Mr. Adam Smith wrote of specialization, or the division of labor, in The Wealth of Nations several hundred years ago. He “foresaw the essence of industrialism by determining that division of labour represents a qualitative increase in productivity.”
Medicine is becoming more specialized. So specialized, in fact, that we now term it sub-specialization. Our most specialized hospitals are now quaternary hospitals (after years with tertiary label) which “typically provide sub-specialty services, such as advanced trauma care and organ transplantation.” We have no reason to think that further specialization will not continue. Medical students are skipping over primary medicine, instead opting for specialty service for a multitude of reasons.
Some have warned that a lack of primary care providers is going to be a problem. Most recently the Health Blog wrote of the problems related to fewer general surgeons by presenting this scenario involving a patient who needs surgery:
Imagine that the five-person surgical group faced with the problem patient in the not-too-distant future has its own issues. The colorectal surgeon is away at a national meeting. The hepatobiliary surgeon has exceeded his or her mandated work hours for the past 24 hours and is home. The breast surgeon doesn’t do emergency laparotomies, the needed procedure. And the minimally invasive surgeon only did two open ulcer operations during her residency training. Oh, and the surgical oncologist no longer performs abdominal surgery.
What to do? The usual go-to guy would be the general surgeon, who could be counted on to deal with the complex case of the moment with aplomb. But the ranks of competent, broad-based surgeons are dwindling, as John Welch, a general surgeon affiliated with Hartford Hospital and the University of Connecticut School of Medicine, warned in a speech before the New England Surgical Society last fall. So the hypothetical five-person group, sans general surgeon, may be here before you know it.
Sub-specialists already reign. As we noted last month, more than 70% of surgeons do a sub-specialty fellowship these days. And the number of general surgeons per capita has fallen 25% in the past quarter century.
The question: is all of this specialization good for health care?
The seemingly ultimate proponent of specialization, Mr. Smith, provided a caveat in his writing: “in a further chapter of the same book Smith criticises the division of labour saying it leads to a ‘mental mutilation’ in workers; they become ignorant and insular as their working lives are confined to a single repetitive task.”
Obligatory jab: sound familiar?
As patients with comorbidities (especially obesity) continue to complicate medicine, treatment often calls for balancing many therapies for very sick patients. Sub-specialization has been positive in advancing medicine. But increasingly we need individuals to manage a patient’s many treatments.
Last week I went on a tour of a brand new hospital. They are trying many new things (most of them evidence based). In particular, the patient rooms were built to accommodate all needs a patient may have while in the hospital. There are no specific floors for specific patients. So a nurse may be caring for a pediatrics patient, an ICU patient, and a stroke patient (etc.) during the same day. The tour guide commented on the difficulties encountered in helping nurses shift their perspectives from caring for patients with a common diagnosis to caring for patients with different diagnoses.
In other words, despecialization.
Is this the future? Are there significant problems with specialization?
The Freakonomics Blog highlighted a recent story by Michael Pollen in The New York Times writing on Wendell Berry’s economic insight:
For Berry, the deep problem standing behind all the other problems of industrial civilization is “specialization,” which he regards as the “disease of the modern character.” Our society assigns us a tiny number of roles: we’re producers (of one thing) at work, consumers of a great many other things the rest of the time, and then once a year or so we vote as citizens. Virtually all of our needs and desires we delegate to specialists of one kind or another — our meals to agribusiness, health to the doctor, education to the teacher, entertainment to the media, care for the environment to the environmentalist, political action to the politician.
Mr. Pollen links the issues of specialization and a personal attempt to go green:
Specialization is what allows me to sit at a computer thinking about climate change. Yet this same division of labor obscures the lines of connection — and responsibility — linking our everyday acts to their real-world consequences, making it easy for me to overlook the coal-fired power plant that is lighting my screen, or the mountaintop in Kentucky that had to be destroyed to provide the coal to that plant, or the streams running crimson with heavy metals as a result.
In medicine, it could theoretically be said that sub-specialization has obscured the lines of connection—and responsibility. We have all heard a story about a patient who didn’t receive a simple drug treatment because the bevy of specialists caring for her all thought that another physician had done it.
Despecialization will continue to occur in some health care environments as our system continues to evolve—possibly even in the traditional specialities. However, sub-specialization is a great thing for individual patients. The work these people do is saving lives that just a decade ago would have been lost. But the problem is that while we continue to move medicine forward we seem to have forgotten the importance of the generalist. Sure, there are many people advocating for primary care. But actions speak louder than words. Continuing specialization will advance medicine in the future…if generalists are given the proper attention. We must save the generalist!
Collectively, on the average, health care needs to despecialize.