Grandfathering

In the "good old days," anesthesiologists did it all. After residency, one could and was expected to anesthetize cardiac patients, pediatric patients, and obstetric patients. But as science and medicine progressed, fellowships were developed for those who wanted further in-depth exposure to a subspecialty field like pediatric anesthesia or cardiac anesthesia. Eventually, these fields became officially recognized and developed separate board certification processes. Whereas older attendings didn't have fellowship opportunities, recent graduates have a smattering of choices to get further certification.

Now, hospitals, surgery centers, and institutions want to say they have board certified pediatric and cardiac anesthesiologists doing relevant cases. But all of a sudden, the only people they can hire are the young attendings who did the fellowship; all the older attendings who have done pediatric or cardiac anesthesiology for decades do not have subspecialty certification. Yet an attending with thirty years of experience taking care of children doesn't need a fellowship and may be better than a freshly minted physician who finished fellowship last year. But because the latter applicant has board certification, he gets the job so that the hospital can boast board certified subspecialists.

There is a process of grandfathering into board certification without doing a fellowship if one's practice consists of a high percentage of subspecialty cases. But this is a long and involved procedure and providers may not feel it's worth it. In the end, despite a desire to promote subspecialization, the process restricts those generalists who've been doing subspecialty cases for generations.