The General and the Specific

As medicine becomes more and more subspecialized, the generalists lose skills they used to have. Decades ago, all anesthesiologists did cardiac, thoracic, obstetrics, pediatrics; because there wasn't further specialization, we were expected to do it all. Of course over time, medicine becomes more complex; the surgeries we do today involve much more technology, equipment, skill, and expectation than those in the past. We are doing harder surgeries on sicker patients, a phenomenon that leads to more specialization, more training, and more differentiation.

But after a month of cardiac anesthesia at the VA doing run-of-the-mill community-level cases, I think that there's something lost when generalists no longer do specialized cases. It would be inappropriate for a general anesthesiologist to do an aortic root replacement or brain surgery for a neonate. But it's not out of the question to expect him to manage a simple three vessel bypass or inguinal hernia repair on a child. The problem with subspecialists is that we now expect a cardiac anesthesiologist to do all heart cases and a pediatric anesthesiologist to do all the kids. But with a limited supply of subspecialists and a growing number of surgeries, this becomes untenable. Furthermore, if the generalist lets his skills atrophy, then cases that used to be appropriate no longer remain so, a sad reflection that we no longer practice to the fullest extent of our training.

I understand the nature of increasing complexity and increasing subspecialization. But this does not mean that the generalist's sphere of practice needs to change.