The (sub-)sub-specialization sham.

In Featured by Edmund Kwok17 Comments

There was a time when your doctor did everything. Sore throat and a nasty cough? You’d see your doctor. 40 weeks pregnant and about to give birth? Your doctor would do the delivery. Your child slipped and broke a bone? Your doctor would splint and care for the fracture. Hell, if you had an appendicitis, there was a good chance your own doctor would be doing part (if not all) of the surgery.

Fast forward to 2012. We have specialists in everything from specific parts of your heart to your left pinky toe. One cannot make it through a year of medical ailments without being referred to a host of various specialists; gone are the days when your primary health care physician actually took full care of your health.

That’s a good thing. Or is it?

The benefits of specialization are easy to appreciate from the perspective of medical progress. Our knowledge and advances in medicine has exploded since the early 1900’s, when the medical profession first recognized the need for officially recognizing (and board certifying) various specializations beyond a generalist. Extra training and dedication is required for true specialists to learn and to further the intricacies of their specific field. Cardiology and Orthopedics were once subspecialties of Internal Medicine and Surgery, respectively – today, it is difficult to envision them as not being their own rightful independent fields of medicine.

But have we gone too far? In the endless pursuit for greater excellence and advancement, many physicians are spending more and more post-grad years in fellowships of extremely niche areas. No longer are we talking about a physician who specializes in bones, but one who sub-specializes in shoulders only (and even those who only sub-sub-specializes in cancer affected joints). It is not uncommon these days to have your broken ankle fixed by one orthopedic surgeon, but referred to another surgeon for your recurrent shoulder dislocations – because he/she is the “shoulder guy”.

I’m picking on the ortho guys – this is actually quite widespread throughout the medical system. We have internists who only look after diabetes and its complications; should they even still be called endocrinologists, or even general internists? We are training radiologists to only read certain types of imaging, and of only certain body parts. Cardiology fellows spend extra years with the hopes of only performing PCIs, or only dealing with electrophysiology-related issues.

Are doctors whole doctors anymore?

The bigger societal question we should all be asking is this: is there too much sub-specialization going on, especially in the setting of an ever growing physician shortage? A small percentage of the population may benefit from the extreme expertise of all these specialists – but an exponentially larger percentage of our population are having trouble even finding a regular family doctor. In 2007, 1.7 million Canadians aged 12 or older were unable to find a regular physician … and our physician-to-population ratio is projected to fall even more in the coming years.

What’s really crazy is that I know many, many friends and colleagues who, after years of medical school and residency training, remain unemployed! A majority of them want to stay in a large urban center, even though that’s not where the work is (the true need is in more rural communities). In a bid to increase their chances of landing a job in those competitive and saturated markets, many physicians are choosing to further sub-specialize – even in fields that they aren’t even truly interested in.

I think the main problem is this: there currently is no guidance and/or control over what physician/specialist mix the medical education system is supposed to produce. The government may short-sightedly increase medical school enrollment, but that will only perpetuate the problem without restrictions on how many of each speciality/sub-specialty we should train. We need to take the time, and really examine the healthcare needs of Canadians in various communities, and tailor an appropriate mix of physicians and specialists to fill those needs; no more, no less.

The brakes should be put on this runaway train of over-trained and over-qualified physicians before our physician shortage reaches a greater level. Maybe we should once again let our doctors be whole doctors treating us in a patient-centered way, instead of a jigsaw puzzle of sub-specialists treating us in a disease- or organ-centered manner.

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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