Over the past 2 centuries, medical care and scientific discovery have hinged upon inter-disciplinary understanding of general medicine. When Sir William Osler recognized platelets as a blood element in 1874, he used the same microscopic insights that allowed him to describe the morpho-pathologic features of breast cancer. Cushing, Lister, and Pasteur similarly made seminal revelations that spanned multiple disease entities. Over the subsequent 150 years, a medical landscape that transcended body organs and tissue types has evolved and expanded into specific but limited realms of clinical and research foci.
1.Specialization, subspecialization, and subsubspecialization in internal medicine.
This evolution of specialization and subspecialization has been a natural response to the substantial growth in clinical knowledge and in the basic sciences. It has allowed for the generation and amplification of clinical and scientific data necessary for the effective delivery of care. However, continued branching of medical specialties into even narrower circumscribed territories could have a deleterious effect on patient welfare. How do we identify the critical point beyond which further sub-division creates more harm than good?
In both cognitive and procedural endeavors in medicine, incrementally greater levels of training lead to better outcomes. There are data from several retrospective cohort studies that suggest that early involvement of cardiologists is associated with improved outcomes in patients with heart failure and myocardial infarction.
2.- Ansari M.
- Alexander M.
- Tutar A.
- Bello D.
- Massie B.M.
Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting.
This is likely due in part to greater compliance with evidence-based guideline recommendations with resultant lower rates of cardiovascular hospitalizations in patients with heart failure, and earlier reperfusion times in myocardial infarction. Moreover, subspecialists can play a pivotal role in the establishment of systems and networks to enhance overall patient care. In preventive cardiology, this phenomenon is similarly recognized with higher rates of statin adherence (and potentially fewer cardiovascular events) associated with cardiology care.
3.- Chan D.C.
- Shrank W.H.
- Cutler D.
- et al.
Patient, physician, and payment predictors of statin adherence.
Although these results are intuitive, the studies had numerous methodological limitations (i.e., measured and unmeasured confounders and non-official cardiology “curbsides”). Though further investigation of the interaction between physician specialty and subspecialty and patient outcomes is needed, it is likely that greater and narrower expertise is associated with improved clinical care, but that there may be a ceiling effect to that relationship. In other words, more niche-specific investment and knowledge may not universally translate into superior outcomes, a condition which may give rise to overspecialization.
What is overspecialization? Does it occur at the subspecialization or at the sub-subspecialization level? Is it encountered at similar levels of subspecialization in various medical branches? In surgical domains, where intensive exposure to anatomy and mastery of techniques is crucial, a trend of greater subspecialization will almost always be associated with better outcomes. However, in non-interventional branches of internal medicine, where physiological mechanisms overlap and risk factors are shared, more restricted expertise at the expense of core specialty knowledge may be suboptimal. Overspecialization may therefore be sub-specialty-dependent and defined as redundant stratification of medical domains that potentially could result in worse clinical outcomes, less favorable patient experience, or higher health care expenditures. In overspecialized milieus, the provision of care may be hampered by longer waiting times, overtesting, and overtreatment.
4.- Thind A.
- Stewart M.
- Manuel D.
- et al.
What are wait times to see a specialist? An analysis of 26,942 referrals in southwestern.
, 5.- McCoy R.G.
- Van Houten H.K.
- Ross J.S.
- Montori V.M.
- Shah N.D.
HbA1c overtesting and overtreatment among US adults with controlled type 2 diabetes, 2001-13: observational population based study.
It may occur when patients with a disease subtype are managed by a micro-community of experts who may lack the cognitive flexibility and synergistic intellectual capacity of a more sizable and broad-based cadre of physicians. Overspecialization may be detrimental, but the answer is not to underspecialize but to match the patient to the most appropriate physician, and if the diagnoses are standard and common, the less specialized physician can deal with these.
An important adjunct is the “team approach” whereby a patient’s primary physician recruits a variety of sub-specialized experts who cooperate in formulating a treatment plan. Examples include a heart failure cardiologist and a dysproteinemia-focused hematologist who interact to optimize the care of a patient with systemic amyloidosis with cardiac involvement. Another example would be a cardiologist with sophisticated imaging expertise, a cardiothoracic surgeon, and infectious disease expert collaborating in the management of a patient with infective endocarditis.
How do we prevent overspecialization and instead improve coordination and efficiency of care? First, we have to recognize that there may be a limit to the added utility that comes with greater degrees of medical specialization. The nature of specialization and subspecialization needs to adapt to evolving clinical challenges. For example, the field of diabeto-cardiology emerged in response to the rising epidemic of diabetes and the improved cardiac endpoints with new anti-diabetic drugs. Similarly, the evolving discipline of cardio-oncology developed from the longer survival of cancer patients with adverse late cardiovascular outcomes in addition to the cardiotoxicity of newer chemotherapeutic agents. Both arenas mandate a high-level understanding of cardiovascular disease and a different set of medical conditions. The message is that effective subspecialization is often the broadening of a specialty, rather than its narrowing, that allows it to become multi-disciplinary and holistic.
What we need are objective data to inform us about the quality of our current level of subspecialization. Studies that would look at validated metrics (e.g., clinical outcome benchmarks, rate of inappropriate prescribing, and health care costs) of generalists and specialists and compare them with those of subspecialists and sub-subspecialists are likely to shed light on the level of specialization that is associated with the greatest degree of clinical betterment.
6.Toward precision policy - the case of cardiovascular care.
With such studies, we may determine that sub-subspecialists (in a certain sub-specialty) generate more costly care and have similar patient outcomes to those of less-heavily specialized physicians. In fact, there is evidence to suggest so. An economic analysis showed that areas with a more specialized physician workforce have higher health care spending but similar mortality rates.
7.The productivity of physician specialization: evidence from The Medicare Program.
Investigation of geographic areas introduces a myriad of confounding factors, making determination of causality impossible. Nevertheless, these limited data suggest that higher health care costs are not synonymous with better care, and that subspecialization is not an automatic recipe for superior outcomes.
If studies show that certain sub-specialty groups produce comparable or inferior results to those of less specialized physicians, we may need to reassess whether the composition of specialists and subspecialists in our system is optimal. Studies that would evaluate temporal trends in clinical end-points, comparing less and more sub-specialized medical environments and, ideally, a randomized intervention that would evaluate clinical performance metrics in more and less subspecialist-abundant clinical groups, may expose potentially correctable pitfalls of our profession. Based on the results of those studies, we may need to consider backing off on our culture of increasing subspecialization. Alternatively, if studies show that sub-subspecialization has a continuous and positive association with outcomes, we may need to foster it further.
Before we deepen an already sub-specialized profession, we need data about the impact of subspecialization on the delivery of care. Comparing more and less sub-specialized physicians could be a starting point and will teach us the true value of subspecialization and how far it should go. In addition, investing in team-based medical care is essential if we wish to harness the power of inter-specialty expertise for the benefit of the whole patient. This form of multi-disciplinary management, particularly useful in patients with complex medical conditions, is key to improving outcomes and could help determine the ideal degree of specialization.
References
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Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting.
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Patient, physician, and payment predictors of statin adherence.
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What are wait times to see a specialist? An analysis of 26,942 referrals in southwestern.
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BMJ. 2015; 351h6138Toward precision policy - the case of cardiovascular care.
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Article info
Publication history
Published online: July 29, 2019
Footnotes
Funding: None.
Conflict of Interest: Dr. Bhatt discloses the following relationships: Advisory Board: Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, PhaseBio, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice-Chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Medtelligence/ReachMD (CME steering committees), Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Abbott, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, St. Jude Medical (now Abbott), Svelte; Trustee: American College of Cardiology; Unfunded Research: FlowCo, Fractyl, Merck, Novo Nordisk, PLx Pharma, Takeda.
Authorship: All authors had access to the data and a role in writing this manuscript.
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