In this rant I will use the term partialist as a derogatory. It does not refer to subspecialists in general, just those who ignore any problem that does not fit their tunnel vision of their purview.
Back in the day – the 1970s when I was training, most physicians approached patients first with their subspecialty interest, but they still exhibited generalist thinking. We had internal medicine subspecialists on the wards and they could discuss the variety of internal medicine as well as their area of expertise. In fairness, we were already seeing the emergence of partialists, those who only will address their subspecialty.
I was talking to a medical student yesterday. She told me a story about seeing a patient for a routine subspecialty visit. She diagnosed depression (part of the "12 point" review of systems required for billing) and wanted to address the depression. The subspecialist clinic had no interest in that problem.
Too often in the hospital I see one subspecialist call for 3 other subspecialty consults. Of course, I declare that what the patient really needs is 1 good doctor.
I do know subspecialists who have not become partialists. I believe our current payment system encourages this segmentation, because thinking generally does not enhance payment.
But I believe we all have a responsibility to consider the patient rather than the disease – please check out the Osler quotation. For those students and residents who plan to subspecialize, please remember that no organ system functions independently of the others. The patient deserves global rather than partial thinking. Become a subspecialist, but avoid becoming a partialist.
{ 4 comments… read them below or add one }
that is easy to say for a hospitalist. you are constantly dealing with general medical issues and probably have kept your knowledge base at least somewhat up to date in many areas. are you going to follow that patient for the depression forever? are you going to handle the late night calls? are your partners willing to receive those calls in the middle of the night? are you using the same antidepressants you trained with 20 years ago and not giving best treatment to the patients?
Great post. I gave up allergy because it was so focused on partialism. Patients would drift from allergist to allergist in my community and more often than not the allergist would not address the most simple questions relating to asthma, eczema, etc. Forget about non allergy problems.
It was all about skin tests and allergy shots and nothing else.
You succinctly described what I have observed for years. I wish that I had the term partialism in my head as I was leaving allergy for general medicine.
I always felt that I should put allergy into context of the state of health of the individual relative to smoking, obesity, asthma care, etc. That is what I was taught at Osler’s hospital in Montreal Canada. But even there I was once reprimanded for pointing out to a patient that his URT symptoms were do to active smoking rather than allergies.
Bohdan A. Oryshkevich, MD, MPH
I have recently experienced this with my mother, where certain specialties were so tunnel-visioned that the big picture wasn’t being appreciated. And don’t get me started about the hospitalists!
Her docs were pissed that I pushed for imaging (I even told them what they would find).
I’m pissed that I’m (mostly) right – her pelvic mass is now biopsied and we go to oncology this week.
This wasn’t a hard diagnosis – even me, a general OB-Gyn could figure it out.
It is a billing nightmare to address the whole patient when the patient is being seen by specialists. Medicare states that 2 doctors cannot manage the hypertension as an outpatient, unless the specialist is doing a one time consultation. Most specialist takeover care for HTN/MI care. Then the primary care doctor has to find other codes to bill. Medicare denies claims if 2 doctors bill the same ICD9 code on inpatients. Also there are newer fraud rules, that are very confusing, where two doctors are not supposed to bill Medicare for the same diagnosis. If I send a patient with prostate CA to a urologist, I am not supposed to bill or manage the prostate CA any longer, if the urologist has taken over care. It is very confusing. Some of my local specialist required in the referral to know if it is a consultation as an inpatient or outpatient or a transfer of care for the diagnosis in question.
Another problem is that across an office visit or hospital stay, I can only bill a maximum of 4 diagnoses. I may find a dozen problems to address, but I have no way to bill any higher than a certain number of codes. Most basic office visits are 1-3 ICD9 codes, with more frequent visits required to address the more complex patients.