General Physicians In The Era of Specialization

The health care system in Siliguri has experienced unprecedented change and growth in the past twenty years. These changes reflect a multitude of developments, including fundamental shifts in the political and philosophical underpinnings of Indian life, dramatic advances in the technology of medicine, evolving expectations on the part of the consumer toward physicians, and different characteristics of the population and the health care problems they experience. 

With growing sophistication of technology, the superspecialists have become increasingly dependent on technology/instruments to make a diagnosis. This has, unfortunately, led to clinical medicine taking a back seat. This has also made therapy more expensive, more tedious and more inhuman. So, when a middle-aged male comes with chest pain, he undergoes a hemogram, full biochemical profile of renal and liver functions, ECG, TMT, X-ray, echocardiogram, angiography, CT scan and so on, and still the diagnosis of dry pleurisy is missed. Or, when a 65 years old male reports to an orthopaedic surgeon for low backache, he undergoes CT and MRI scans, a referral to the rheumatologist, and even a disc surgery, while the actual diagnosis (multiple myeloma) is left for an internist to pick up later.

 Old clinicians’ tools such as history taking, physical examination, and thoughtful analysis are gradually being consigned to history as these are considered inefficient, inaccurate, and time consuming. Super-specialist practice contributes to fragmentation of patient care and diffusion of responsibility.

Super-specialist care is also more costly than generalist care, tends to involve greater use of technologies and results in referrals to additional super-specialists for difficulties outside the expertise of the referring specialist, leading to cost escalation. The cost issues have come under increased pressure in recent years with the emergence of managed care with talented general physicians in Siliguri, and institution of the gatekeeper mechanism for limiting access to specialists. Even for us in India, time has now come to analyses the role of an internist in this era of super-specialization.

Why General Physicians Are Still So Important 

No amount of technological sophistication can replace information derived from history and physical examination. For example, occupational history may provide essential clues to the correct diagnosis. Insights into the cause of a patient’s persistent fever might lie in knowing the patient’s lifestyle or occupation: the source could be endocarditis in an intravenous drug user or tularemia in a rabbit hunter. 

India has followed the British pattern of doctor’s duty rotation. Physicians, who practice a super-specialty, have to maintain their general skills and knowledge and share general physician call rotation. Few consultant physicians practice purely general medicine. Proponents of superspecialisation harp on the point that acutely ill patients are best treated by a doctor who specialises in their condition, but the evidence for this statement is not clear-cut. It is true that patients with asthma9 or with gastrointestinal haemorrhage may do best under the relevant specialist. Such benefit, however, has not been shown for disorders where the diagnosis is less clear at presentation. In a recent study, employment of general practitioners in accident and emergency departments resulted in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utilisation, but the impact on patient outcome andsatisfaction needs to be considered further10. Super-specialist care is not only more costly than generalist care, but also less satisfying for the patient, due to compartmentalisation11. Moreover, when the patient comes to the casualty, it is not always possible to identify the relevant specialty straightaway. It needs clinicians who understand a wide range of specialties. An alternative strategy would be to have every super-specialist available round-the-clock, to be able to deal with acute problems arising from any system. The latter is not only impractical at present but also full of additional problems. A patient being looked after by the “wrong” super-specialist is likely to be poorly managed. With a greater the degree of specialization within the system, the staff will see fewer patients from “alien” specialties and thus run the risk of atrophied generalist expertise.