Expertise and the Compartmentalization of Medicine
Today was awesome. It was also a totally regular day. I hope those thoughts still occur simultaneously in a few years.
Outside of the workday though, I did have the opportunity to speak with my brother, (shout-out!) and one thing we discussed did bring up some interesting thoughts I had about medical sub-specialization.
(Side note: yes, I did update the layout to the blog for the first time in... well, maybe ever. Please feel free to leave a comment if you hate it or can't read it because the inter-chromatic contrast is too low or something)
I touched on this briefly in a previous post, but I want to expound on a facet of it today. It's commonly understood that, especially in surgical fields, medicine has become hyper-compartmentalized. The days of going to your GP for everything from a cold, to choking on a hot dog, to a broken leg to delivering a baby, are done... at least in developed areas. In or around major metropolitan areas, nobody is Archibald "Moonlight" Graham anymore (sorry, Dad, not even me).
That's a good thing if you ask me. The reasons are plenty, but one of them is there's just so much MORE we know these days. Medical school curricula of today are more or less unchanged in anatomy and physiology when compared to sixty years ago (debatable, I get it, but work with me here). But pharmacology, basic science, and especially clinical medicine (which is likely all you really care about as a patient, to be honest) have simply exploded in the last few decades. There is just a cornucopia of processes and factoids that have been elucidated or theorized recently, and that matriculating medical students and residents must now be able to recall. In fact, each specialty has its own new cornucopia of facts. It a cornucopia of cornucopias.
The easiest way to prove this is true is to take a brief look at some of the recent questions in the Orthopedic in-service exams... what is the mechanism of action of Denosumab? What oncogene is found associated with Synovial Sarcoma? This histology is consistent with which type of collagen? What is the rate of union of this fracture when treated with percutaneous fixation? What amino acid... etc... ORTHOPEDICS! The carpenters! The ones who are constantly called the neanderthals of medicine, we who are allegedly too clueless to correctly order a beta blocker, or take a blood pressure, or prescribe a statin. We... are expected to know these minutiae.
The point is, it must be pretty brutal to be a nephrology fellow right now. I can only imagine the torture (actually I can't, because I can't remember which organ system nephrologists actually take care of?)...
No, of course that isn't the point. The point is we are hyper-specialized and one of the reasons is this explosion of knowledge. It's great that we know so much more, and I like to believe that, in most cases, it has helped medicine advance and improved outcomes.
Another thing many people don't realize is that all the relevant clinical stuff (how do I... when do I... etc) that we need to know as heart doctors, or bowel doctors, or pancreas doctors, or toe doctors, is picked up in residency and beyond. Medical school provides foundations to understand the stuff that comes later, that's about it. The longer the residency and fellowship, the more one picks up before being out on their own.
I think it's also somewhat true as a corollary that the longer fellowships tend to trend with the specialties that rely the least on medical school knowledge. Family medicine, you could argue, at 3 years, uses more medical school knowledge than, say, Neurosurgery (7 years). For what that's worth.
But (finally getting to the point) it has also come with some drastic changes to how patients and doctors interact. Specifically, I'm referring to situations when the doctor is assessing or treating something OUTSIDE of their dedicated field of specialty. I know internists like to joke about how little I know about what they do, but I carry no delusions that I know anything about it. I used to [maybe], but there are probably many patients sitting in a nephrologist's waiting room who know the lungs better than I do (JUST KIDDING, I KNOW NEPHROLOGISTS REALLY TAKE CARE OF LIVERS).
They don't know orthopedics because they 1) don't learn it, and 2) what they did once know, they forgot, and 3) what they haven't forgotten they don't regularly practice. Many schools don't even teach any more about Orthopedics than you can scrounge together during anatomy. An hour-long lecture here or there, maybe. Many internists do recall, for example, that there's something important about the scaphoid bone, for instance, but not exactly what or why, nor where that bone is or certainly not what it looks like. And guess what? That's ok.
Let me rephrase. It is NOT OK with me that some medical schools choose not to formally teach Orthopedics. It IS OK that doctors forget what they once learned, but do not practice on a regular basis.
The problem arises when doctors do not wish to admit that their knowledge of a specialty is limited or bordering on nonexistent. We want to portray ourselves as knowledgeable in front of our patients, totally get that. But it can harm the patient if you are just treating based on your gut, or something you think you remember from a 4-minute lecture delivered years ago by a retired non-clinical professor who did not specialize in anything and has not read any of the recent literature.
Many other doctors do not even realize how sub-specialized Orthopedics has gotten. I'm doing my fellowship in Hand surgery... focusing on problems from roughly the elbow (give or take) down to the fingertips. This is an area of Orthopedics that many Orthopedic Surgeons [willfully] erase from their memories following our 5-year residencies [in a similar fashion to how I've erased Spine]. Nobody will argue that Orthopedic Surgeons do not have large egos... and yet a majority of us will happily, eagerly even, refer a hand patient to a colleague or partner who specializes in it. They are not interested, maybe, but they also recognize that they just don't know that area well.
And they recognize that it's okay. Phoning a friend is fine.
There are conditions that even someone as sub-specialized as "Hand Surgeon" will refer to an EVEN MORE specialized hand surgeon who only does, for instance, hand tumors, or who is a wrist arthroscopy wizard or something.
If other doctors don't recognize how sub-specialized our worlds are becoming, then patients undoubtedly can be expected to miss this concept sometimes. I think it's important to let patients know what you know, and what you don't know. We like to think since we're doctors, we are mostly intelligent (I guess?), and some stretch that to "infallible." Or think that's the expectation. It's really not. Patients don't expect us to know everything.
Patients do not expect us to know everything!
This leads me to a shout-out for a comment on a previous post, by Jonny H. He hit the nail on the head. "Patients don't care how much you know, until they know how much you care."
What is more caring than doing the right thing as you humble yourself in front of a patient and say, "Listen, genuinely, I want to help you with this. But I am not the best person to care for you for this issue. I know who can help you better than I can, and I would like you to see them", rather than wearing your knowledgeable smile and saying "Yep, I'm sure, just put some ice on that and it'll be fine."
But it's also up to us, the specialists, to accept these requests for consultation with a smile, and say "sure, I'll see that patient for you, no problem." With the "bogus consults" always eventually come the real ones... and you never know when a patient who used to be a "bogus-type" will develop a problem in your area of expertise, or will have a cousin or friend who they will refer to your office because you were so impressive.
Remember EVERY interaction is a chance to make a good impression! You never know who is a "connector"!
OK, now I'm just getting tangential. Enough writing, time to go read part of a 2500-page book just about Hand Surgery.
Outside of the workday though, I did have the opportunity to speak with my brother, (shout-out!) and one thing we discussed did bring up some interesting thoughts I had about medical sub-specialization.
(Side note: yes, I did update the layout to the blog for the first time in... well, maybe ever. Please feel free to leave a comment if you hate it or can't read it because the inter-chromatic contrast is too low or something)
I touched on this briefly in a previous post, but I want to expound on a facet of it today. It's commonly understood that, especially in surgical fields, medicine has become hyper-compartmentalized. The days of going to your GP for everything from a cold, to choking on a hot dog, to a broken leg to delivering a baby, are done... at least in developed areas. In or around major metropolitan areas, nobody is Archibald "Moonlight" Graham anymore (sorry, Dad, not even me).
That's a good thing if you ask me. The reasons are plenty, but one of them is there's just so much MORE we know these days. Medical school curricula of today are more or less unchanged in anatomy and physiology when compared to sixty years ago (debatable, I get it, but work with me here). But pharmacology, basic science, and especially clinical medicine (which is likely all you really care about as a patient, to be honest) have simply exploded in the last few decades. There is just a cornucopia of processes and factoids that have been elucidated or theorized recently, and that matriculating medical students and residents must now be able to recall. In fact, each specialty has its own new cornucopia of facts. It a cornucopia of cornucopias.
The easiest way to prove this is true is to take a brief look at some of the recent questions in the Orthopedic in-service exams... what is the mechanism of action of Denosumab? What oncogene is found associated with Synovial Sarcoma? This histology is consistent with which type of collagen? What is the rate of union of this fracture when treated with percutaneous fixation? What amino acid... etc... ORTHOPEDICS! The carpenters! The ones who are constantly called the neanderthals of medicine, we who are allegedly too clueless to correctly order a beta blocker, or take a blood pressure, or prescribe a statin. We... are expected to know these minutiae.
The point is, it must be pretty brutal to be a nephrology fellow right now. I can only imagine the torture (actually I can't, because I can't remember which organ system nephrologists actually take care of?)...
No, of course that isn't the point. The point is we are hyper-specialized and one of the reasons is this explosion of knowledge. It's great that we know so much more, and I like to believe that, in most cases, it has helped medicine advance and improved outcomes.
Another thing many people don't realize is that all the relevant clinical stuff (how do I... when do I... etc) that we need to know as heart doctors, or bowel doctors, or pancreas doctors, or toe doctors, is picked up in residency and beyond. Medical school provides foundations to understand the stuff that comes later, that's about it. The longer the residency and fellowship, the more one picks up before being out on their own.
I think it's also somewhat true as a corollary that the longer fellowships tend to trend with the specialties that rely the least on medical school knowledge. Family medicine, you could argue, at 3 years, uses more medical school knowledge than, say, Neurosurgery (7 years). For what that's worth.
But (finally getting to the point) it has also come with some drastic changes to how patients and doctors interact. Specifically, I'm referring to situations when the doctor is assessing or treating something OUTSIDE of their dedicated field of specialty. I know internists like to joke about how little I know about what they do, but I carry no delusions that I know anything about it. I used to [maybe], but there are probably many patients sitting in a nephrologist's waiting room who know the lungs better than I do (JUST KIDDING, I KNOW NEPHROLOGISTS REALLY TAKE CARE OF LIVERS).
They don't know orthopedics because they 1) don't learn it, and 2) what they did once know, they forgot, and 3) what they haven't forgotten they don't regularly practice. Many schools don't even teach any more about Orthopedics than you can scrounge together during anatomy. An hour-long lecture here or there, maybe. Many internists do recall, for example, that there's something important about the scaphoid bone, for instance, but not exactly what or why, nor where that bone is or certainly not what it looks like. And guess what? That's ok.
Let me rephrase. It is NOT OK with me that some medical schools choose not to formally teach Orthopedics. It IS OK that doctors forget what they once learned, but do not practice on a regular basis.
The problem arises when doctors do not wish to admit that their knowledge of a specialty is limited or bordering on nonexistent. We want to portray ourselves as knowledgeable in front of our patients, totally get that. But it can harm the patient if you are just treating based on your gut, or something you think you remember from a 4-minute lecture delivered years ago by a retired non-clinical professor who did not specialize in anything and has not read any of the recent literature.
Many other doctors do not even realize how sub-specialized Orthopedics has gotten. I'm doing my fellowship in Hand surgery... focusing on problems from roughly the elbow (give or take) down to the fingertips. This is an area of Orthopedics that many Orthopedic Surgeons [willfully] erase from their memories following our 5-year residencies [in a similar fashion to how I've erased Spine]. Nobody will argue that Orthopedic Surgeons do not have large egos... and yet a majority of us will happily, eagerly even, refer a hand patient to a colleague or partner who specializes in it. They are not interested, maybe, but they also recognize that they just don't know that area well.
And they recognize that it's okay. Phoning a friend is fine.
There are conditions that even someone as sub-specialized as "Hand Surgeon" will refer to an EVEN MORE specialized hand surgeon who only does, for instance, hand tumors, or who is a wrist arthroscopy wizard or something.
If other doctors don't recognize how sub-specialized our worlds are becoming, then patients undoubtedly can be expected to miss this concept sometimes. I think it's important to let patients know what you know, and what you don't know. We like to think since we're doctors, we are mostly intelligent (I guess?), and some stretch that to "infallible." Or think that's the expectation. It's really not. Patients don't expect us to know everything.
Patients do not expect us to know everything!
This leads me to a shout-out for a comment on a previous post, by Jonny H. He hit the nail on the head. "Patients don't care how much you know, until they know how much you care."
What is more caring than doing the right thing as you humble yourself in front of a patient and say, "Listen, genuinely, I want to help you with this. But I am not the best person to care for you for this issue. I know who can help you better than I can, and I would like you to see them", rather than wearing your knowledgeable smile and saying "Yep, I'm sure, just put some ice on that and it'll be fine."
But it's also up to us, the specialists, to accept these requests for consultation with a smile, and say "sure, I'll see that patient for you, no problem." With the "bogus consults" always eventually come the real ones... and you never know when a patient who used to be a "bogus-type" will develop a problem in your area of expertise, or will have a cousin or friend who they will refer to your office because you were so impressive.
Remember EVERY interaction is a chance to make a good impression! You never know who is a "connector"!
OK, now I'm just getting tangential. Enough writing, time to go read part of a 2500-page book just about Hand Surgery.
borrowed from https://only4medical.wordpress.com/2017/06/04/medical-signs-based-on-specialization/
Good stuff
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