S is for Specialist


An expert is someone who has succeeded in making decisions and judgments simpler through knowing what to pay attention to and what to ignore.
(Edward de Bono)


There are about 50 common types of  medical and surgical specialists.  The list runs from allergists to vascular surgeons.  So, in the big picture of health care where do they fit?  Do they add to health care quality?  Are their services cost-effective (as you might evaluate a drug or device)?  When should a patient see a specialist (or not)?  Why are specialists happier than primary care doctors?

Many years ago there were no specialists.  Doctors delivered babies, set broken bones and used leaches.  Treatment of war wounds with amputation heralded surgery as a specialty in the latter part of the 19th century.  As time went by other specialties came into being mostly because specialists were the conduit from research to clinical practice.  As medical information was more widely available specialists simply had more experience with uncommon or difficult problems.  Specialists led the way for new treatments .  Pulmonary doctors treated consumption (TB).  Cardiologists studied EKGs.  Obstetric specialists invented forceps for difficult births.  Now there are at least 50 varieties of specialists.

The specialist world is divided between procedural (surgical) and medical (expert advice) specialists.  A cardiac surgeon is a good example of a surgical specialist.  An endocrinologist is a good example of a medical specialist.  Some specialists do a little of both like cardiologists who do heart catheterization procedures and provide expert advice for treatment of heart disease.  Medical research has exploded to such an extent specialists still maintain an edge by focusing on smaller and smaller areas of expertise.

One might be led to believe every condition should be evaluated by a specialist.  But, there is good evidence to the contrary.  Based on Medicare data:  Areas with more specialists spend more on health care for Medicare beneficiaries but see no improvement in the quality of care, mortality, or patient satisfaction.  The foundation of modern American medical care is being questioned.  What went wrong?  Is it Kryptonite?  How can this be?

 

There are two answers to what went wrong.  First, knowledge about a disease does not always lead to cure but always runs up the bill for tests.  Second, medication and surgery do have complications that can be serious to the point of shortening a person’s life.  In aggregate the specialty world “hit the wall”.  The positives could not offset the negatives.

The foregoing indictment of specialists really put the wind to the sails of primary care.  In fact, treatment of most common ailments is well established with what are called “evidence based guidelines”.   Quality, safety, cost-effectiveness, and patient satisfaction thus depend on a good process to implement the known guidelines rather than special knowledge.  Until recently primary care providers had the lowest job satisfaction of any provider group.  Now, with a new sense of importance and purpose they seem to be personally happier.

The specialty world is fighting back by addressing cost-effectiveness.  Cardiologists have devised cost-effective strategies for treatment of heart attacks (evidence based guidelines) with dramatic improvement in survival.  Oncologists are following guidelines for treating many cancers and engaging hospice at a more appropriate time.  Gastroenterologists have found they can prevent colon cancers by following evidence based  guidelines for doing colonoscopy.   The world’s specialists are not all on board with the idea of being  cost-effective.  Those who do procedures are still criticized for doing them too often (if you have a hammer everything looks like a nail).

THE BOTTOM LINE:

  1. If you have health problems then have regular visits with a primary care provider.  They usually do have good advice about going to specialists.
  2. Do your homework.  Search the Internet about your problem.  If there are ideas you find then discuss them with your primary care provider.
  3. There is still some “ego” challenge for a primary care provider to ask for help in difficult situations.  The simple question: “Do you think a specialist could help us with this problem?” is usually well received.
  4. If you have a life altering problem or are hospitalized more than once for  the same disease a visit to a specialist is certainly reasonable.
  5. If you do go to a specialist make it clear you want your primary care provider kept informed.  Likewise, make sure the primary care provider communicates with the specialist (sends periodic updates) and follows the recommendations primary care actually  requested.

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