The construction and deconstruction of medical specialities: ‘Practice sprawl’

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The first decade of the 21st century has witnessed the development of intense competition for patients and services among medical specialists. While much of this competition has been for market share within a particular subspecialty practicing within a defined geographical boundary, some has occurred between different specialties. An increased number of specialists, diminishing resources, and constant or even decreased payment for services, account for the rapid and unprecedented pace of ‘de-specialization’ among medical subspecialty groups. De-specialization is probably nowhere more evident than in the fields of cardiology and cardiovascular surgery, blurring the archaic, traditional role of the medical practitioner as the diagnostician/apothecary and the surgeon as the procedure-oriented practitioner.

The phenomenon of de-specialization represents a dramatic reversal of a process that has been ongoing for the last 200 years. Prior to the mid-19th century, medicine was practiced in three very distinct branches; medicine, surgery, and apothecaries. Specialization was limited to surgery, wherein a body of practitioners known as “experts” limited their practice to specific operations; for example, fracture setting, hernia repair, or lithotomy. Many of these specialists were unlicensed itinerants and, as such, held a relatively low status in the profession. Because most surgeons were trained informally outside of an academic institution, they carried the title ‘Mister’ rather than ‘Doctor’; a tradition that survives today in the United Kingdom and some other European countries.

One of the first ventures into specialty practice occurred in 18th century France. A male midwife attended the delivery of a child by the mistress of Louis XIV, and the presence of an obstetrical “expert” became fashionable. Obstetrical specialization became common-place in Paris of the 1830s, developing with the post-Napoleonic scientific and educational reform. Medicine and surgery, quite separate at this point, began to coalesce into a single profession within conjoined university-based training programs. Surgical education began with instruction in anatomy, followed by training in operative techniques.

In North America, specialization developed much more slowly, initially limited to obstetrics and ophthalmology. The smaller American medical schools of that era, each with perhaps eight to ten professors, did not have the medical infrastructure to foster specialty development. But the tide turned for American medical specialization in latter half of the 19th century. US medical schools, previously autonomous, began to affiliate with the newly enlarging universities. Medical education underwent a reformation and training became more scientific. Specialization became an agenda item in American schools and medical societies.

The process of medical specialization in the US was accelerated by adoption of the German academic model of medical training. As well, elder generalists were willing to create specialty positions for young doctors that would not directly compete with their own practice. By the 1870s, many New York City medical schools had professorships in neurology, gynecology, dermatology and the then nascent specialty of pediatrics. Initially opposed by the American Medical Association, specialty societies began to proliferate. With the development of specialty boards the number of general practitioners fell precipitously. In 1935, specialists comprised 31% of the physician population; by 1963 GPs made up only 28% of physicians and by 1977 this number had fallen to 13%. By the turn of the 21st century, the vast majority of physicians considered themselves to be specialists. Internal medicine, general pediatrics, and family practice were all considered to be independent specialties, sometimes vying for patients in an era of diminished demand.

Where are we headed?

While demand for physician services remains strong, supply is overabundant in certain highly technical, lucrative subspecialties; particularly in the larger American cities. Interventional cardiology is one such subspecialty. In a 2003 essay on manpower, Dr Ted Feldman, the then current President of the Society for Cardiac Angiography & Interventions, suggested that the 135 interventional cardiology fellows that completed training every year would soon be an inadequate number to provide for rising demand1. However, in the same paragraph, Feldman noted that more than 6,000 operators performed approximately one million percutaneous cardiac procedures annually – or about 150 procedures per physician per year. With falling payment rates for interventional procedures, this number would barely pay the overhead of a busy practice.

These observations may underlie the ‘practice sprawl’ of specialties such as interventional cardiology. In an effort to maintain volume and income, practitioners have broadened the spectrum of the procedures they offer. The peripheral vasculature seemed a likely target for the cardiologists; the technical details of peripheral percutaneous procedures are similar to those in the coronary circulation. And, with the opportunity to address arteries in the neck, abdomen, and legs in the same patient population referred for coronary disease, the supply and demand equation became more lucrative for the doctor.

One would predict that as prices (third party payer rates) fall, the same number of physicians will strive to increase procedure volume. Healthcare costs will rise, and the payers will push pricing still lower. A downward spiraling scenario can be predicted, promoting the continuation of practice sprawl, de-specialization of medicine, and deconstruction of medical subspecialties, until such time as the healthcare economic model of payment is dramatically altered. These observations alone argue for a new look at models of physician manpower, insurance payment, and specialization in the medical field.

1. Feldman, T. Interventional cardiology manpower needs. Catheterization and Cardiovascular Interventions. 2003;58:137-8.

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