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Too much specialization?
A look at the proliferation of sub-subspecialties

Keywords: What is going on with the growing medical trend toward ever-more specialized care ?


by Ruben J. Nazario, MD



Published in the May 2012 issue of Today's Hospitalist

I AM PATIENTLY WAITING FOR AN MRI RESULT when they tell me the radiologist has left the building.

"What? I thought we had 24-hour radiology coverage?"

"Well, yeah, general radiology coverage. But I'm talking about the musculoskeletal radiologist. He leaves at 5 p.m."

"Musculoskeletal radiologist? I didn't even know such a thing existed! So a regular radiologist can't read an MRI of the leg?"

"Nope. Call back in the morning."

And with that, my LOS went from 0.5 to 0.7, making me lose about 1% of my productivity incentive. The whole episode got me thinking: What
At what point does subspecialization become too specialized?

is going on with the growing trend toward ever-more specialized care?

I thought the whole purpose of specialization was to acquire the technical skills necessary to address complex medical problems. As such, training in subspecialties has grown exponentially as the care we provide has become more technically complex.

But where does it end? At what point does subspecialization become ... well, too specialized?

Sub-subspecialists of the future
In the spirit of imagining future dystopias, here's a list of potential sub-subspecialties. If you already have one of these or if you've heard of other types of sub-subspecialists, please write in, along with your credit card number and social security number:

1. Distal phalanx hand surgeon: Not to be confused with the knuckles surgeon, who actually trains in podiatry school, or the palm-of-the-hand surgeon, who is actually a dermatologist trained in palm reading.

2. Tween pediatrician: A subspecialty within adolescent medicine that specializes in Justin Bieber hysteria, PlayStation and Wii reflexes, and anti-bullying strategies.

3. Left-lung radiologist: Not to be confused with the right-lung radiologist, the diaphragmatic radiologist (known as "diaphrad") or the lingular radiologist (mistakenly referred to as the "linguist"). The latter is actually a subspecialty of ENT.

4. Islets of Langerhans gastroendocrinologist: An offshoot of Type-II diabetology, which requires a year of research trying to figure out why there are so many things named after Langerhans (same for the research area of stressologists preoccupied with Cushing).

5. The dead-people pathologist: This one takes a holistic approach to deceased people. Not to be confused with the medical examiner, who is a physician who really wants to be a lawyer, or the skinny-slides pathologist, who is often at odds with the frozen-section pathologist (because stuff in the frozen section makes you fat ... get it? ... OK, lame).

6. The cardiac-massage cardioelectropathophysiologist: This one takes your beating heart and squeezes it into submission, but only after you've had a heart transplant. If your heart stops before transplant ... well, that's when the dead-people pathologist intervenes.

7. And finally, the personalized medicine concierge doctor: An offshoot of the personalized medicine movement, the PMCMD knows where to get the best petit fours in the city, has a direct line to the best chef in town for all your social events, and can check—utilizing your own genomic material—if you're allergic to the latest molecular cuisine dishes. If you break out in hives, he can even give you a subatomically dosed infusion of epinephrine to avoid serious side effects to your vivacious telomeres.

New specialties, new markets
And so on and so forth. Pretty soon we'll have 1,000 board associations to certify this plethora of sub-subspecialists. By then, prices for board certification will be above $10,000 a pop and you will have to recertify every other year to keep up with the newer trends in medicine, like merry-go-round group psychiatry and inside-out gut devolution surgery.

This is great for the boards, which stand to make even more money that they can use to figure out a better way to screw doctors over in the name of "quality control." It's also good news for the economy because the explosion of new procedures and diagnostic tests will certainly create an ever-ballooning deficit that will require floating the value of the dollar against the Malaysian ringgit. And selling Alaska to the Chinese.

But the best outcome of an expanding sub-subspecialist work force? The creation of new markets for medical publications.

Can you pass me the latest issue of "Today's Meningoencephaloneurocardiovasculopathologist"?

Ruben J. Nazario, MD, is a pediatric hospitalist at Inova Fairfax Hospital for Children in Falls Church, Va. Check out Dr. Nazario's blog and others on the Today's Hospitalist Web site at www.todayshospitalist.com.




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