The Early Days of Medicine
It is fascinating how medicine has evolved. In the early days, a doctor took care of patients from newborns to the elderly and everything in between. There did not appear to be any evidence of medical specialization in the US prior to 1855. For example, the governing organization of pediatrics, the American Academy of Pediatrics, was only formed in 1931. This was followed by the creation of the pediatric certification agency, the American Board of Pediatrics, in 1933. Prior to this, there was no governing body in the field of pediatrics, and any doctor could care for children without verification that they actually knew how to manage children’s health issues.
To give this further perspective, my specialty of pediatric critical care medicine only started its specialty fellowship training programs in the 1970s and early 1980s. It was formally recognized as a specialty in critical care medicine in 1981. A special section in the American Academy of Pediatrics was provided in 1984, and a subspecialty certification exam was required in 1987. In the grand scheme of the history of practicing medicine, pediatric critical care medicine is just in its infancy (pun intended).
Advent of Medical Subspecialization
This development is not unique to pediatrics or pediatric critical care medicine. All medicine has grown and expanded beyond its original borders. As knowledge in one area accrues, the ability for one specialty to retain all the relevant information and experience diminishes. The information gets parceled out into various groups and subgroups to allow a deeper understanding of medicine and, ultimately, further specialization of medical practice.
Also, as medicine successfully saves lives and lengthens the life spans of populations with specific diseases, new specialties are created to care for individuals in adulthood who would not have survived past childhood. This is particularly true in congenital heart disease. Some infants are born with heart defects that were lethal in infancy 40 or 50 years ago. Now, they survive after surgical interventions and are becoming adults in larger numbers. Pediatric cardiologists once cared for these children up until early adulthood. However, with adult medical issues, they weren’t the best to be caring for this population. Thus, the adult cardiology subspecialty of adult congenital heart disease was developed to care for adults who had survived childhood after the repair of the heart defects they were born with. The first adult congenital heart disease clinic was established in 1976, but it wasn’t until 2015 that training became standardized, and an adult congenital heart disease certification exam was offered.
Expansion and Fragmentation of Medical Knowledge
We can all appreciate the advancements in medicine and all the amazing things that are now achievable through discovery, scientific study, and field experience. But, as medicine advances, it is sometimes not appreciated how the field evolves to accommodate these advancements. Medicine has become a field that once entrusted the care of a patient to a single doctor. Now, taking care of a single patient is a team effort. It is not that illnesses have become more complicated. It is that our understanding of these illnesses has grown to the point where multiple individuals with the deepest understanding of different facets of a disease are needed to provide the best achievable outcome for those who require it.
Nevertheless, it is important to realize that while astounding things can happen as medicine evolves and subspecialization occurs, our expanding understanding can precipitate problems. One of the issues that stands out in my mind is the coordination of care. As more subspecialists weigh in on a particularly complex issue, each approaches the medical issue from their perspective and may not consider the perspective of others or the patient in his or her entirety. For example, a patient comes in with an overwhelming, total body infection (sepsis). Multiple organs can be affected, such as the lungs, heart, and kidneys. So, a patient with sepsis may require subspecialty involvement from pulmonology, cardiology, nephrology, and infectious disease. While each is approaching the illness from their perspective as a specialist in their particular organ system, they may not be considering how their recommendations coordinate with or affect the medical care plan of the other subspecialists.
Balancing Subspecialization and Holistic Care
While it is fascinating to ponder how medicine will evolve and mind-boggling to fathom how our lives will be improved, it should give us pause to think about how all of this will be managed. The complexity of the body deserves the most advanced knowledge, equipment, treatments, and procedures available. Yet, with all of this, the demand for coordination, communication, collaboration, and appreciation has never been greater. Without smooth coordination of care, unhindered communication between teams, encouraged collaboration, and appreciation for others’ perspectives, the knowledge and expertise that we have gained during medicine’s evolution will be fragmented and useless at best and harmful at worst.
The future of medicine lies in balancing the depth of specialized knowledge with the breadth of holistic care. Strategies that enhance coordination, promote interdisciplinary collaboration, and integrate patient-centered approaches must be prioritized. By doing so, we can harness the full potential of medical advancements while ensuring that each patient receives comprehensive and cohesive care. It is more important now than ever that we strive to maintain the same level of holistic care and attention that characterized the single physician's approach to the delivery of patient care in the early days of medicine, despite how advanced we have become and will become in the future. The proverbial sword of medicine is a powerful tool to battle illness and disease, but one should not forget that it has two edges.
How do you think the shift towards medical specialization has impacted patient care in your experience or opinion?
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