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.