Chapter 5: Super-specialist – boon or bane

Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

We have run into the law of diminishing returns in health care, where we are doing more and more, with higher and higher technology, at more and more cost and less and less benefit – Richard Lamm The whole imposing edifice of modern medicine is like a celebrated tower of Pisa – slightly off balance – Prince Clarkes

Introduction

Super-specialist has a depth of knowledge in a small part of medical science at the sacrifice of breadth. He has a deep understanding of a narrow field that is vital in management of selective complex cases related to his specialty. It means there has to be a generalist who can detect such a case that needs the services of a super-specialist. If a patient visits a super-specialist directly, there is a greater chance of a doctor ruling out diseases related to his super-specialty with as many tests as possible and patient referred to a generalist.

Generalist has a wider but superficial knowledge, breadth without depth and should have an ability to detect a problem that needs a referral to a super-specialist of relevant specialty. Super-specialties are well developed in adult medicine / surgery in India and are also developing over last 2-3 decades in Pediatrics with increasing speed, so also in most other branches of modern medicine.

Diseases do not respect a specialty

Apparently localized disease to a small area of the body also may affect structure or function of other systems and hence most diseases are general in that sense. It is therefore necessary that every patient must be thoroughly examined even when presented with localized disease and every doctor – generalist, specialist and super-specialist- must be knowledgeable and competent to do so. Moreover, few symptoms represent multiple systems. Surgical diseases often are first seen by generalists and at times, medical problem may simulate a surgical issue and be seen by a surgeon. Is it not then necessary that irrespective of specialty, every doctor needs to be a basic generalist?

Making of a super-specialist

After completing basic graduation (MBBS), specialty training spans over three years (MD / MS). A specialist must continue to be an excellent basic generalist with deeper knowledge – increased depth in common problems but maintaining wider breadth and so should be able to handle atypical presentation or complications of common diseases in the community. However, during super-specialist training, the trainee focuses on a narrow part and loses the contact with general medicine / surgery. As time passes, he gets more detached from the generalist approach of basic medicine. As mentioned above, no disease respects the boundary of any system. Thus, super-specialist has to refer a patient to one or many specialists for even simple issues that are perceived to be beyond his domain. In such a situation, often there is no single doctor coordinating views of different specialties. It is nearly impossible for direct communication between different specialists and is often a cause of concern to a patient. In such a situation, a patient could be treated by doctors of different specialties without coordination between all of them.

Pros and cons of a super-specialist

With deeper knowledge of a small part, super-specialist is able to diagnose common as well as uncommon presentation of rare diseases. He is able to keep up-to-date in his narrow specialty and thus knows the latest advances in his field. This is a boon for a patient suffering from such a rare disease. However, a super-specialist often tries to rule out every possible disease in every patient, forgetting Sutton’s law “think common first” or as it is said “when you hear hoofbeats think horses, not zebras”. (Suttan’s law is named after Willie Sutton – a bank robber who when asked by the judge why he thought of robbing the bank, he said that is where most money lies). Thus, super-specialist does not consider common diseases as he has lost exposure to common problems and in turn depends heavily on multiple tests rather than clinical judgment. He does not consider provisional diagnosis to plan investigations as he considers possibility of every disease in each patient and so can opine only after all test results. All of us are aware of fallacies of test results. This assumes far more importance when resources are limited.

How to ensure “boon” and avoid “bane”?

There is no doubt, we need super-specialists and in future also super-super-specialists – one who would know everything about a smaller part of a super-specialty. Super-specialty is for the few and by the few. But to ensure rational benefits to the community, a super-specialist must be an excellent basic generalist. In order to be a sound generalist, super-specialist must spend 3 months of each year in general medicine/surgery throughout his career. If not, a super-specialist could become a bane. I recall having met the Chief Pediatric endocrinologist at Great Ormand Street Children’s hospital in London who insisted that each faculty member in his department worked in general pediatrics for 3 months each year. This was necessary because children referred for short stature to his department from all over Europe were often suffering from non-endocrinological problems such as celiac disease or chronic renal dysfunction. In absence of such a periodic exposure to general pediatrics, patients would be subjected to multiple investigations to rule out endocrine issues and then referred to a generalist. Super-specialist should not make a diagnosis on the basis of tests alone but must consider bedside provisional diagnosis thereby limiting tests to a minimum. While making a definitive diagnosis is a priority, rational practice demands minimum laboratory tests planned on the basis of provisional bedside diagnosis. Super-specialists often miss this approach and consider possibilities more than probabilities in every case. Then it becomes a bane. Let us not forget medicine is an art of probability.

Supply should be commensurate with demand

We need to estimate the future demands of super-specialists and plan supply chain accordingly. India is close to achieve an ideal doctor-population ratio of 1:1000 though it is skewed in terms of geographical distribution and it includes generalist doctors (family physicians) and also specialists-generalists (MD/MS). As per the Pareto principle, 80% of problems are solved by 20% effort and the remaining 20% of problems by 80% effort. This applies well to medical practice. Thus, we definitely need more family physicians than specialists and more specialists than super-specialists. Of course, at all levels, doctors must practice preventive medicine promoting health rather than just being disease managers. The present generation of medical graduates is attracted to ever-advancing medical technology to become super-specialists. If this trend continues, the community may not be best served by the shortage of generalists. Super-specialists are necessary for the few and should be few.in numbers. Facilities for modern technologically advanced super-specialists such as transplant surgeons, immunologists and geneticists should be restricted to a few centers so as to develop large expertise rather than every small centre dabbling into it. In USA, the ratio of general paediatricians to pediatric super-specialists is 2:1. This is ideal only when vaccine and hygiene-preventable diseases are extinct in the community. However, our epidemiology of diseases is different and as of now, we need far more generalists than super-specialists.

Personal notes

It is not rare for the community to seek super-specialty opinion directly with a focus on one major symptom. I have seen a patient with vomiting directly meeting a superspecialist, GI specialist who rules out problems of his domain after several tests, surgeon ruling out intestinal obstruction, neurologist asking for neuroimaging to rule out brain tumor, nephrologist ordering renal function tests and metabolic specialist going through many tests. Highly accomplished doctors ask for all these tests so as not to miss any disease. Only if these super-specialists were excellent generalists, diagnosis could be achieved most rationally with minimum tests. As a senior generalist, patient often seeks my opinion after visiting few super-specialists, especially when symptoms are vague and overlapping such as prolonged fever or persistent vomiting. This is a reverse referral and speaks of compartmentalization of medical practice that becomes a bane. I recall when my father as a family physician would accompany a patient to a specialist that facilitated better monitoring of a patient and also a learning opportunity to a family physician. He could also question the specialist for clarification. Such a rapport between a referring doctor and a specialist is almost non-existent today.

A cow was shown to an intern and asked to identify the animal. He instantly said it was cow and when asked whether he would investigate to confirm, he emphatically refused, he was sure. Same animal was shown to a specialist who also identified the animal right but wanted to confirm by tests “just to be sure”. He had leant “evidence-based medicine”. He did not want to miss any other diagnosis. Finally, same animal was shown to a super-specialist. After a close intelligent look at the animal, he said there would be many possibilities such as hypertrophied goat or atrophied elephant that he would investigate to rule out. He also cited case reportsin world literature in his support. And once all such possibilities were ruled out, he would consider it to be a cow. Finally, everyone got it right but intern was most rational, specialist cared for evidence-based diagnosis and super-specialist would not take any chance.

Take home message

Every doctor must be a competent generalist irrespective of his specialty or super-specialty. Success is achieved with wider experience achieved through formative years and sustained through periodic exposure to general approach. Thus, every doctor must try to be both – a generalist must know bit of specialty and specialist and super-specialist must know enough of basic general medicine. This alone will avoid perverse effects of super-specialisation and serve the community better.

Chapter 5: Super-specialist – boon or bane