First, we must address semantics. This post, Generalists vs. Specialists, stimulated these thoughts. Often in organized medicine we (especially internists and family physicians) emphasize that internists (whether inpatient or outpatient focused), family physicians, pediatricians, general surgeons, etc. are specialists, while we reserve the term sub-specialists for cardiologists, or vascular surgeons, or gastroenterologists. For the sake of consistency with common usage, I will refer to generalists and specialists rather than specialists and sub-specialists.
The essay's point (as I interpret it) focuses on the value and danger of specialization. While the essay does not talk directly about health care, one can easily gain some important lessons.
When do we need a specialist? I would say that for a discrete problem that requires a depth of knowledge and sufficient experience caring for that discrete problem, a specialist is highly desirable. In internal medicine, if you have a disease with rapidly evolving treatment options (e.g. Crohn's disease, HIV, acute coronary syndrome, rheumatoid arthritis, severe psoriasis), then a physician who specializes in that disease will have more experience and more resources to help you design the proper treatment strategy.
When do we need a generalist? The #1 reason for first consulting a generalist is to decipher symptoms and develop a diagnostic strategy. All physicians hear about patients who first consult a specialist because they think they know what their diagnosis is. However, when you go to a specialist, they will focus primarily on their specialty. As Maslow said, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”
But all chest pain does not come from the heart; all shortness of breath is not a lung problem; all abdominal pain does not require surgery. The generalist more often will consider the broad range of possibilities diagnostically.
We also need a generalist when we have several chronic diseases, and many patients fit that description. One generalist generally trumps 3 specialists. Let us assume you have heart failure, COPD, CKD stage 3, type II diabetes mellitus, and severe osteoarthritis. How do we balance your treatments and diagnostic strategies? Such a patient needs 1 excellent physician who will consider the benefits and harms of treating each of the problem with respect to all the other problems.
Generalists and specialists each have their role in health care delivery. In the best health systems we work together with the generalist taking the lead and involving specialists when we need their expertise. This concept works in both outpatient and inpatient medicine.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.