Over the past 2 centuries, medical care and scientific discovery have hinged upon inter-disciplinary understanding of general medicine. When Sir William Osler recognized platelets as a blood element in 1874, he used the same microscopic insights that allowed him to describe the morpho-pathologic features of breast cancer. Cushing, Lister, and Pasteur similarly made seminal revelations that spanned multiple disease entities. Over the subsequent 150 years, a medical landscape that transcended body organs and tissue types has evolved and expanded into specific but limited realms of clinical and research foci.1Â This evolution of specialization and subspecialization has been a natural response to the substantial growth in clinical knowledge and in the basic sciences. It has allowed for the generation and amplification of clinical and scientific data necessary for the effective delivery of care. However, continued branching of medical specialties into even narrower circumscribed territories could have a deleterious effect on patient welfare. How do we identify the critical point beyond which further sub-division creates more harm than good?
In both cognitive and procedural endeavors in medicine, incrementally greater levels of training lead to better outcomes. There are data from several retrospective cohort studies that suggest that early involvement of cardiologists is associated with improved outcomes in patients with heart failure and myocardial infarction.2 This is likely due in part to greater compliance with evidence-based guideline recommendations with resultant lower rates of cardiovascular hospitalizations in patients with heart failure, and earlier reperfusion times in myocardial infarction. Moreover, subspecialists can play a pivotal role in the establishment of systems and networks to enhance overall patient care. In preventive cardiology, this phenomenon is similarly recognized with higher rates of statin adherence (and potentially fewer cardiovascular events) associated with cardiology care.3 Although these results are intuitive, the studies had numerous methodological limitations (i.e., measured and unmeasured confounders and non-official cardiology “curbsides”). Though further investigation of the interaction between physician specialty and subspecialty and patient outcomes is needed, it is likely that greater and narrower expertise is associated with improved clinical care, but that there may be a ceiling effect to that relationship. In other words, more niche-specific investment and knowledge may not universally translate into superior outcomes, a condition which may give rise to overspecialization.
What is overspecialization? Does it occur at the subspecialization or at the sub-subspecialization level? Is it encountered at similar levels of subspecialization in various medical branches? In surgical domains, where intensive exposure to anatomy and mastery of techniques is crucial, a trend of greater subspecialization will almost always be associated with better outcomes. However, in non-interventional branches of internal medicine, where physiological mechanisms overlap and risk factors are shared, more restricted expertise at the expense of core specialty knowledge may be suboptimal. Overspecialization may therefore be sub-specialty-dependent and defined as redundant stratification of medical domains that potentially could result in worse clinical outcomes, less favorable patient experience, or higher health care expenditures. In overspecialized milieus, the provision of care may be hampered by longer waiting times, overtesting, and overtreatment.4., 5. It may occur when patients with a disease subtype are managed by a micro-community of experts who may lack the cognitive flexibility and synergistic intellectual capacity of a more sizable and broad-based cadre of physicians. Overspecialization may be detrimental, but the answer is not to underspecialize but to match the patient to the most appropriate physician, and if the diagnoses are standard and common, the less specialized physician can deal with these.
An important adjunct is the “team approach” whereby a patient’s primary physician recruits a variety of sub-specialized experts who cooperate in formulating a treatment plan. Examples include a heart failure cardiologist and a dysproteinemia-focused hematologist who interact to optimize the care of a patient with systemic amyloidosis with cardiac involvement. Another example would be a cardiologist with sophisticated imaging expertise, a cardiothoracic surgeon, and infectious disease expert collaborating in the management of a patient with infective endocarditis.
How do we prevent overspecialization and instead improve coordination and efficiency of care? First, we have to recognize that there may be a limit to the added utility that comes with greater degrees of medical specialization. The nature of specialization and subspecialization needs to adapt to evolving clinical challenges. For example, the field of diabeto-cardiology emerged in response to the rising epidemic of diabetes and the improved cardiac endpoints with new anti-diabetic drugs. Similarly, the evolving discipline of cardio-oncology developed from the longer survival of cancer patients with adverse late cardiovascular outcomes in addition to the cardiotoxicity of newer chemotherapeutic agents. Both arenas mandate a high-level understanding of cardiovascular disease and a different set of medical conditions. The message is that effective subspecialization is often the broadening of a specialty, rather than its narrowing, that allows it to become multi-disciplinary and holistic.
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-Ohad Oren, MDa, Bernard J. Gersh, MB, ChB, DPhilb, Deepak L. Bhatt, MD, MPHc,
