HealthManagement, Volume 20 - Issue 1, 2020

Summary: As healthcare enters a new decade, will it need ‘superspecialists’ or ‘deep generalists’ – clinicians with the deep knowledge of one area of medicine, but also of a range of other areas. Prof. Levi spoke to about why the current subspecialisation-oriented model is unsustainable and how it can be changed through education.

The consensus is that demand for certain specialists will change and/or decrease. What are the most ‘vulnerable’ areas in this regard?

It has already been clear in the past few decades that more general specialisms, such as geriatrics or acute medicine are less popular than highly specialised disciplines. This is partly due to the way we train medical students and postgraduate trainees, focusing mostly on superspecialised medicine and giving much less attention to the more general specialisms.

My view is that there is basically nothing wrong with specialisation or superspecialisation: in this age of rapidly developing medicine it is really good we have people that know a lot of a specific area of medicine and can drive innovation and research. The issue is, however, that superspecialism not only means that you know a lot of a small, very specific area, but also that you are not interested anymore in the rest. I feel that this is not beneficial to patients and leads to a massive fragmentation of medical care.

Specialisation is commonly perceived as allowing for more professional autonomy, better financial reward, social prestige, etc. In turn, generalism implies less prestige and autonomy. Is this perception a challenge?

It is how ‘sexy’ these jobs appear to trainees and which examples they see in practice. With strong role models in universities and teaching hospitals advocating a more holistic approach and discouraging the idea that every organ or cell needs another doctor, junior colleagues would get a better view of a general approach. And I feel indeed that we should turn remuneration upside down, so the broader you are and the larger the responsibility you take for the patient as a whole, the better your salary.

Besides the financial issues, do you agree that a systemic shift towards deep generalism would also require a major cultural shift in terms of what physicians understand to be their primary obligations?

Our focus was and is and should be to help people who are ill – not only help your favourite organ or favourite set of cells but the patient as a complete human being and not as a collection of tissues and organs. That means that if you treat a patient with heart disease, there is no reason whatsoever to not also treat a concomitant urinary tract infection instead of referring that patient to an infectious disease specialist for that problem.

Again, I feel that it is not so much about sub- or superspecialisation but much more about an attitude towards your job. It is perfectly fine to be an expert in leukaemia or interstitial lung disease, as long as you are prepared to treat co-morbidities such as diabetes, heart failure, arthritis and simple infections as well. Every doctor, however specialised, has been trained to do that. It is just a matter of willingness.

With the focus shifting to disease prevention and sustaining wellbeing, health will be defined holistically encompassing mental, social, emotional, physical, and spiritual health. What skills other than medical, will be necessary for healthcare professionals?

I think that holistic thinking also means understanding a patient’s mental situation and social issues. It actually makes your work nicer and more satisfying as well.

Due to overspecialisation within the medical professional field, regulation has become very fragmented. Have any steps towards unification of regulatory frameworks been taken yet?

In my opinion, regulation is miles behind. In fact, what you now see is all kind of restrictions that stimulate fragmentation rather than a more general approach. Why should growth hormones only be prescribed by endocrinologists or why should some (very simple) anti-cancer agents be reserved for oncologists only?

What measures can various stakeholders – hospitals, governments, education, professionals – start implementing today to achieve the needed level of superspecialism in the future?

The best way to change this is through education. If students or trainees see that their supervisors value being a highly specialised doctor with a more generalist approach, they will immediately copy that behaviour. Lack of education to keep a generalist approach is really a very poor excuse nowadays with very handy electronic support systems, such as up-to-date or similar systems, readily available.

How will ‘generalism,’ etc ultimately reduce healthcare costs?

Superspecialism is a form of reductionism that will lead to over-treatment because physicians will focus too much on the cure of their favourite organ or disease while losing sight of the big picture. A more general approach would actually more often lead to the recommendation to refrain from very intensive treatment in many patients.