Something I hear often, and sometimes think myself, is “doesn’t medicine have enough specialties already?” After all, at the hospital where I practice the orthopedic doctors are segregated into those that focus on sports medicine, or the upper vs. lower extremity. Even though I know all of these orthopedists fairly well, I have a great deal of trouble remembering who is the knee person, and who to call for shoulders. If every traditional field in medicine continues to divide and subspecialize there is an increasing risk that we will grow further apart and have a harder time relating to each other professionally, and even more difficulty presenting a unified voice of all physicians before legislators or the public? I am very concerned about this problem, and do not see a simple solution. But concern about a potential “Tower of Babel” in medicine with many specialties which don’t speak the same language is not a good reason to inhibit specialization and increased expertise of any one group. The way to address this problem is through things such as improved mechanisms of communication.
Most patients believe our medical system clearly benefits from the existence of many different specialties. Few would want to go back to the system of limited physician specialization of 50 years ago. It seems likely that a person living in the middle of the last century would have all of their medical needs addressed by one or two doctors throughout their life (e.g., an internist or general practitioner, and possibly a surgeon at some point). That led to terrific patient-physician continuity for much of the population. And that continuity has been dissolving over the last 30 years, in large part due to the explosion of new specialties in medicine as well as economic forces and other factors. But I’m reminded regularly that patients want to see a number of different specialists at different times during their life, even if that means they see less of their primary care doctor (PCP) and have less overall continuity of care. After all, if a patient learns from her PCP that she needs to have her gallbladder removed, she isn’t likely to lean toward the PCP and say “You’re the doctor I know best, and I want you to take our my gallbladder instead of having it done by a stranger I’ve never met.” Instead patients say the opposite: “Send me to a doctor I’ve never met, but one who is an expert (experienced and board certified) in taking out gallbladders.”
So I think that we simply need to accept that increasing subspecialization is going to be part of our health care system for the foreseeable future. Rather than trying to resist or reverse it, we should simply be careful not to grant new subspecialty status too quickly. And all doctors should make sure that they spend time and energy focused on ensuring that doctors of all specialties maintain effective methods of communication about patients they care for together. Hospitalists will play an important role in this since ours is a specialty based on a site of practice rather than a particular disease or organ system. Like other generalists, such as PCPs and Emergency Physicians, we will be part of the glue that connects physicians by regular interaction with doctors from a wide variety of specialties.
We should also think about the effect a specialty of Hospital Medicine would have on the broader primary care community. For example, the American College of Physicians (ACP) has watched the birth of a number of medical subspecialties in the last 40 years, and most practitioners in each specialty have moved away from the ACP as their professional society and to their own subspecialty organization. This has led to a fracturing of internal medicine into many subgroups such that it might not be unusual to find one internal medicine subspecialty group arguing with another, rather than all speaking with one voice through the ACP. Each group has lost some clout and effectiveness as a result. But Hospital Medicine is still a generalist specialty (based on the site of care), unlike subspecialties such as cardiology and infectious disease, and should maintain a close connection with the ACP. If the formal recognition of Hospital Medicine as a specialty significantly dissolves the connection between ACP and SHM then both groups stand to lose a great deal. The leaders of these groups will need to work diligently to prevent this.