Sub-sub-sub-subspecialists!!!
Listen up, you youngsters!!! When I graduated from Medical School many decades ago, things were different. After residency, I ended up in a small town for several years. In rural areas, things were different. By “rural”, I’m not talking about Point Barrow Alaska. I’m talking about areas that were just an one or two hours outside of major city hospitals in states like Missouri.
General surgeons were REAL general surgeons. By “general,” I mean they did everything. They did the usual belly surgery. They did vascular work. Yet, they also even did orthopedic work. Yes! Really! They actually operated and managed patients with hip fractures! How did their patients do? They did pretty well.
Primary Care doctors, meaning both Internal Medicine and Family Practice did all sorts of stuff. They managed heart disease, Neurology, Rheumatology, Endocrinology and GI. In fact, they even did upper and lower endoscopies. Family Practice doctors also delivered babies. We all managed complex ventilator patients. We inserted Swan Ganz catheters. Some Internists inserted pacemakers. Old time primary care doctors would even take out your appendix!
Flash forward thirty-five years. What the heck happened to us?
Primary Care is now divided into outpatient and hospitalist doctors. Hospitalists are subdivided into intensivists and non-intensivists. In the old days, we did all three. Now, whether inpatient or outpatient, every problem gets a consult. Actually, that’s not true. They get CONSULTS, emphasis on the plural. Do we actually do anything ourselves anymore? We also have Urgent Care specialists, Concierge specialists, alternative medicine specialists, “medical home” doctors and so on. Does anyone just “go to a doctor” anymore?
Cardiology has turned totally crazy. First it was Invasive versus Non-Invasive. Then some turned into Rhythm specialists. There are also TAVR doctors. Now, we are seeing Heart Failure specialists. Many of my patients are literally seeing SEVERAL different Cardiologists at the same time. No wonder our town is now swarming with Cardiologists, but somehow also has a shortage of Cardiologists!
Meanwhile, Orthopedics used to be the MANLY field where you used hammers and drills to fix whatever patient problem came into the office or hospital. Now we have hand specialists, shoulder specialists, knee specialists, spine specialists, sports specialists….. Good grief!
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General Surgery has changed. It’s lost the “General” part. No more orthopedics. No vascular. Now, it is just hernias, gallbladders and appendixes. Even colon surgery now gets referred to the Colon Rectal doctors. We now have leg vein “institutes.” Probably, one reason is the techniques have changed: Robotic, open, laparoscopic, etc. In the old days, everything was the same: OPEN. I’ve even heard older surgeons lament the experience gap with younger surgeons because there are so many surgical options to just taking out your gallbladder. Many believe the complication rate with this procedure has increased over the years.
How did this happen? One obvious answer is that everything got more advanced and complicated.
In the old days, you didn’t need a Neurologist to take care of Multiple Sclerosis. You just hospitalized them and pumped them full of Solumedrol. But, things changed. Now, the drugs are effective, but also numerous, complicated and, of course, kind of dangerous.
In the old days, when we encountered atrial fibrillation, we used Digoxin. That’s it. Nothing else. Now, atrial fibrillation has become a complicated world of drugs, ablation and other treatments that require its own specialized sub-Cardiology specialty.
Thus, every patient seems to have a vast array of specialists now involved in their care. Patients gripe how their medical care is more demanding in retirement than their jobs when they were still working.
The sheer number of consultants is a recipe for disaster. Every couple of weeks I have to stop a vascular surgeon from sending my renal insufficiency patients for contrast studies. Patients are bewildered when two of their Cardiologists disagree with each other on their medications. Add in “Physician Extenders” and the crowd, with its potential for disaster, only increases.
So… IS IT ANY WONDER WE HAVE A DOCTOR SHORTAGE?
Lawyers, you left out the lawyers.
I had a mid-fifties guy come into my office once for a new-patient, get acquainted H & P. Three slots later when we’re all done, I gave told him we needed to address the BP, check some fasting lipids, stop smoking, and given his stone-cold normal EKG, set him up for a stress test. He was so relieved.
“You mean I don’t have to have a cardiac cath?” he gratefully asked. No, I replied, why? You aren’t having any chest pain or SOB with any exertion, no PND, no (all the usual questions, repeated).
“No” , he said, “Wow, that’s great news, I thought for sure you were going to send me for a cath.” I smiled, thinking we were off to a great start and that I was managing him rather well, covering all the bases. No I repeated reassuringly, no need for a cath, just a stress test.
Then he explained: “See a friend of mine is a malpractice attorney, and he said with my risk factors I should get a cardiac cath.” My blood suddenly cold, my jaw kept forcibly closed, I asked, “You went to a lawyer for medical advice?” The patient said, “Oh yes, he handles a lot of these type of cases.”
I put on my best phony smile, and said, “You know, he has a point. I’m going to get you a referral to a cardiologist immediately. If you have ANY chest pain, shortness of breath, weakness, (all the usual symptoms, etc)… prior to that appointment, go to the ER immediately. Okay, well thank you so much for coming in, we look forward to seeing you for your follow up!” We smiled at each other, shook hands, and I watched him all the way across the parking lot and into his car. I told the nurse to set him up for a cardiology referral before she did anything else that day. And then I told the receptionist, “Send that son-of-a-bitch a ‘fired’ letter, I never want to see him in here again.”
That’s also how consults happen.
DAMMIT I want a RIGHT pinky finger specialist.
I wish I had thought of that line!
Wow! A lot to “unpack” here as the TV journalists often say, but you and I obviously come from the same generation. I trained and (largely) taught myself to do everything, which is why my urgent care clinic was so successful until the local hospitals got into the game with their megabucks. I sutured, open abscesses, burred rust rings off corneas, put casts on minor fractures, gave allergy shots after RAST testing, and even occasionally made hospital rounds. After I sold my practice to the local hospital and then retired a few years later, the doctors who remained no longer sutured or did practically any procedures—they were referred straight to the ED. Not to mention my (properly diagnosed) ADHD patients, some chronic pain patients—all referred or discharged. I call it “intellectual laziness.” Our medical generation is never to be again. The funny thing is, I never made a decent salary until I worked for the hospital.