Specializing

A few decades ago the medical school curriculum committee was meeting to discuss updates to the standard curriculum. As they debated on what courses needed to be added/dropped they decided to ask Dr. James Kirklin (CT surgeon) what information was important for medical students to learn prior to graduating. Without hesitating he replied, "They should know it all."

I want to be a cardiologist. Specifically, I want to focus on heart failure. But not just heart failure; I want to be an expert on acute heart failure. And if I really get to do exactly what I want, I'd like to work on peripherally inserted mechanical support devices for acute heart failure.

My own career goals make what I am about to say that much harder to believe. I hate the current medical model that emphasizes super-specialization at the expense of a broad based knowledge base.

It used to be that the same doctor that diagnosed your heart attack could take out your gallbladder and deliver your baby. Understandably, as knowledge about the various medical fields (Surgery and Medicine) grew, practitioners started focusing in on either surgery or general medicine. As we learned more about the body, these fields further subdivided and now you had speciality training in various subdivisions of either medicine or surgery (cardiology, pulmonary, renal, etc... or GI surgery, cardio-thoracic surgery, etc...). However, as recently as the 1950s, physicians were still trained in both surgery and medicine. In fact, it wasn't until the 1960s-1970s that you had many specialities grow and develop their own specific training pathways. Up to this point, the growth towards specialization dovetailed nicely with and likely contributed towards the explosion in knowledge about the various specialities.

However, sometime between the 1970s and now, we started fracturing the medical landscape into smaller and smaller pieces. Some of this was a direct result of the exponential increase in knowledge. You had cardiologists becoming sub-specialists in heart failure, catherization, or electophysiology. We also started to self-segregate based on other, less clear factors. You had the start of ER and hospitalist medicine. If you just want to focus in on the acute management of all medical problems but did not want deal with any of the long term management or consequences, you could train to be an ER physician. Likewise, if you just wanted to manage inpatient medical issues, you could train to be a hospitalist. These new subdivisions were not directly linked to organ systems or disease processes, but rather to certain situations in health care delivery.

Let me offer an analogy comparing our health care system to flying an airplane. Initially all pilots could fly all airplanes as there weren't that many different kinds. As varying models were designed, pilots started to specialize in certain types of aircraft. The Cessna pilot and the 747 pilot became specialists in their own type of machinery. However, what you didn't see happen is the development of a pilot who specialized in takeoffs, and one that specialized in landings, and one that specialized in flying through hurricanes. What you didn't see is one pilot managing the airplane during takeoff and then openly admitting that he didn't know (or care to know) about how to continue to fly the plane and/or land it, and that that was someone else's responsibility. Add a healthy dose of poor communications between all involved parties to this super fragmented model and you have a great recipe for chaos. If you think such a system of flying airplanes would surely lead to mistakes and deaths, then welcome to our current health care system.

As we have developed this amazing, detailed knowledge base about the human body, physicians have gravitated towards the fields and opportunities that most interest them while at the same time paying lip service towards retaining the basic knowledge base about the field as a whole. Despite my desire to focus in on a very specific patient population, I ardently believe that my ability to offer good care will involve more than a detailed knowledge about a focused problem.