Civilian Forward Surgery

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Veneficus

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If I had my way.

Emergency medicine would be gone. I work in and I am familiar with several systems where there is no "emergency" specialty and it works just fine. If not better.

At the very least I would make it a subspecialty of anesthesia or IM.

Dermatology, gone. Duties assumed by GP or IM.

probably simpler to roll interventional cardiology and interventional radiology all into vascular surgery.

I would condense many of the surgical subspecialties too.

Hepato/biliary and Colorectal would be put right back into general surgery.

Sports medicine would be entirely covered by Ortho.

Nuclear medicine would be a function of radiology or vice versa, no need to have both whatever group gave more lobbying dollars.

Eliminate family med entirely, just roll it into internal med.

Eliminate preventative medicine entirely. Those roles are easily covered by non physicians at a much cheaper rate.

Combine Neuro/psych, with psych being a subspecialty of neuro.

Could always roll PM&R into ortho as well.
 
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Veneficus

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Dwindlin

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reasonable or desirable?

Reasonable.

And having thought about it I'll give you the interventional cards rolled into vascular (Though EP should be a function of Cards still...as I already said the access is a monkey skill and not what makes that fellowship challenging). Though IR does much much more than just vascular type cases, so I don't think you can get rid of them (at least in this country an overwhelming majority of image guided biopsies have been taken over by IR).
 
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Veneficus

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Reasonable.

And having thought about it I'll give you the interventional cards rolled into vascular (Though EP should be a function of Cards still...as I already said the access is a monkey skill and not what makes that fellowship challenging). Though IR does much much more than just vascular type cases, so I don't think you can get rid of them (at least in this country an overwhelming majority of image guided biopsies have been taken over by IR).

So how do you account for places where emergency is part of anesthesia or IM?

Are they just bad systems?

Perhaps their doctors do not have the skills or ability?
 

Dwindlin

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So how do you account for places where emergency is part of anesthesia or IM?

Are they just bad systems?

Perhaps their doctors do not have the skills or ability?

I didn't say that, however there are no systems that are going from having a separate EM specialty to one where it is incorporated somewhere else, in fact the opposite is true.

Again, the more we learn the more it is necessary to specialize. Also, we haven't even talked about preference and resource management. Take your ideal for ortho covering all of sport med. Sounds great, but there is the fact that people have free will (at least here they do), and not every one who does orthopedics wants to deal with spots med issues, not to mention (again at least here) we have a shortage of all surgical specialties so guess what, that family med doc with training in sports med would love to run a sports med clinic to free up the surgeons to do surgery. Now one could argue that's what mid-levels are for which yeah that's one option (a whole other conversation), personally though I would rather see a doc.

There is also the aspect of training models. You eliminating FM and rolling it into IM, again could it be done maybe, but honestly the model here is changing. As it stands now most IM programs have their residents do only a half day of clinic a week for their 3 year residency. IM is rapidly becoming a hospital only based specialty (which I think the hospitalist model is great). Again, the vast majority of people going into IM don't want to run an outpatient clinic, but those going into FM do.
 

Rialaigh

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I didn't say that, however there are no systems that are going from having a separate EM specialty to one where it is incorporated somewhere else, in fact the opposite is true.

Again, the more we learn the more it is necessary to specialize. Also, we haven't even talked about preference and resource management. Take your ideal for ortho covering all of sport med. Sounds great, but there is the fact that people have free will (at least here they do), and not every one who does orthopedics wants to deal with spots med issues, not to mention (again at least here) we have a shortage of all surgical specialties so guess what, that family med doc with training in sports med would love to run a sports med clinic to free up the surgeons to do surgery. Now one could argue that's what mid-levels are for which yeah that's one option (a whole other conversation), personally though I would rather see a doc.

There is also the aspect of training models. You eliminating FM and rolling it into IM, again could it be done maybe, but honestly the model here is changing. As it stands now most IM programs have their residents do only a half day of clinic a week for their 3 year residency. IM is rapidly becoming a hospital only based specialty (which I think the hospitalist model is great). Again, the vast majority of people going into IM don't want to run an outpatient clinic, but those going into FM do.


I would agree with this statement to an extent. The more we learn the more it is necessary to specialize to be able to have providers that have absorbed all that knowledge. However I am not of the belief that you have to specialize more to improve survival rates and quality of life at discharge, in fact I think the opposite is true.

In other words, you must continue to specialize to an absurd extent within the research community. But from a practical medical standpoint that will improve survival and quality of life to patients at discharge I think that more specialties of a similar nature does little, nothing, or even has a negative effect (I think I could argue negative effect) on patient care.
 

Dwindlin

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I would agree with this statement to an extent. The more we learn the more it is necessary to specialize to be able to have providers that have absorbed all that knowledge. However I am not of the belief that you have to specialize more to improve survival rates and quality of life at discharge, in fact I think the opposite is true.

In other words, you must continue to specialize to an absurd extent within the research community. But from a practical medical standpoint that will improve survival and quality of life to patients at discharge I think that more specialties of a similar nature does little, nothing, or even has a negative effect (I think I could argue negative effect) on patient care.

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.
 
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Veneficus

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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)
 
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VFlutter

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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.

I do not think the issue is the specialization itself but the over use of consults. IMO consults should be used when the PCP has already performed the basic diagnostics to rule out the common conditions or there is a significant medical need.

In my experience some doctors will consult on the slightest whim. The patient has a headache? Neuro consult. He just threw up? Call GI etc etc. They never investigate the problem themselves. Most of which can easily be ruled out without the services of a specialist.

I frequently have this problem at work. Consults do not communicate with each other or the attending. Just the other day I had Cards and Nephro come in for three days straight discontinuing each other's lasix orders until they finally got the bright idea to call each other. It is ridiculous. And we have all computer charting and orders so it is easy to read consult notes/orders.

I also had a doctor literally yelling at me in the middle of the nurses station for giving a scheduled med that another doctor put in, was D/C'd by yelling doctor, then re-entered by the doctor (and was medically indicated). After a few minutes of name calling and chart slamming I suggested that he discuss it with the doctor who keeps putting the order in and not me. He then stormed off into the sunset.

I wish the PCP would be coordinating care but I have only seen a handful of older doctors who truly do that.
 

lightsandsirens5

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Kind of a side note here, but I think in order for something like this to be anywhere close to cost effective our entire system of call taking and dispatching needs to be totally revamped.

How often do we actually get accurate information regarding the patient condition pre-arrival. Half the time we know if they are alive or dead. That is all. And sometimes even that isn't right.
 
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