SPECIALISTS: WE MUST HAVE THEM!

I’ve discovered that some specialists have a very easy time of it. Seeing patients, that is! They really do. Imagine that if all you saw patient after patient, were knees, or eyes, or prostates, or rashes? You’d get pretty good at it. Someone said “repetition is the best teacher!” So why wouldn’t you? How many different problems can occur with a prostate? Not that many; once you determine the patients symptoms are from a big prostate, all that’s left is to decide if it’s benign, cancerous, or infected? There aren’t many other possibilities. Yes, I know some rare, odd condition can occur, but 99% of the time it isn’t hard to tell what the patient has. Imagine diagnosing and treating prostates most of the time! 

Knees? Now that’s a complicated joint, mechanically, but once you know the anatomy of the knee, it’s not too hard to figure out what’s wrong with it, especially with today’s imaging technology. There’s only bones, cartilages and ligaments that can go haywire. Options are few! The painful, swollen knee is not too hard to diagnose nowadays. Probably, by the time the patient gets to the specialist, the diagnosis will already be made. His family doctor saw him, ordered an MRI, and told him what was wrong! Mr. Smith just has to see the ortho doc to get it fixed. So Dr. Orthopedist sees his fifth patient that afternoon with a knee problem, with the diagnosis handed to him on a platter. Not too difficult.

Then there’s the eye doctor? Now, there’s a narrow field (pun intended). All the ophthalmologist sees (another pun intended) is eyes, pair after pair! As a senior medical student, I spent two weeks in hospital ophthalmology clinics seeing, you guessed it, only eyes. It was boring. Every patient had the same complaint—“I can’t see!” Of course, that complaint took on different formats, from blurry, to cloudy, to hazy, to double vision, all the way to “something’s wrong.” The diagnosis usually came down to cataracts, glaucoma, macular degeneration, some infection, or, rarely, a tumor. After two days in that clinic, I reached the point of craving to put a stethoscope on a chest, examine an abdomen, or, heaven forbid, do a rectal exam. Eye patients were not easy to please, either. Everyone feared they were going blind and that prescription for new glasses just wasn’t cuttin’it! “I still can’t see!” When you only take care of eyes, you develop methods and answers to be certain the patient is satisfied.

The skin is the largest organ in the body so dermatologists have a lot of area to cover (not another pun!). Again, they see the same organ system patient-after-patient. Most dermatology patients have a rash, a suspicious mole, or they itch. So the choices are limited. Theirs is primarily a visual profession. They are “tasked” with looking at the skin, seeing its abnormality, and making the diagnosis by recognizing what it is. They have an out, though! If they can’t tell what it is by looking, they biopsy it. They take a small piece of the skin or mole and examine it under the microscope. Then, once they know the diagnosis they slap on a cream, freeze it, or cut it out. The cutting part is where a change occurs. The simple becomes a complicated, laborious procedure that requires another doctor, a sub-specialist—a Mohs surgeon. Up to that point things have been very routine.

I think you can see my feelings about some specialists. The problems they see are limited to one area or organ, and the solutions and recommendations for treatment become repetitious. Besides, the family physician or ER doctor frequently has already nailed the diagnosis and is sending the patient to the specialist either for confirmation or to begin a complicated treatment regimen. 

Conversely, intermingled with the run-of-the-mill, everyday, common problems, is the occasional challenging, “I’ve-only-seen-one-of-these-before” types of patients. They have something unusual the specialist remembers seeing as a resident, but hasn’t seen since. Fortunately, these types of patients don’t appear all that often. When they do, the doctor must be “on his toes,” or he/she might just miss it. He/she has to be vigilant and pay attention to the patients’ symptoms. 

Internists, Nephrologists, Endocrinologists, Hematologists, Oncologists, Cardiologists, Neurologists, Critical Care specialists, and Geneticists are in a different realm, however. Theirs is not a practice filled with day-to-day routine and repetition. Every patient is different; every patient is complicated, every patient is challenging. Yes, maybe internists see a lot of people with high blood pressure, high cholesterol, or diabetes, but these disorders have a multitude of secondary complications. And these specialities care for people who have long term, disabling problems or are accompanied by a high mortality rate. Nearly every day, Oncologists or Cardiologists have patients who die! Neurologists have patients with horrible strokes!Nephrologists tell people they need dialysis or a kidney transplant. These are tough, complicated situations that change peoples’ lives. 

I’ve left out surgeons on purpose because theirs is a still different realm which is difficult stress-wise, time-wise, and never routine. They can be called any time, day or night, for any thing. They never know when that will be or what it will be. The successful surgeon is good with his hands, an artist of sorts, thorough and meticulous. They learn and perform complicated procedures whose outcome depends on their expertise. I think you can see strong evidence of the difference posed by some specialties. 

Some specialities are limited, repetitive and boring. Some specialties are complex and fraught with tragedy and death, and some are demanding of time, sacrifice, and talent. Which one a young doctor chooses is determined by many factors. Of course I’m biased in this opinion, but the family medicine practiced by my generation of physicians fits most of these categories. It was occasionally repetitive, but never boring. It was always challenging and complicated. Many patients experienced personal or family tragedies and died, and time demands and sacrifices were common. You have to know all this going in, but it’s an educated choice made during the many years of your training. If you want a routine, scheduled life, there’s a specialty available for you. If you want confusion, chaos, and tragedy, that’s available, too. For most young doctors, their first decision is the right one. But occasionally, an early or mid-career correction is made when that first choice wasn’t what you had hoped. 

Specialists! We have to have them. Thank goodness we are blessed with many good ones. They bailed me out a lot of times, and for that I am thankful. However, in family medicine offices, many of the same procedures “specialists” do are routinely done. Yet, family doctors are not given equal recognition of that fact. We are thought of as being “triage agents.” Nothing is farther from the truth. As I said above, my generation of FP’s sent patients to specialists already diagnosed. They arrived diagnosis in hand. All that was left for the specialist was to treat the patient and manage them chronically. We did the hard part for them. I’m not bragging; just telling it like it is/was. Occasionally, specialists sent patients back to us to manage. They said we knew them better and could do just as good a job as they did. That was very gratifying. 

Today, things are different. With NP’s and PA’s seeing the bulk of acute patients, triaging is more common. In-depth diagnosis and management is left to the specialist. That’s ok, but where is the family doctor in this picture. His role is diminished; he is by-passed; he becomes insignificant. I have no doubt most doctors my age are bothered by that situation, but it’s too late to do anything about it. The medical profession no longer wields the power and influence it once did, especially in primary care. We gave that away years ago. It’s what the government claimed the public wanted. I vehemently disagree.