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Physician Specialty Silos Can Cause Friendly Fire Casualties

It’s no secret that medicine has become a highly specialized business. While generalists used to be in charge of most patient care 50 years ago, we have now splintered into extraordinarily granular specialties. Each organ system has its own specialty (e.g. gastroenterology, cardiology), and now parts of systems have their own experts (hepatologists, cardiac electrophysiologists)  Even ophthalmologists have subspecialized into groups based on the part of the eye that they treat (retina specialists, neuro-ophthalmologists)!

This all comes as a response to the exponential increase in information and technology, making it impossible to truly master the diagnosis and treatment of all diseases and conditions. A narrowed scope allows for deeper expertise. But unfortunately, some of us forget to pull back from the minutiae to respect and appreciate what our peers are doing.

This became crystal clear to me when I read an interview with a cardiologist on the NPR blog. Dr. Eric Topol was making some enthusiastically sweeping statements about how technology would allow most medical care to take place in patient’s homes. He says,

“The hospital is an edifice we don’t need except for intensive care units and the operating room. [Everything else] can be done more safely, more conveniently, more economically in the patient’s bedroom.”

So with a casual wave of the hand, this physician thought leader has described a world without my specialty (Physical Medicine & Rehabilitation) – and all the good that we do to help patients who are devastated by sudden illness and trauma. I can’t imagine a patient with a high level spinal cord injury being sent from the ER to his bedroom to enjoy all the wonderful smartphone apps “…you can get for $35 now from China.” No, he needs ventilator care and weaning, careful monitoring for life-threatening autonomic dysreflexia, skin breakdown, bowel and bladder management, psychological treatment, and training in the use of all manner of assistive devices, including electronic wheelchairs adapted for movement with a sip and puff drive.

I’m sure that Dr. Topol would blush if he were questioned more closely about his statement regarding the lack of need for hospital-based care outside of the OR, ER and ICU. Surely he didn’t mean to say that inpatient rehab could be accomplished in a patient’s bedroom. That people could simply learn how to walk and talk again after a devastating stroke with the aid of a $35 smartphone?

But the problem is that policy wonks listen to statements like his and adopt the same attitude. It informs their approach to budget cuts and makes it ten times harder for rehab physicians to protect their facilities from financial ruin when the prevailing perception is that they’re a waste of resources because they’re not an ICU. Time and again research has shown that aggressive inpatient rehab programs can reduce hospital readmission rates, decrease the burden of care, improve functional independence and long term quality of life. But that evidence isn’t heeded because perception is nine tenths of reality, and CMS continues to add onerous admissions restrictions and layers of justification documentation for the purpose of decreasing its spend on inpatient rehab, regardless of patient benefit or long term cost savings.

Physician specialists operate in silos. Many are as far removed from the day-to-day work of their peers as are the policy wonks who decide the fate of specialty practices. Physicians who have an influential voice in healthcare must take that honor seriously, and stop causing friendly fire casualties. Because in this day and age of social media where hard news has given way to a cult of personality, an offhanded statement can color the opinion of those who hold the legislative pen. I certainly hope that cuts in hospital budgets will not land me in my bedroom one day, struggling to move and breathe without the hands-on care of hospitalists, nurses, therapists, and physiatrists – but with a very nice, insurance-provided Chinese smartphone.


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7 Responses to “Physician Specialty Silos Can Cause Friendly Fire Casualties”

  1. Stan Smith says:

    As a retired Family Physician with a special interest in PM&R, I have observed the inequitable distribution of resources from the less glamorous to the sexy sub specialties despite obvious patient needs. Unfortunately, the administridiots who usually lack any medical training, opt to place resorts where they are most likely to attract headlines. (And perhaps even bonuses!)
    St Smith
    medicalmanes.com

  2. Worksure says:

    Medical writings and Research solutions-provision of medical services by excellent and commited medical writers as well as medical experts.On the basis of research and clinical trials conducted by Life sciences,writers puts their endeavour to provide users with fully reliable genuine information.

  3. Doris RN says:

    As a nurse for almost 40 years I heartily agree with you. I have worked in rehab and homecare as well as acute care ICU. We still need hospital care for those injuries/illnesses that can not be handled safely without trained care and observation.Acute rehab can not be accomplished without many disciplines including Physical/Occupational therapists and many times Speech and respiratory therapists .Although all these individuals can make home visits the intensity of needs means it is not the best use if our resources to spend time traveling to each individual. Homecare by definition is short term intermittent service. So yes let each specialist remember ,the high profile, glamorous areas are not the only things that hospitals must provide

  4. Amen, Doris. Thanks for stopping by the blog. :-)

  5. Spring Texan says:

    Wow. Thanks for this and the following column.

    Yes, four years ago an indigent friend was injured in a horrible motorcycle accident, her legs totally crushed, and she got terrific hospital and surgical care (probably 15 surgeries or more), but then was dumped in a nursing home and could not get occupational or physical therapy at all. This was so insane given the relatively minor cost of PT and OT relative to what she had received. The discouragement when the nursing home did not even have time to get her out of bed without a fight was immense.

    She eventually got Medicare and Medicaid (easier because of her advanced age) and did get some PT and OT and finally a couple of stays is now living at home independently after over a year and a half in first institutions and then with another friend.

    But it all made me appreciate how crazy it is and how wrong. Your specialty is HUGELY important and thank you for doing the work you do. Yes, it’s not sexy and it gets totally overlooked and ignored. I don’t know how to fix it, but the Topol comment is a prime example of total idiocy and romancing technology not medicine. I get equally frustrated when people rave over personalized genomic medicine and the sci-fi potential while so much that is so basic and important gets ignored,

    I wish I could plaster your column all over the internet!!

  6. Spring Texan says:

    The earlier comment should have read “finally a couple of stays IN A REHAB HOSPITAL” doesn’t make much sense the way I wrote it. (there doesn’t seem to be a way to edit the old post)

  7. Dr. Val says:

    Thank you, Spring Texan. Kind words go a long way in keeping spirits up – especially for the non-sexy among us! :-)

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