Generalists vs Specialists vs Super Specialists

 For those in the medical profession and for the lay persons these terms require to be defined correctly. In our childhood say almost 4-5 decades back most cities and small towns were filled with the General Practitioners who practiced in the Dawakhanas with compounders and an assortment of tablets, pills and lotions which were stored in large jars and dispensed in paper bags and bottles provided from the clinics. These were an assortment of doctors whose qualification ranged from MBBS to homeopaths, ayurveda and unani medicine and a category of RMP's. They had the experience and skill sets and relied on solid clinical examination techniques. They were well versed with the seasonal trend of diseases and over time knew the family and their ailments and literally became family physicians. They became the General Practitioner the so called ubiquitous GP. These doctors were like full of native experience and intuitive knowledge practiced the art of medicine, provided personalized services with a lot of reliance on bedside clinical medicine and gave immediate care without creating panic fear and subjecting the patient to costly investigations. But with time a broad specialities and evolution of technology and the increased complexity of disease patterns, this kind of practice became a bit risky and delay in taking timely action became a problem at times. Besides, the specialists who were fresh inexperienced but bursting with knowledge often showed the General Practitioners in poor light. But on the flip side the GP's too hit back when the specialists increased the cost of treatment. This situation was not helping both so the Specialists started wooing the Generalists who had the confidence of patients with inducement to refer patients to them. This was initially in the form of gifts but later became what is now called cut practice. This broke the bond of trust and ultimately led to the erosion of ethics in healthcare. For more on this and the corrupt practices I would refer you to the book https://www.amazon.in/Healers-Predators-Healthcare-Corruption-India/dp/0199489548

However in this blog I do not want to dwell on this aspect of the problem but on the decline and increasing obsolescence of the Generalists and the broad specialists due to the rise of the super specialist. 

 The general practitioners are the original generalists, and by the very term they are general, which means they cater to everything that they are trained to treat. However, with every advancement in modern medicine more and more specialisation started occurring. This led to broad specialists but these too were based on deeper knowledge of basic skills and some organ or regional divisions. They were General medicine, General surgery, gynaecology and obstetrics, paediatrics, orthopaedics, ophthalmology, ENT, chest, physicians, endocrinologist, Dermatologists and urology et cetera. Note in most of them the general tag remained, and all of these were offered in medical schools post basic qualifications that is MBBS(Bachelors). Then came the degrees which were offered after the basic degrees designated as MCh and DM DM (Doctorate of Medicine) & M.Ch (Master /Magister Chirurgiae)    Till this time, both the generalists and the specialists, along with the super specialists complemented each other. Even so the tendency to go directly to the specialist led to a diminishing role of the generalist and at times people went to super specialists bypassing the specialists. The warning bells and gradual death of the specialists became increasingly evident. But modern medicine and the increase in the availability of highly technical and advanced procedures, led to a situation where almost all generalists and most specialists found that the skills in which they were trained during their medical training were inadequate to address these difficult problems. Therefore, within the broad specialities, they started occurring Super specialities, which slowly led to a gradual decline and obsolescence of generalists and specialists in medical practice throughout the world.  

While the level of super specialisation has been by and large dictated by the explosion in technology and know how it is also dictated by individuals who took a liking to certain procedures. Besides this commercial and market factors relating to demand supply and the profitability of the procedure or branch of knowledge has a role to play. Over time these too have changed and evolved. The degree of specialisation is increasing beyond our imagination, and if I were to mention the subjects in which super specialisation has occurred, it will even surprise some of the medical persons reading this blog. Starting with my own field of Orthopaedics, while it is commonplace to hear about Super specialities like arthroscopy, joint replacement, hand surgery, and spine surgery the further fragmentation relates to revision joint replacement surgery, Knee replacement, Unicondylar knee replacement surgeon, shoulder surgeon, arthroscopy by region , brachial plexus surgeons, bone tumours and foot and ankle surgery along with hip arthroscopy being the areas of Super specialisation. In other fields, laparoscopic surgery and robotic procedures are progressively like a ladder going up and killing the rung below. In the field of Cancer Surgery the regional cancer surgery has become the norm rather than the exception. If we think that this is only relating to procedure and surgeries, we are mistaken as there are specialist among physicians like once physicians, dealing with haematological conditions and among the leukemias specialists ones that deal with Acute and chronic conditions separately. Even in the field of diagnostics, the availability of interventional Radiologists and modality-based specialists have relegated the poor X-ray reading specialist to an obscure obsolete place. In pathology too this division between clinical pathology and microbiology and histopathology and within that also molecular and genetic laboratories create fragmented specialists which mushroom up like idiopathic growths. The next level of super specialists that have taken birth are AI and AI assisted robots who are seeking to replace humans and killing even the super specialists.  

The advantages of having super specialists is self evident in terms of the unique skill sets they offer thanks to training and acquired skill sets which the broad specialists cannot offer.There was a phase when the awareness of these specialities was not known and many didn’t understand the services offered. So these persons were dependent on the specialists to refer patients. The same cycle of referral practice which is a mild term for cut practice took root. The expectations of patients with severe diseases and complex problems to become normal or even better than before have increased beyond imagination. The resultant improvements in quality of life are literally game changers in terms of increased health-span land lifespan. Contrary to the prevailing belief that super specialists increase the cost of treatment and healthcare I personally do not agree as the benefit of superior results in the long-term far outweigh the initial short-term increase in cost of healthcare. Unfortunately, in our country, the lack of penetration of insurance and the tendency of the general public to not provide enough savings for healthcare results in delay in availing these advantages leading to prolonged morbidity and suffering.  

All is not hunky dory as far as super specialists are concerned as there are real downsides to their presence. From the point of view of Medical education, young doctors are very early in their training narrowing down to the super speciality they wish to pursue and do not concentrate on foundational skills.In our training days, we used to try and diversify our skills and learn all kinds of procedures without restricting oneself to certain specialities. Because in those days the facilities for performing these special procedures were a few and far between and therefore it felt safe to become a generalist, and make sure, one earned one living. The lack of regulation in the country relating to Training for the super speciality procedures leads to many self-styled super specialist, who, after attending a few workshops position themselves as specialist and tend to learn in the job. This is truer than one imagines and if one is not careful one sees doctors who advertise themselves as super specialists without adequate training or qualification. Today the scenario is different and students almost want to directly become super specialists. I cannot help but share an anecdote where a colleague of mine related to an incident where the trainee third year resident when given the opportunity to do discectomy independently refused to do so and asked his superior to give him an opportunity to do an arthroscopy instead. This was unheard of in my training days. Going abroad for fellowships relating to specialities has become a norm rather than an exception, and some of the people do not come back, resulting in a brain drain. However, those who come back are given better jobs and higher pay scales even though they lack experience and wisdom of old age. The dictum that a good physician knows when not to intervene is neglected and the younger aggressive foreign trained fellow is promoted as his work brings revenue to the hospital. To tackle this problem we need medical audits and truthful report of clinical outcomes. National Registries need to be created to help separate rice from the chaff. This which will enable us to discard procedures which are not really beneficial.

T The second aspect relates to tendency of the super specialists to adopt a more aggressive approach and there is tendency for a person who has a sophisticated knife to be tempted to use it more and take more risks than necessary. The hype and raised expectations and use of subtle and sometimes not so subtle marketing can lead to the remedy becoming worse than the cure.  

The third problem even leads to a situation where a person admitted to a hospital with one problem, lands up, getting referred to multiple specialists relating to different systems of the body being affected, especially in patients are old and suffering from multiple comorbidities. In such a case, the story of the 6 blind men and the elephant comes to mind. All the specialists are looking at their own speciality and nobody is looking at the patient as a complete whole. This often leads to confusion and complications, which are iatrogenic in nature. It seems like a situation, which occurs in a team which has many individual stars without the captain to mind the team into a cohesive unit. It is in this case that is specialist or generalist can actually play a good role and coordinate action around the patient. 

So So what does the patient do? He will do his homework and research before choosing the doctor. The power asymmetry of a doctor patient relationship needs to be broken and in a polite and assertive way the patient can question the doctor ask for his qualifications and training record and an explanation about his worries and anxieties along with details of the procedure to be performed. And finally come to the Specialist and Generalist for the final opinion and solution. Thus spake General Orthopedic Surgeon Vispi Jokhi.

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