed it and I flushed with embarrassment for him. I connected with this little man. Head, hands and heart devoted to the sick, he could handle any problem. He was the doctor I wanted to be. This was 25 years ago.
The broad professional competence that our guest had was a great blessing to many in his community. It is also, unfortunately, soon to vanish from American medicine. Even our general practice physicians - who don't do procedures like surgeons do - are fast changing from prescribing docs to "medical distributors" : farming out the problems they find to specialists. (Pneumonia? See the pulmonologist. Tonsillitis? Ear, nose and throat doctor.)
There are clearly good reasons for this; medicine as a whole is getting better and we expect higher levels of knowledge in our docs. I certainly wouldn't want anyone but a neurosurgeon dissecting a tumor out of my brain, or anyone but smart oncologist coming up with the drug cocktail that might save my life from a cancer. It's usually not that hard, though. The great
bulk of patient visits are for really simple things - questions that a reasonably bright resident would get right. Most pneumonias, for example, are pretty easy to treat; the internist should have no trouble doing it himself. But sub-specialization is the trend.The reasons for this are tied
up in ego, education and mostly economics.
The ego thing is a medical classic. Just follow the cliches - BIG specialist, little old family doctor. Yes, the impressive title might still be a huge deal for some, but it really does seem that the kids in med school now are a little wiser and promise to be less esteem-driven than past generations. That's good because they promise to be more fully orbed, empathetic humans; but it's also bad because they take a lot more time off. The big egos of my generation pushed their owners through quite a bit of extra hard work.
Education in medicine means residency and fellowship. Residency is, for some, very pleasant - a long continuation of at least some of the comforts of childhood. When you're a resident, the chairman is always right. You rotate off services - the worst disaster patient is somebody else's problem at the end of six weeks. There's no office to run, no payroll, insurance, rent etc. You only do the interesting part of the job: medicine. Long fellowships and residencies prolong this state. And produce a bunch of narrow specialists.
The strongest push toward specialization, however, is financial. And the crowd follows the money. Ophthalmology presented a great example of this. Back when Medicare payed $5000 for taking out a cataract, fully half of the class of medical students I taught were trying to get ophthalmology residencies. (Although three-fourths of them had declared "primary care practice in under-served urban environments" on their med school applications. ) Now that a cataracts pays $600, there are maybe a couple kids per class going into the eye field. Because specialists did more training, because they use more expensive parts and pills, because they (might) handle more dangerous situations, because there are fewer of them, they tend to get
more money than generalists.
So whom do you go to for what? Unless you have a close friend or relative in medicine, you still need a good generalist - someone who knows you and knows the ropes. This is going to take effort and maybe some money; there are fewer of them and HMO fees are so low that many won't take on new patients except as a favor. This is especially true for the good ones who really
spend time and develop a relationship with their patients. Internists vary tremendously. Some treat everything, some just do check-ups and referrals. If competent, the former will save you a lot of anxiety, waiting-room time and money. They will treat the pneumonia or the backache themselves, instead of sending you to the pulmonary doc or orthopod.
Will there ever be a truly general surgeon like my guest attending back in med school? Probably not. At least not anywhere they have running water. The training programs for different types of surgery have evolved too far apart. And, of course, the malpractice lawyers would take the guy's house the first time a patient didn't do well.
The trend to specialize and now sub-specialize ("He only does knees") is playing havoc with emergency medicine, too. How can a neurosurgeon who "only does back surgery" be on call to treat head trauma in an emergency department? General surgeons, right now, are a dying breed; their residency programs have failed to fill for the past few years. As the specialists narrow down and lose competence in their "parent" fields, they will necessarily leave certain patients without needed, basic care. It's a serious problem that calls for a nationwide strategy.
Yet the real fun of our field is putting it all together and getting a happy human being out of one who came in disturbed by a problem. Keeping up one's interest level in treating only a narrow patient population can be a challenge. I do mostly shoulders (that's my sub-specialty) , but also hands, knees, hips, various fractures, a few feet and, unavoidably, some backaches.
Despite the backaches, general orthopedists are pretty lucky still to be able to have this run of the body. I couldn't imagine just putting in 10 total knees a week, 49 weeks a year, until they carried me out toes up. It is clearly less stressful and likely more profitable to do just one "special" thing but, at least in our eyes, it can't be as interesting. And for patients with common, messy, low-paying diseases, it can't be as helpful.
(AAFP)