KNOWING A LOT ABOUT A LITTLE: THE MYTH OF MEDICAL SPECIALIZATION

by Steven Goldsmith MD

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KNOWING A LOT ABOUT A LITTLE: THE MYTH OF

MEDICAL SPECIALIZATION

by Steven Goldsmith MD

“He said my bronchial tubes were entrancing,

My epiglottis filled him with glee,

He simply loved my larynx

And went wild about my pharynx,

But he never said he loved me.”

— “The Physician,” Cole Porter

Why can’t your doctor cure you? Why despite your countless medical appointments, are you still unwell? A major clue lies in the metastasis of specialization and subspecialization throughout my profession. Until the early twentieth century, other than some surgeons the great majority of U.S. physicians were general practitioners. Virtually no professionally recognized specialists existed until the birth of the first residencies in 1927 and the establishment of medical specialty boards in the 1930s. In 1940, 24 percent of U.S. physicians specialized, with 76 percent GPs, who remained jacks-of-all-trades, operating, delivering babies, and tending to all medical conditions. Since then general practitioners gradually disappeared into virtual extinction like the medical house calls they performed. MDs with generalist, primary care inclinations entered instead the fields of general internal medicine, pediatrics and, since 1969, the new oxymoronically billed “primary care specialty” of family medicine—essentially general practice minus surgery and deliveries.

Meanwhile the trend toward subspecialization accelerated. For example, of those physicians entering internal medicine residencies, the percentage choosing eventual subspecialties (e.g. endocrinology, infectious disease, cardiology, nephrology) rose from 7 percent before 1960 to 64 percent by 1990 to 88 percent by 2015. By 2015 the percentage of subspecialty practices among all U.S. physicians was 67 percent. At my alma mater, of the 121 graduates of the Columbia University Vagelos College of Physicians and Surgeons Class of 2019, zero chose a family medicine residency.

Multiple factors have influenced this trend, but crucial among them is the value Medicine and society confer upon expertise within smaller and smaller realms of knowledge. Those who master these ever-contracting realms become the ultimate arbiters of truth. We accord specialists greater esteem and deference than we do generalists. Specialists are those we must seek when generalists throw up their hands. To acquire certifications in their specialties they train for another one to four years. Because we equate their greater length of training with greater value, we pay specialists higher fees. Subspecialists are the elite of the elite, the court of final appeal for decisions about diagnosis and treatment; if they don’t know, how can lowly generalists know? We fete the reputations of “brilliant” neurosurgeons; but when is the last time you heard of brilliant family practitioners?

Unfortunately Medicine’s wholesale specialization has not improved society’s health, which has declined big time, as my previous posts note. Instead specialization has fragmented care so that the individual at the center of the symptoms gets lost. It also increases the expense of health care. Most of us have a primary care physician or PCP, aka the gatekeeper, who dispatches you to different specialists for different problems when s/he cannot diagnose or cure you. Our medical appointment schedules can resemble the proverbial cross-European vacation: if it’s Tuesday, this must be my cardiologist’s office; Wednesday, my dermatologist’s; Thursday, my neurologist’s; Friday, my psychiatrist’s so I can get a drug for the stress that all my medical appointments produce.

But wait. Surely the explosion of knowledge in the biomedical sciences within the past century necessitates specialization. What physician can possibly learn about and remember so many new diseases, procedures, and medications, especially if s/he is a primary care physician charged with the evaluation of every non-surgical health problem under the sun? Specialization, the argument goes, is the inevitable result of greater volumes of knowledge. We cannot stem this trend any more than King Canute could halt the ocean tides. But the explosion of medical knowledge has not stemmed the tides of disease for a simple reason. The knowledge that has exploded has concerned the diagnosis and treatment of ever smaller and more isolated entities—molecules, cellular components, microbes, pathophysiological processes in one or another organs or tissues—but not the diagnosis and treatment of whole people.

To examine how we vastly overvalue specialization, imagine you have a nasty sore throat—painful, red, accompanied by swollen glands and a fever. Question: What part of you helps you to recover completely from that ailment, helps you to heal yourself? Answer: In order for you to recover fully, your immune system mobilizes. It orders all hands on deck, producing microbe-fighting cells, antibodies, and the like. Your vascular and lymphatic systems accelerate their circulation in order to deliver to your throat materiel (cells, chemicals) to combat the invasion while they remove debris and toxins from the area. Your nervous system superintends your thermal regulation so you generate a fever that kills the microbes. Your endocrine system produces corticosteroids and other hormones that boost your response to this stress. The network of cerebrocortical associations among the nerve cells in your brain enhances your ability to deal with this illness, providing you with the mental wherewithal to call in sick to work, drink plenty of fluids, take Tylenol. Your renal system will excrete or retain fluids as your system requires. Multiple interacting systems—nervous, muscular, skin, thermoregulatory—will cause you to perspire if your core temperature is too hot or shiver if it is too cold. And if your general vitality is less—you feel run-down, tired, under the weather—you may have a harder time recovering, in which case the sore throat lingers or recurs. So your overall vitality needs to be up to snuff. In short, the part of you that helps you get well is . . . ALL OF YOU!

You accidentally slice your finger with a knife. If it requires no sutures the cut will heal in a few days. But how? What part of you causes the cut to heal? Wrong question. Because the wound triggers an alarm that recruits your entire system for action. Your immune system produces inflammation around the cut in order to enhance healing. But the functionality of your immune system depends upon your general vitality, on the state of your adrenal hormones, on the ability of your stomach and intestines to break down and absorb the nutrients required for such healing. Your circulation must be intact (people with impaired circulation in their limbs such as diabetics are less able to heal wounds). And the efficiency of the circulation can be impaired if your heart or lungs are. Your mind must be sufficiently intact to remember to cleanse and bandage the cut. So what part of you heals a cut? In fact, what part of you heals any of your health problems? Everybody: ALL OF YOU.

There are no parts of you isolated from other parts. All organ systems, all biochemical reactions and physiological processes in your body interact with all others directly or indirectly. It is impossible to study a single part or a single circumscribed set of phenomena in your body to the exclusion of others. And it is impossible to target in treatment any part of you or any circumscribed set of phenomena without affecting everything else within you. To attempt to do so is like surgically excising the state of Ohio and expecting no repercussions within the rest of the United States.

Your entire being constitutes a system that in health works like a fine orchestra, depending as it does upon the interplay of all its elements. Yet Medicine does not get it. It acts as if you are an inanimate object like a 2004 Toyota with separable parts—a stuck window crank here, a bald tire there—and not a living system that embodies different rules. It disregards your nature, your identity as a whole, integrated system. Medical schools graduate physicians who are bright, highly credentialed, and hard-working. Yet functionally they are morons. They excel at atomizing us into our components but remain clueless about treating people.

For these reasons one excellent family practitioner or general internist is worth fifty specialists and twice as many subspecialists. Medicine needs to revise its priorities.

Be well.

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