The Hyper-Specialization Cliff

I remember my first day of clinical rotations like it was yesterday. I had my fresh short white coat, my gently used stethoscope, an eye card, my reflex hammer, a pharmacopoeia, and the handy survival guide for clinical rotations that our medical school provided. I felt ready. I was going to heal people.

I learned very quickly that a lot of care for patients admitted to the medical service at a county hospital had very little to do with healing. It was more about mitigation, addressing social issues, dealing with the lack of a medical or societal safety net for some of our most vulnerable community members.

As an a medical student, we each had to pick up 4 patients on call. We would obtain the medical history, perform the physical exam, often draw our own labs, wheel patients down for x-rays (we could not get a CT or ultrasound at night and MRIs were rare as hen’s teeth), perform our own EKGs (and try to interpret them), and most importantly, formulate a differential and plan.

If you had a good senior resident, then they gently led you in the correct direction. If not, then after morning rounds with the resident team, me and my fellow medical students would head to the library where we would pour over Harrison’s or another medical reference trying to find answers.

I new my calling was not internal medicine when after presenting my first patient to the attending where I reviewed the diagnosis and plan for a patient we admitted with diabetic ketoacidosis, he asked for my differential diagnosis. I stood there confused. We had “the” diagnosis so talking about other possibilities seemed like a waste of time to me when we had 19 additional patients to see followed by hours of work to implement the plan.

My senior resident chimed in with a brief summary of what we discussed last night and we were able to move on. The pace of rounds frustrated me and I was more interested in solving problems and doing procedures than perseverating on obscure causes of the common diseases we were caring for.

As I progressed in medical school, my path took me further and further away from this tradition of considering differential diagnosis based on physical exam, laboratory, and imaging findings to more technical aspects of the care we deliver. I gravitated toward surgery first which I enjoyed. However, general surgery did not appeal to me because I felt they were jacks of all trades and masters of none. Hence I delved into the surgical specialties and found my home in Urology.

After finishing medical school, I had two years of surgery to contend with before being able to devote my efforts to urology alone. It is during those two years that I truly learned how to care for sick people and I often thought back to those Medicine rounds wishing I had learned how to read EKGs better, that my physical exam skills were better, and that I could come up with a longer differential diagnosis than three possibilities especially when those three didn’t hit the mark. I rotated in the cardiac and surgical ICUs where often I was the only doctor at night having been told by senior residents to “call me if you need me but need me if you call me.”

The most striking example of where I truly needed to be a doctor first and a surgeon second was in the ER. We did not have an ER residency when I began my training and as a second year resident, I was responsible for evaluating all the patients triaged to the surgical side along with my intern. Sure, we could call the ER attending but they were often overwhelmed on the medical side. Night after night, I would have to try and figure out the potential causes of a person’s abdominal pain. Often, they were not surgical but once triaged to surgery, they were my patient to try and come up with a disposition.

After I survived my time in general surgery, I was able to focus on Urology. However, Urology is a surprisingly broad field where we care for a variety of problems from kidney stones to cancer, metabolic disorders to incontinence, children, women, men, and elderly patients. Despite enjoying the variety, I still craved technical mastery and chose to specialize in oncology and minimally invasive surgery. I completed my fellowship and have been an academic Urologist for almost 13 years specializing in kidney, bladder, and testis cancer. I still manage common urologic problems on call and see a fair number of patients with hematuria and elevated PSA in my clinic but my practice is focused on a narrow group of patients and heavily emphasizes surgical care.

Why am I telling you all of this? My experience is very similar to many specialists and even many “generalists” wind up developing a niche over time. The reason I am writing about this is that I believe that our excessive specialization in medicine is creating harm for both our patients and for our profession. Let me break it down.

On the surface, specialization offers patients the opportunity to see a doctor who has laser-focused expertise in their problem. This should result in better outcomes for the patient and for many complex surgeries, there is data that supports that a surgeon with high surgical volumes produces better results than a lower volume clinician. This assumes that a patient has a diagnosis but when they don’t, a patient must often go from one doctor to another to try and find answers. Sometimes the dots get connected but the more common scenario is that the specialist is only able to rule out that the patient does not have the problem that they treat. Even when the doctor possesses the skill to dig deeper, they often do not have the time required to think about the differential diagnosis and complete the necessary problem solving that goes into less common disease identification. This is the time when a patient needs Dr. House and they are nowhere to be found.

The bigger problem for patients is that specialization limits access to care. For example, in an academic medical center, physicians often limit their practice to a small number of diagnoses based on their clinical and research interests. This leaves patients with some diagnoses on a long list waiting to be seen potentially leading to delay in diagnosis and care. I often tell my colleagues that while most of us are sub-specialized, except for pediatric and pelvic floor urology, there is no specialty board and that all of us should be able to function as general urologists. Even our colleagues in community practice are specialized through a process of elimination based on interest and resources and often patients are forced to seek care outside of their local community incurring additional costs to help manage their disease.

More insidious is the attitude that some clinicians develop based on their specialization. They approach their patients’ medical care with a hammer and every disease they see is the nail they treat calling into question the appropriateness of a patients’ care.

And while these are huge problems especially when access to care is a major problem for many Americans, this hyper-specialization is hurting us as doctors as well. Our training programs are perpetuating a model of sub-specialization that may not be preparing our trainees to go out and meet the needs of the patients they are expected to care for. In the best of circumstances, these doctors have partners that can help them or a referral center nearby to help them solve problems for their patients. In the worst of cases, though doctors without a safety net feel put out on a limb potentially leading to bad outcomes.

In these cases, patients often seek answers to their medical problems outside of conventional medical care. Sometimes these can work but they are just as likely to be ineffective, costly, and potentially delay definitive care. Overall, this weakens the role of doctors in communities leading to frustration on both ends.

Perhaps the greatest problem for physicians of this super-specialization is the psychological distress it can create. We want to be able to help the people that come to us for help. They sometimes have problems that we should be able to fix but we lack the general knowledge to do so. Our sub-specialization is likely a source of burnout as it has made us overly reliant on systems resources which narrow our autonomy and take us further away from serving patients which is what has brought us to medicine in the first place.

There is a third aspect to hyper-specialization which impacts us all as a society. Because many doctors know only a small slice of medical care, we have become overly reliant on referral to deal with care that we should be able to manage. For example, I learned how to work up chest pain and evaluate cardiac fitness for surgery as an intern and resident. I could still easily order a stress test on a patient with a cardiac history prior to surgery but I also know that the anesthesiologist will want clearance from a cardiologist prior to surgery. So I make a referral to a cardiologist. Many of our consults are wasteful not only because we can do the necessary work-up but also because they sap time away from the doctor seeing the referral to provide more complex care. This adds cost without a tangible benefit. There are many examples where either we refer for convenience or because of health system norms that do not serve the needs of our patients.

Hyper-specialization also leaves potential gaps in care for communities that cannot attract a specialist or do not have the volume to support the specialty practice. This is a huge problem for rural communities that are increasingly losing hospitals that cannot remain solvent due to a lack of medical staff that can help care for a population and maintain a bottom line.

We can solve this problem and both help ourselves and our patients. Taking a page from medical systems of other countries, we could require medical graduates to serve time as general physicians in underserved communities. This would help alleviate issues of access to care. It would also allow new graduates to continue to expand their general medical knowledge. These new doctors could continue to receive educational support from their medical schools through didactic training and access to faculty for advice and expertise. This service could be compensated through salary and by paying off part or all of a new doctors loans. The money to make this happen could come from both insurers and hospitals who would see cost savings by allowing patients to continue care in the lower cost setting of the community or offsetting the need to seek emergency room or higher level care through improved access. Thus, the opportunity cost for a young doctor would be mitigated and they would continue to gain valuable experience to improve the care they deliver in the future. It would also help re-establish the vital relationship between doctors and a community.

For practicing physicians , solving this problem is more complex. However, there are things that we can all do to help us increase our relevance to more patients. First, continuing to take call keeps most of us connected to our broader specialty. The trend toward paying doctors for emergency and consult call appropriately acknowledges the time and effort required to do this work but it has allowed some physicians who are busy with their clinical practice to recede from the life of the community. Rather, some call expectation should be linked to clinical privileges at a hospital as was the common practice in the past but as support for this effort, physicians should receive loan repayment. Even though I am a specialist, I take call at a community hospital where I operate and also cover call at one of our affiliated hospitals a few times a year. Sure, I get paid for it but I also benefit from being able to continue to practice general urology and reduce the overall burden of call for my colleagues who primarily practice at these sites.

While there is no going back to the day where a local community doctor delivered a baby, performed an appendectomy, and provided for all of their patients needs, I believe our current system has gone too far and we need to find a way to reconnect with why we started on our medical journey- to care for people. I believe we benefit both our communities and ourselves by walking back from the hyper-specialization cliff.

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