Let's say you have a "typical" brain cancer and don't have any other accompanying issues -- then a rad onc might make the same treatment decision as a rad onc who was also trained in neurosurgery. Let's say all goes as planned and you become well. The additional neurosurgery training did not make any difference in that particular case.
But let's say you have a brain tumor with unusual anatomy or pathology, your clinical course is unusual, you have multiple other morbidity issues, and so your treatment is based on individual clinical judgment -- this is bizarre for most physicians, but not so bizarre for referral to a tertiary care center.
If it were me with the tumor, I would specifically look for advice from a hem-onc, a neurosurgeon, and a rad onc -- all of them. And I would specifically seek out a physician who had experience in any combination of these fields -- this would be even better to me than individual physicians discussing their ideas in tumor board.
I say this, because it is somewhat analogous to the 3 blind men who describe an elephant, and one views the elephant like a snake because he concentrates on the trunk, and another views the elephant like a tree because he concentrates on a leg, etc. They are all correct, but they don't understand each other's views as well, because each person only brings his own specialized experience to the table. Not to stretch the analogy to death, but if one person knew the trunk and leg both very well, he would likely have a clearer picture of the whole animal than either person alone.
Many of you likely know this story, but there is an interesting anecdote of how Judah Folkman started thinking that angiogenesis might be crucial to cancer growth and survival.
Being a surgeon (not a cancer specialist), Folkman stated that any surgeon knows that many tumors bleed like mad in the OR when excised, and that the bleeding is unusually difficult to stop. He said the angiogenesis concept seems obvious now, but years ago, he could never convince pathologists that there might be a reason for all of this bleeding. He said pathologists could never be convinced because they only saw the tissue and fixed vessels, not the bleeding in the OR. Some pathologists even politely informed him that all tissue bleeds when it is cut.
Folkman said that the primary clue behind his hypothesis came because he had an intimate understanding of how difficult it was to stop the bleeding from excised tumors, in comparison to normal tissue that was cut. He said that unless he had seen the excessive bleeding with his own eyes and understood that it was consistent and unusual, he would never have had a true understanding that angiogenesis was important to contemplate. So despite much antagonism to his crazy angiogenesis idea from cancer specialists who had much more experience in treating cancer than himself, he stuck to his guns.
My point is that a specialty is often much enhanced by the addition of what is often thought of as irrelevant basic science or clinical knowledge in a completely different field.
The difficulty, of course, is the time to train in all of these fields. Even if I had a "typical" brain tumor, I would seek out the unusual rad onc who also has experience in hem-onc, neurosurgery, or even in any other field typically thought of as "irrelevant" to rad onc. If I couldn't find one, then I would go to the second best choice and go to an only hem-onc or only neurosurgery physician for additional advice. Yes, even for a very typical brain tumor that manifests typically. You just never know.
I do not think it is the right attitude, that a rad onc thinks of his field as the only field he really needs to know well, and that hem-onc or neurosurgery experience would add so little to his patient care as to not make a difference. I guess one could argue that after all, a rad onc only does rad onc tasks on the vast majority of days, so "irrelevant" knowledge he has never used doesn't matter, right?
An anesthesiologist has "irrelevant" general medicine knowledge that he almost never uses on a daily basis. Nurse anesthetists often have the SAME anesthesia-specific clinical knowledge as an anesthesiologist.
Would you consider a nurse anesthetist commensurate to an anesthesiologist because they can perform the exact same clinical tasks the exact same way? What about a midwife vs. an ob-gyn, or an optometrist vs. an optho? The exact same field-specific knowledge in the exact same cases can sometimes translate into very different clinical decisions.
One might argue that rad oncs are very knowledgable in rad onc, so it isn't the same thing to compare technicians, but it is. What about the unusual cases that even puzzle superb rad oncs? For many clinical scenarios, there is no protocol-based, evidence-based treatment, so treatment is just based on clinical judgment.
Where does that judgment come from? If rad onc-specific experience is the same between 2 rad oncs, then a difference in judgment for a given patient might come from additional training in any other field of medicine, no matter how "irrelevant" it may seem. If anesthesia-specific experience is the same between an anesthesiologist and a nurse anesthetist, then a difference in judgment might come from "irrelevant" general medicine knowledge about say, a patient's rare renal disease.
As a nonsequitur, if one is practicing in the States, I don't understand why a U.S. physician would specifically choose an IMG over a U.S. med grad as his doc. For the extra clinical judgment or experience? How does being an IMG give one better clinical judgment or experience for U.S. disease than being a U.S. med grad?
On the contrary, an IMG has to be aware of how specifically Americans manifest a particular disease. The same disease does not manifest the same way or have similar prevalence in all countries, between different races and cultures. The same symptoms bring up very different diff dx in different countries. If I were practicing in South America, I would feel at a disadvantage to counterparts who trained in South America all along, because I would be wary that I might be thinking CAD and angina while they might be thinking myocarditis. I might ask about pharyngitis rather than skin infections for post-strep GN. It's not a big deal, but I think it is not the right attitude to not realize the differences.
If your training was pretty much the same as in the States, then you might as well have trained in the States. If your training was in a 3rd world country, then the additional experience might give better clinical judgment in loa loa infection or in physical exam assessment as an internist, but I don't see the advantage as a rad onc.
Anyway, the main point is that even the most experienced physicians cannot predict when a surprise case will come, especially when it looks so simple or "typical", or there would be no such thing as M&M conference. It depends on if one plays by statistics, or plays by absolute numbers -- is "overall" your goal, or does every individual matter to you? The problem is that one can never predict when that "unneeded" additional knowledge could not only be of use, but could be crucial.
I am not saying that rad oncs who don't have additional training in another field are incompetent in rad onc. I am saying, however, that I would always choose the rad onc with additional training, even if the extra training isn't used on a daily basis in rad onc.
Steph, academic attending physicians who teach future generations should be the last people to perpetuate the idea that additional knowledge that is rarely used would not make any difference for clinical care delivery in his field. If field-specific experience is the same between 2 people, a broader knowledge base, even if it may seem irrelevant or unneeded on a daily basis, is always preferable. I thought it was only non-physicians that physicians had to convince of this.
