I'm sorry, but there is a reason community shops end up sending a good number of patients to large academic facilities, and a number of times those patients end up with a common disease that just happened to have an uncommon presentation. This happens more frequently than most realize...the only way you're going to catch these is see them...and the only way you're going to see them in a number to actually get comfortable is to concentrate down the patient population you're seeing.
Don't mistake what I'm saying...I'm not suggesting we need more subspecialists than primary care docs (in a raw numbers game), but you are both flat wrong if you think there isn't a need for the current level of specialization.
I think there is an unaccounted for issue where much of the disagreement comes from.
The more subspecialized medicine becomes, the more disconuity there is with pt care. Even in systems which are completely electronic, often one doctor does not read or know the total picture. Each time the patient goes to another doctor, something in the history or treatment is lost.
Some will argue that the PCP should be coordinating this, but should be and what really happens is different.
The problem you described is not unique to any particular specialty. It is a problem inherent in seperation between academic and non-academic medicine. The solution to that is not more specialization, the solution is to require affiliation in academic medicine.
That will likely never come to pass anywhere.
In some countries, (at least 3 I am aware of) they are actually seperating academic medical training from general medical training, with both seperate applications and training requirements.
Sadly, this distances the two even further.
I do not buy the argument that specialists who see a finite number of cases will more readily identify unusual presentations.
It is often joked by the local cardiologists that if you are referred to them, they will find a cardiac problem and treat you for it. If you didn't have a cardiac problem why would you go to a cardiologist?
What you end up seeing is a patient with a comorbid pulmonary disease winds up in cardio, where they treat the hell out of the cardiac issue, and if the patient doesn't resolve then send them to Pulmo. The exact opposite happens as well and even the most general patients wind up seeing 3 or 4 or more doctors before somebody narrows down the problem.
It is frustrating for patients, wastes tremendous time and money, and delays treatment.
It is a sick game of duck, duck, goose.
The ability to identify uncommon presentation from zebra hunting is a matter of correlating the knopwledge of physio, patho, diagnostic findings, and patient presentation.
A mistake is made and lack of diagnosis doesn't come from lack of familiarity, it comes from a fundamental deficit in the application of medicine.
The idea that you can diagnose a patient from "textbook" presentations and apply a standard treatment is flawed.
As you know, it is actually fairly common for diseases not to present from textbook symptoms. Sometimes the textbook is oversimplified.
I use an example I encountered, malaria. The only case of malaria I saw presented in a textbook way. When I was discussing it with another doctor who sees a lot of malaria, she informed me that only that particular species of malaria presents in such a way. She then went through the different species and their respective common presentations.
She was not an infectious disease expert, she is a GP who primarily practices austere medicine and has all over the world.
For my own part, I have discovered what is learned in medicial school is not the end of knowledge, it is only the beginning.
I am rather dialed into pathophys because of an interesting turn of events, I have developed an uncanny ability to hunt zebras and discover abnormal presentations because of it. From mastery of this, abnormal presentation means nothiing to me.
My "specialized" knowledge is in intensive care medicine, and the focus of it is further specialized specificall with shock. (I wrote my dissertation on it) butit doesn't mean that I am totally mistified by diseases or presentations outside of this area.
It goes back to my question of wants vs. needs.
People want to specialize in certain aspects of medicine. It is easier. But whether those specialties are needed is another matter. Like I said, there are places where EM doesn't exist. It is a job, not a specialized body of medicine. After having seen it, I think it works better that way. But some people want to focus on the aspects of EM.(limited though they are)
