The decline of clinical medicine

       Due to today’s unprecedented bursts in technology and science, medicine has had to transform itself into a conglomerate of subspecialties in order to process the deluge of information coming its way.  In contrast to today’s scientifically explosive state, in the past, medical doctors were general practitioners who performed daily duties—delivered babies, cared for children and adults, did surgeries, and knew most of what was clinically relevant to manage the entire spectrum of medical problems that faced their times and situations. 

         Modern scientific growth brought with it an ever-growing number of medical subdivisions.  First, general medicine split into its four major specialties—Pediatrics, Adult Internal Medicine, Surgery, and Obstetrics & Gynecology—but soon after, these specialties began to further subdivide into subspecialties.  Thus, a pediatrician could become a pediatric cardiologist, an internist—a gastroenterologist, a surgeon—a cancer surgeon, and an obstetrician—an infertility doctor.  With more advancements in science, these initial subspecialties were forced to further subdivide so that now a cardiologist could become an electro-physiologist, a radiologist—an invasive radiologist, an ophthalmologist—a retinal surgeon, a pulmonologist—a sleep physiologist, a neurologist—an epileptologist, and so on…         

         As the rapid expansion of science created further medical subdivisions, the clinical arena became too huge and too diverse for the average consumer to comprehend.  To further complicate matters, doctors were now able to offer their patients a vast array of procedures and tests, which inflated medical costs beyond what was customary and reasonable.  Furthermore, as the numbers of narrowed subspecialties proliferated, subspecialists competed by learning more and more about less and less, which forced patients into seeking myriad doctors in order to take care of their myriad problems. 

         This clinical branching out not only increased medical expenses, it also reduced medical efficiency, patient satisfaction, personal comfort, and left many patients medically homeless.  Not having a medical home with a personal physician who could competently address the patients’ total, primary care needs proved disquieting and also encouraged further fragmentation.  Thus, if a patient visiting a cardiologist complained about his stomach, he was referred to the gastroenterologist.  And when at the gastroenterologist, if he complained about his joints, he was referred to the rheumatologist.  And when at the rheumatologist, if he complained about his skin, he was referred to the dermatologist, etc. 

         After a few spins on the subspecialty merry-go-round—and without a personal, primary care physician in charge of the whole human being—miscommunications, mistakes, and costs spiraled more and more out of control.  Meanwhile, the flourishing of subspecializations brought with it a devaluation of the primary care specialties.  While reimbursements for subspecialty services, procedures, and tests increased, reimbursements for primary care services actually declined.  As a result, medical students became disenchanted with primary care specialties and began to favor narrower subspecialties where they could earn more income and have better quality lives.  This, in turn, decimated the ranks of the primary care specialists, who used to contain the patient and protect him from improperly squandering resources on subspecialty merry-go-rounds and on inappropriate self-referrals prompted by fears and misunderstandings.

         Primary care specialists—who used to spend their valuable time dissecting patients’ needs, reviewing their medications, following the national medical guidelines, providing preventive services, returning phone calls, answering questions, educating, reassuring, aborting unnecessary emergency or urgent care visits, blocking improper self referrals, containing costs, and providing comfortable medical homes—found themselves unable to provide this high quality care because they had to see a larger number of patients in order to offset their rising overheads.

         To manage this dilemma, primary care specialists began to depend on medical assistants and also started to refer their patients to multiple subspecialists—not because they did not know what to do but because they could not afford to spend the time to do what was needed.  This tacit patient bumping added to the fragmentation of care, further increased its expensive inefficiencies, and further increased the use of subspecialty medical assistants in order to meet the rising demands.  With the declension of proper supervision of these medical assistants, patients started to report that they rarely saw the physician in charge.  This slippery primary care slope has now reached alarming proportions and continues unabated without an end in sight.

         To further add to our current problems, non-evidence-based practitioners who blatantly repudiate scientific scrutiny increased their ranges and amplified their domains by providing what the medical profession was no longer able to provide—a medical home.  Patients found themselves favoring those non-evidence-based practitioners who provided them with total care, compassionate support, one-on-one time, highly seasoned explanations, and lots of hope.  An exponential growth in the use of non-evidence-based remedies, nutrients, vitamins, minerals, herbs, therapies, and procedures started to fill in the gaps that were once filled by master clinicians who specialized in primary care, practiced evidence-based medicine, knew their patients at an intimately personal level, and protected their patients’ health and interests with their good counsels.      

       Fragmentation, an inevitable consequence of complexity, rises in proportion to the growth of disciplines and societies.  Nevertheless, encouraging fragmentation at the expense of fundamental disciplines that have well served society is economically shortsighted and can only lead to dire consequences such as spiraling costs, inaccessibility, redundancy, waste, inefficiency, injustice, loss of faith in science, and the flowering of all kinds of unscientific ideas, beliefs, and treatments.