Tuesday, December 29, 2009

If We Are All Specialists, Are None of Us Specialists?

I have been thinking about training and licensing and how things have changed during my lifetime.

Gather round children while Grandpa tells about how we became docs in the olden days.

When I was in medical school we did the first three years with increasing clinical exposure. Everybody took the same courses, there were few or no electives. The quality of experience you got in your clinical rotations varied with hospital and clinician but that averaged out.

Fourth year was what was called a clinical clerkship or where I trained, a medical student internship. You were dropped in on the wards with little preparation or supervision to look after whatever disasters were there. True you were "supervised" by interns and residents but they often had disasters of their own to deal with. You did a lot of what we called scut work which was noneducational service oriented work but I, at least, learned a hell of a lot in that year. The clinical clerkship was based around the core rotations of medicine, surgery, paediatrics, obstetrics and psychiatry. There were electives of course. Again, while there were differences from hospital to hospital, everybody more or less got the same experience in fourth year.

When you graduated you were what was called an undifferentiated physician. You needed one more year of training to get a license in most provinces. This was done via a rotating internship which was again based around the 5 core specialties (sometimes less psychiatry). Almost everybody did this, even the future specialists. It was possible to do a straight internship but very few people did this. The rotating internship was a lot like the clerkship except you were more senior and you had the opportunity to work in another centre.

So one year after medical school, basically everybody had the same training, and the same experience. Those of us who chose not to become specialists became general practitioners. General practitioners at that time did a lot things including some surgery, orthopaedics, obstetrics, emergency work, anaesthesia as well as what we now call family medicine. How much they did varied from centre to centre with rural doctors doing more than city doctors, although not necessarily so. Some people had taken extra training, some people just went out and did it.

This idyllic world was already about to end around the time that I finished medical school. Sometime in the past, some general practitioners, resentful of the supposed prestige of specialists, decided that they too could become specialists and the "specialty" of family medicine was born. This was quickly followed by the family medicine "residency" which lasted 2 years as opposed to the one year rotating internship. I worked along side these "residents" in family medicine as an intern. We of course called this the "internship for slow learners".

We shouldn't have laughed at them. Only 8 years after I graduated from medical school the rotating internship was dead. The only way to get a licence to practise in any Canadian province was to do a specialty or to complete the family practice "residency".

Now back when I was coming out of medical school and internship, I really couldn't have told you what specialty if any I wanted to do. I was 24 single, sick of training and not having any money. I was happy to be "just a GP". There were lots like me; we drifted around doing locums for a few years before having a revelation and starting a specialty. I think the specialties preferred it that way, they got older, battle tested residents. I should also mention that it was often people passing time before specialty training who staffed the remote communities which is why there is such a shortage of docs in those areas.

With the general practice route now closed off however now you had to decide on a specialty sometime before early in fourth year. Coincident with this, most medical school went to a two year student internship with core rotations mixed with lots of elective time. The elective time has for the most part, become a time to visit various programs and get some brown-nosing in, in the hope that they will rank you high in the match saving you from a career in radiation oncology.

This has resulted in medical students now spending large chunks of their clinical years doing electives, often in a small number of specialties. I was impressed, not necessarily in a good way, in how much time our prospective residents in anaesthesia spent doing electives in anaesthesia. This often means that students slide through rotations they are not interested in, knowing that they will not be failed and they will not be asking for a letter of reference from that rotation.

The result is after 4 years, instead of undifferentiated physicians we now have "specialists" in plastics, anaesthesia, urology; whatever they decided sometime in third year they were going to be. This means we have internists who know nothing about obstetrics, neurosurgeons who know nothing about psychiatry etc, etc.

The point I am making is that 25 years ago, all doctors graduated equal and then some went on to be a specialist in a certain field. These specialists had at least had a taste of what other doctors have to deal with and the relationships between specialties was better. Specialists were physicians who happened to be specialists. Now however we have all been put into our silos early on in our careers; I can still consider myself a physician who specializes in anaesthesia, but the graduates of the last 10-15 years who are no longer physician specialists but now merely anaesthesiologists.

As a future consumer of healthcare I am not optimistic where this is going.


burnttoast said...

How is medical education paid for in Canada? I was stunned to learn the debt load of my younger anesthesiologists. $250,000 is average. One woman voiced the concern that she needed to pay off her student loans before setting money aside for her two kid's college fund. A med student knows what their debt load will be, and knows what they have to earn to make those payments, and have the lifestyle they aspire to upon completion of training. That pretty much rules out most primary care "specialties". I disagree about the good old days and GPs doing everything. I can remember announcing I was changing to anesthesiology at a FP weekly grand rounds (I was in my second year.) An FP who was widely known to be incompetent (and he was, trust me) slapped me on the back and roared, "That's great! I used to pass alittle gas in the OR from time to time myself!" I got cold chills thinking of it. Dealing with awake patients who can run away (or get a second opinion) if needed is one thing, but caring for an anesthetized patient making it up as you go along, strikes me as a bad idea. I would find even the anesthesia care team (code for CRNA stable) safer.
The real problem is no one coordinates the specialists. Patients lack the expertise, or even worse, are too sick. Most of the patients I see in the big private hospital could benefit from some continuity of care, and someone coordinating the dance of tests, drugs, and consults. Our FPs don't even set foot in the hospital anymore, the hospitalists fill that function, sort of. Think ER docs on shift work on the wards. Of course, the patient is a total stranger, and has no say in the selection process. I would answer your question as "If we are all specialists, then we all lack the knowledge and skill of the generalist." Unfortunately, those traits are neither valued or rewarded in our current US healthcare system. Happy New Year!

Bleeding Heart said...

Medical education while still highly subsidized in Canada still leaves students with high debts. I have heard of residents with $100K debt loads.

I agree that GPs doing anaesthesia sends chills down my spine; however many of them were quite good and it was a group of GP anaesthetists in rural BC that got my interested in anaesthesia. In Canada our GP-anaes do 1 year of training although I suspect there are still a few out there who were "grandfathered" in with much less training. We all know that there are some specialists we would never let anaesthetize us or our family.
We of course don't have CRNAs in Canada.

Anonymous said...

The powers-that-be that run medical education are totally in love with their own, ridiculous, ideas.

As it stands, there is a HUGE push to get medical schools in Canada to teach students exclusively from a "family medicine" perspective. Yet, when it comes time to actually get a job and practice medicine, most students opt to specialize(and who can blame them?) and will never see medicine from a generalist perspective from day one of residency onward.

This disconnect will only be remedied one of two ways:

1. Primary care is dissolved and specialist care is the only care available. Though the gov't waxes prophetic about the values of primary care, its all lip service. Naturopathic doctors(aka witch doctors) have obtained the same prescribing and procedural rights as a CCFP certified physician in BC, and the same will soon happen in ON. Nurse practitioners will soon follow suit. With this coming paradigm, primary care will be handled by lower-levels while the MDs will all be specialists.

2. The CCFP relinquishes their family practice residency requirement and humbly allows a reversion back to the days of the rotating internship. This is what I feel would be far better for patient care. You make great points about it, and surely more people would opt to stay in primary care because of the early time at which a large salary boost occurs. Further people would try primary care for at least a while because they would not be penalized if they had not determined their ultimate career choice while in medical school(as it stands now, if you want to do a specialty, you have until CARMS round one to decide and that's it)

The common thread is that generalist practice does help patients, but also that generalism does not equal specializing. Therefore, primary family medicine is not a specialty, and the CCFP needs to loosen up. Otherwise, it won't be them practicing primary care in the future.

Bleeding Heart said...

What I see is primary care dissolving into urgent care which would be handled by doctors primarily non-specialists (which is what most of them do anyway) and chronic care would be handled by nurse practitioners and some salaried doctors.

I can't see specialists as the point of entry to the system. Imagine how much lab work the average internist would order for every URTI he saw.

Naturopaths? I sure hope not. Nurse practitioners if you can convince them to move out of the cities maybe.

I have heard the odd rumour of the return of a common PGY1 AKA the rotating internship. Of course the Family Medicine and Royal College people who put the kibosh on the rotating internship will take all the credit.

Anonymous said...

Read it and weep.


Primary care physicians and naturopaths are now on equal grounds in BC.

Bleeding Heart said...

Having worked in BC, and still living next door, it is hard not to be aware of the poisonous relationship between the BC Govt., no matter what party is in power and the medical association.

I suspect any regulation empowering naturopaths is more about spanking the doctors than recognising that naturopaths have any role to play in healthcare.