Sub-Sub Specialization

Several years ago, I came across a comment by one Professor Engel (I do not recall his first name or the name of the Journal) regarding specialization. He said: “ A specialist is one who knows more and more about less and less, till he knows a lot about nothing; and a generalist is one who knows less and less about more and more till he knows nothing about everything” (not an exact quote). Those days are upon us already. Efforts are under way to recognize specialized training in extremely narrow fields such as obesity and congestive heart failure. This was the focus of an essay by Drs.Cassel and Reuben in a recent issue (March 24, 2011; Pages 1169-1173) of the New England Journal of Medicine.

When I started in my medical career, a general physician was an internist for adults and children, a general surgeon and an obstetrician, all rolled into one. Even then, it was not possible for one to be proficient in all these areas. Internal medicine, surgery, obstetrics and gynecology, radiology and pediatrics had separated as specialties. Sub-specialization had also started with orthopedic surgery, neurosurgery, ENT surgery etc. Pediatrics had not sprouted sub-branches yet. Internal medicine had started specialization in allergy, heart disease, gastrointestinal diseases and TB (forerunner of pulmonolog.

Scientific investigations in biology and medicine led to newer technologies specific to each organ and explosion of knowledge about diseases in every organ system. It was impossible for any one person to master this knowledge without extended period of training. After the training, when a physician declared himself to be a specialist in his/her field, the society needed assurance that these individuals were competent to practice the specialty.

Sub-certifications started in internal medicine in the 1940’s with four specialties mentioned earlier.Six more were added in the 70’s, 2 in the 80’s, 4 in the 90’s and 4 more in the early parts of this century. Pediatrics had also started sub-specialty boards starting with neonatology in the 70’s. More recently, a few specialists started focusing on specific areas within each of these sub-specialties. For example, electrophysiology of the heart became a focus of study by some cardiologists. This focus led to more research and more knowledge and an extremely few who became experts. Their trainees in turn declared themselves experts in this area of focus.

Drs. Cassel and Reuben raise the following questions in their essay. Each time a new area of expertise is recognized, what should be the role of certifying bodies in assuring to the society about the competence of individuals who claim such an expertise? What is its responsibility towards the society? What is its role in managing proliferation of specialties, resolving conflicts and tensions between specialties about each other’s “turfs”? In addition, what is the cost of training, certification, re-certification and insurance coverage for focused practice which will be passed on to the patient. Finally, where is the balance between fragmentation of care by creating more specialties and assurance of quality of care by certifying those who have had adequate training?

ABIM has defined this problem well by creating criteria for recognition of subspecialties and of Focused Practice through Maintenance of Certification (MOC). Criteria for subspecialty certification include: a unique body of knowledge in the field, has clinical applicability, is based on and contributes to the research base of medicine and improves patient care. The criteria for focused practice are: several internists focus in that area, while others may not practice in that focus area at all and this meets an important social need and offers evidence that focusing practice in that discipline improves patient care. Based on these criteria ABIM has launched certifications in Hospice and Palliative care and Congestive Heart Failure as subspecialties and Hospital Medicine as focused practice. Other specialties may also follow similar trends.

The era of sub-sub specialization is here. We need to manage it well so that the quality of care of patients improves in a cost-effective manner without fragmentation of care.