Overspecialized - Losing a part of medicine?

[karate134]

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The purpose of this thread is to get some thoughts and feedback.
I'm on my way to try and figure out what I want to try and specialize in.

Play along for a minute because I'm going to heavily generalize:
It seems that there's two positions in medicine, either you become ultra specialized and treat a small subset of diseases essentially losing the ability to handle routine things or you do something more general (ie. family med) and essentially get the leftovers from what specialists don't do.

So I'm considering neuro or IM.
IM it seems awesome because it's pretty general and it's the doctor you dreamed of being as a kid. Theoretically, IM covers a lot of ground. But it seems like the specialists manage most of the stuff leaving the IM doc to essentially becoming a manager. That's not a bad thing, but perhaps not for some, like me.
Neuro is neat, but it seems like you become "dumb" to everything else. I'm on my peds rotation right now and was thinking as a neurologist you'd be clueless with any rashes or infectious things you'd see (incidentally or otherwise).

I think you guys know where I'm going with this, so what's your thoughts.

 

[gutonc]

I think you're misguided and this is a typical M3 kind of concern.

Here's the thing...medicine in the 21st century is too complex to be managed by a single person with a single type of training. No matter what you specialize in, you're going to have to refer some stuff out...sometimes a lot of stuff. And to say that neurologists (or any other subspecialists) become "dumb" to everything else is a little insulting. Every physician focuses on what s/he needs to know to do the vast majority of their day-to-day job. Sure, the (good...because being a good PCP is hard) IM PCP is going to be really good at managing most chronic and subacute illnesses, but that refractory heart failure managment, or COPD not responsive to 2 or 3 drugs, or new melanoma or Stage 3 and worsening CKD, or...or...or...those are going somewhere else. That's life.

The bottom line is that you need to decide where you want to fall on that spectrum. You're either going to go wide and shallow or narrow and deep and you're going to "become dumb" to many aspects of medicine no matter what choice you make. Get used to it.

 

[da8s0859q]

Part of why I chose EM was for things similar to what you're saying: what you thought of as "a doctor" as a kid, knowing something about most everything, etc.

That's going to matter less than you think. Choose what you think you'll be happiest doing, and what will let you have the kind of life you want.

 

[karate134]

I think you're misguided and this is a typical M3 kind of concern.

Here's the thing...medicine in the 21st century is too complex to be managed by a single person with a single type of training. No matter what you specialize in, you're going to have to refer some stuff out...sometimes a lot of stuff. And to say that neurologists (or any other subspecialists) become "dumb" to everything else is a little insulting. Every physician focuses on what s/he needs to know to do the vast majority of their day-to-day job. Sure, the (good...because being a good PCP is hard) IM PCP is going to be really good at managing most chronic and subacute illnesses, but that refractory heart failure managment, or COPD not responsive to 2 or 3 drugs, or new melanoma or Stage 3 and worsening CKD, or...or...or...those are going somewhere else. That's life.

The bottom line is that you need to decide where you want to fall on that spectrum. You're either going to go wide and shallow or narrow and deep and you're going to "become dumb" to many aspects of medicine no matter what choice you make. Get used to it.

So I did speak rather colloquially hoping to bypass the pseudo-lawyer-esk speak thus avoiding the disclaimers and excessively long post.
The reason I said "heavily generalized" was to make a very short disclaimer to state that I would be speaking in extremes. It's the same reason I said "dumb" in quotes. It was a way to avoid saying something much longer to avoid political correctness. I also figured that by talking in extremes it's a little easier for most people to make an opinion, etc.

I will expand a little here.
Pretend you're a neurologist, and the pt sees you for something neuro related, but the patient also has X (say a rash or upper respiratory infection). As a neurologist, would they have the training and knowledge to treat X, generally speaking? I know they go through an intern year, but I'm wondering how much of that "sticks", etc. Another crazy way to look at it is if a neurologist for whatever reason wanted to work at a urgent care, would he/she be overwhelmed (generally speaking)?

These may seem like stupid questions, and perhaps misguided, but I'd rather be someone that's misguided and asking stupid questions than someone that's misguided and continuing to walk down the same path.

 

[karate134]

Part of why I chose EM was for things similar to what you're saying: what you thought of as "a doctor" as a kid, knowing something about most everything, etc.

That's going to matter less than you think. Choose what you think you'll be happiest doing, and what will let you have the kind of life you want.

I'm glad you mentioned that. This is exactly what I was thinking. While I didn't actually want to be a doctor when I was a kid (I actually was a public school teacher before this), when I did decide on medicine I had visions of the typical old school black bag doctor that took care of everything. Obviously those days are long gone. And while I knew that going into it, I didn't realize that even within many specialties, there's many subspecialists, thus further breaking down the variety. Naturally this is a win for the patient.

I was actually considering going into EM for the reason you did. It's interesting to note though you feel like it's not as big of a deal as you use to. This is one reason why I like to talk to people like you guys that have done it or going through the process because how would one know otherwise?

Thanks for the reply.

 

[colbgw02]

That's going to matter less than you think. Choose what you think you'll be happiest doing, and what will let you have the kind of life you want.

This.

For the most part, the neurologist doesn't treat the rash because he can't. He doesn't treat it because:

1) He doesn't get paid to do it. Patient encounters are already short enough, so he's not going to spend 5 minutes of 15 minute time slot discussing steroid cream when the patient is there for their tremor.

2) He went into neurology, in part, to get away from the rash. Orthopods have some of the best grades and board scores of any students, yet they're made fun of for consulting medicine to manage SSI. Is that because they really can't do it? Or is it because they know they can get away with it, freeing them up to do what they want?

3) The risk:reward ratio is off. On the off chance that it's a zebra and a bad outcome ensues, what sort of liability has the neurologist assumed? Conversely, what has he really gained by getting it right?

 

[Siggy]

I will expand a little here.
Pretend you're a neurologist, and the pt sees you for something neuro related, but the patient also has X (say a rash or upper respiratory infection). As a neurologist, would they have the training and knowledge to treat X, generally speaking? I know they go through an intern year, but I'm wondering how much of that "sticks", etc. Another crazy way to look at it is if a neurologist for whatever reason wanted to work at a urgent care, would he/she be overwhelmed (generally speaking)?

These may seem like stupid questions, and perhaps misguided, but I'd rather be someone that's misguided and asking stupid questions than someone that's misguided and continuing to walk down the same path.

Part of the problem, from your standpoint, is that a lot of it is about boundaries. The IM team is the primary provider for the patient. It's inappropriate for the neurologist to start futzing with non-neuro condition related medications (changing BP parameters for permissive HTN in stroke patients? Fine. Changing antibiotics for that patient's pneumonia? Not fine). That doesn't mean a conversation can't and shouldn't occur, but there are boundaries.

...of course then there's "FOOBA." "Found On Ortho, Barely Alive."

 

[hamstergang]

If working in the image you hold in your head as a 'doctor' will make you happy, then go for it. To me, image didn't matter at all. I went into psychiatry because that was what I enjoyed most and could therefore do for the rest of my life. Sure, there's a lot in medicine I don't know, but I'm an expert in an area that most other doctors don't know a lot in. It's a trade off that has to be made one way or the other.

 

[karate134]

This.

For the most part, the neurologist doesn't treat the rash because he can't. He doesn't treat it because:

1) He doesn't get paid to do it. ...... what has he really gained by getting it right?

You bring up good points.
I guess I look at it from a patient perspective and let's say that rash was merely dry skin. It's nice to save the patient a trip to the primary care a save 25 dollars. I get that I might not get paid for that skin service, but it helps them out.

Part of the problem, from your standpoint, is that a lot of it is about boundaries. ...
...of course then there's "FOOBA." "Found On Ortho, Barely Alive."

I guess I'd like to be comfortable to handle a little bit of everything. Say you go consult for neuro and the nurse comes up to you and asks you about a non-neuro thing about the patient, say he has a rash or something, I'd hate to shrug and say "ask the IM doc". Sure you don't wanna get on someone's turf, I totally get that. Or in the outpatient setting (see the example above).
It's also possible I'm underestimating the training the intern year gives you.

If working in the image you hold in your head as a 'doctor' will make you happy, then go for it. To me, image didn't matter at all. I went into psychiatry because that was what I enjoyed most and could therefore do for the rest of my life. Sure, there's a lot in medicine I don't know, but I'm an expert in an area that most other doctors don't know a lot in. It's a trade off that has to be made one way or the other.

Good points. I think I definitely agree, we all have to find what we enjoy and go into it.
In some ways, I'm seeing even a "general" doc still can't cover everything (even just the surface of it).

 

[Baritonebass]

What makes you a doctor is your ability to evaluate perform a work up and treat. Most people decide on an area that they enjoy and specialize to see more of that and less of the things they hate... Could be relationships with patients(PCP psychiatry), pathology (Neuro,IM)' or procedures(Surgery). Some choose for life style or money but there's no guarantee that you'll get that in the future... At any rate you'll be talented and smart and a master of you domain... Plus if you don't answer the consult and muck around with other stuff you won't get referrals

 

[DubVille]

I guess I'd like to be comfortable to handle a little bit of everything. Say you go consult for neuro and the nurse comes up to you and asks you about a non-neuro thing about the patient, say he has a rash or something, I'd hate to shrug and say "ask the IM doc". Sure you don't wanna get on someone's turf, I totally get that. Or in the outpatient setting (see the example above).
It's also possible I'm underestimating the training the intern year gives you.

You sound like a "generalist." My favorite thing about being a specialist is focusing on "my area of medicine." Sadly you may also find that part of being the primary doc means you also deal with nearly all of social issues, and less "medicine." It is nice to walk into an ICU bed and just do the emg/ncs and defer all the questions about LTAC, extubation, nursing homes, FMLA paperwork, etc, etc.

 

[Law2Doc]

The purpose of this thread is to get some thoughts and feedback.
I'm on my way to try and figure out what I want to try and specialize in.

Play along for a minute because I'm going to heavily generalize:
It seems that there's two positions in medicine, either you become ultra specialized and treat a small subset of diseases essentially losing the ability to handle routine things or you do something more general (ie. family med) and essentially get the leftovers from what specialists don't do.

So I'm considering neuro or IM.
IM it seems awesome because it's pretty general and it's the doctor you dreamed of being as a kid. Theoretically, IM covers a lot of ground. But it seems like the specialists manage most of the stuff leaving the IM doc to essentially becoming a manager. That's not a bad thing, but perhaps not for some, like me.
Neuro is neat, but it seems like you become "dumb" to everything else. I'm on my peds rotation right now and was thinking as a neurologist you'd be clueless with any rashes or infectious things you'd see (incidentally or otherwise).

I think you guys know where I'm going with this, so what's your thoughts.

You are kind of looking at it backwards from a lot of our perspectives. You laud the generalist for his ability to handle the routine things, and cast aspersions on the specialist who is apparently "dumb" and "clueless" regarding those routine things. But I think you need to appreciate that medical knowledge is extensive, and the number of problems that are strictly "routine" decreases every year as we learn more. The generalist can only go so far in treating many complicated things before he has to pick up the phone and call for help from one of these supposedly clueless guys.

And if you've ever been on the receiving end of a phone call requesting a consult, you might even rethink who is the "clueless" one in the equation. If you could see the eye rolling and frustration on that end of the phone, trying to talk to a doctor who doesn't seem to "get it" -- but I guess this is a bit unfair because at least he knew when he was over his head and should call for help. So yeah, I think essentially calling more specialized doctors "dumb" and "clueless" because they don't deal with mundane rashes or some of the day to day ailments is a lot like goofing on a jet pilot because he can't drive a tractor. Everybody wants to feel superior in their own little kingdom, but in a field where you can't possibly know it all the generalist tends to be the guy calling for specialized help more than the converse.

Also part of the reason NPs are encroaching on PCPs is because having no specialized knowledge makes you a lot more vulnerable.

 

[Law2Doc]

...Say you go consult for neuro and the nurse comes up to you and asks you about a non-neuro thing about the patient, say he has a rash or something, I'd hate to shrug and say "ask the IM doc". Sure you don't wanna get on someone's turf, I totally get that. Or in the outpatient setting (see the example above).
It's also possible I'm underestimating the training the intern year gives ...

1. Say the nurse comes up to the PCP and asks him about the neuro issues -- the PCP is going to be equally clueless and have to shrug and say "the neuro people are handling it".
2. It's not about turf, it's about knowledge base. The generalist knows just a little bit about a lot of things. Often just enough to recognize that it's time to call in a specialist. The specialist knows a lot about his area of expertise. If a guy has a complex neuro problem the PCP is far less equipped to deal with it than a neurologist would be in dealing with a routine hypertension issue.
3. Specialists LOVE to be able to shrug off things like rashes and say "ask the IM doctor." Why are you saying this like it's a Bad thing. They saw their share of rashes during med school and internship and chose not to go into that. It's a great thing for a consult to be able to just say, "that looks pretty bad, better tell this patient's primary doctor to take a look at that", jot your note and walk away.
4. If you are that worried about what a nurse thinks of you if they ask you about things outside if your area of expertise you probably haven't been an intern yet. You get over that. There's nothing wrong with saying "I'm just here about X, another doctor is managing Y". The days of complex patients having a single doctor ended years ago.
5. Yes you are underestimating the training intern year gives you. You will master the basics of managing routine patient issues, like hypertension, ventilation, blood sugar, crit, electrolytes. You will deal with all sorts of rashes, sore throats, nausea, fever. Much of the stuff you are chalking up as IM expertise the specialist did unsupervised at night for a year on relatively sick patients. By contrast, the generalist probably hadn't experienced most of the fields he consults except for a few weeks as a third year med student. So the specialist more or less knows how to manage a patient, but has decided he prefers a Different role. Let's not confuse that as "clueless." the generalist by contrast is calling in a consult not by practice choice or turf but because he truly lacks the expertise.

 

[rokshana]

... and it's the doctor you dreamed of being as a kid....

you believed in santa claus as a kid too...and then you learned the truth...

if your image of being a doctor is based on childhood fantasies, then you need to wake up...as pointed out medicine is much more complex in this day and age and for one person to think they can understand and practice the depth and breadth of all of medicine is hubris...

 

[j4pac]

Do an internship under Gregory House and you'll be fine.

 

[karate134]

Do an internship under Gregory House and you'll be fine.

Docs wonder why they get a bad rep sometimes...

 

[karate134]

Thanks to those that have replied with useful posts. Its hard to know something until youve gone through it, so its nice to hear about those experiences.

 

[galactus]

Your thoughts are the exact reasons why I did a rural FM residency and a subspecialty. Learn/do everything. Take care of an elderly person in the ICU and later that day deliver a baby via c-section. Awesome stuff. I refer when needed. I'm also the provider that people consult to. My practice is half FM and half sports med. When people see me in their specialty clinic they would also ask about this "rash" or whatever, if it's something really minor I would just take care of it, but I suggest them to follow up with their PCP. I don't manage anything chronic in my specialty clinic that is outside the realm of what they are there for, so I suggest for them to "see their PCP", or come see me during my primary care clinic days.

Anyway I agree with everyone posting above. Medicine has become subspecialized, and there's nothing wrong with that! There are people out there that still do general and specialized practice.

 

[j4pac]

Docs wonder why they get a bad rep sometimes...

You take life too seriously.