Caregiver Perspective: Specialization of Medicine
I am concerned that the specialization of medicine is leading to a decrease in the quality of care available rather than an increase. I have seen this more and more over the past several months as my husband has had a series of mystifying medical conditions requiring different “specialties” to determine the underlying cause. These specialties do not always play well together.
Finding the right specialist
Let me share a hypothetical example.
- A neurologist suspects a symptom is suggestive of an orthopedic disorder. He won't initiate a treatment plan because he does not want to offend his colleague or be accused of practicing outside the scope of his specialty. Instead, he refers the patient to an orthopedic specialist for a consultation.
- In our area, orthopedic appointments are in short supply, and it may take as much as three months for an office visit. Meanwhile, the symptoms get worse. The patient eventually sees the orthopedist and finds out the problem needs to be addressed by physical medicine and rehabilitation (PM&R) instead.
- Another month passes waiting for an appointment — another set of scans and x-rays. The problem is much worse now when he sees PM&R who declares that the patient now requires surgery. The patient is referred back to orthopedic surgery and the problem has yet to be resolved or basically treated with a conclusive plan.
My husband's experience at the medical center
My husband has, unfortunately, been in the hospital a lot this past year with unusual symptoms. We use a medical center for his care that is very specialized. Upon admission to the Emergency Department (ED), the ED team drives the treatment plan, admitting him if they can't solve his immediate problem. On admission, another team accepts him as their patient based on his primary diagnosis for that visit. That team coordinates his care and pulls in other medical specialists for addressing secondary complaints. At discharge, his follow-up goes to the primary admitting team. Since Lynn had four admissions this year, he now has four different teams following him for four separate issues.
Using a primary care physician
You can imagine that if I kept all those appointments how costly it would become not to mention how confusing. Instead, I prefer to use his primary care physician (PCP) from Family Medicine for all his treatment plans to maintain a sense of consistency. She works at the same facility and is excellent at sorting out the drama between the medical and surgical teams. She also is terrific about consulting with me through email and by phone about his condition and supports not making unnecessary trips onsite to her office.
Why isn't the neurologist in the driver's seat?
While I'm pleased with our PCP, I must admit that the professional I think should be in the driver's seat coordinating Lynn's care is his neurologist, but he isn't. I don't understand his hands-off approach. I think the neurologist should case manage his care. From my way of thinking, multiple sclerosis affects EVERY organ system of the body. Nerves leave the brain and travel throughout the body, right? That means all parts of the body are affected and therefore the neurologist should be familiar with the entire body.
- Why is it that a neurologist only focuses on the nerves themselves?
- Why aren’t they interested in how all the organs are affected?
- Why are they not acting as the commander-in-chief of the army of specialist gathered to fight the effects of MS that are attacking the multiple systems of my husband’s body?
The neurologist does not look at the big picture
When Lynn goes to a neurologist appointment, he has his reflexes tested, eyes checked, and new neurological symptoms explored, but the neurologist does not ask about any changes elsewhere.
Why doesn’t the neurologist start each appointment with, "Tell me what's different about how your body's functioning since our last visit. Include anything you might have noticed that is different that affects any part of your body that is consistently reoccurring or has been a concern to you. I am also interested in any emotional or mental health changes you may have encountered.” If he asked an open-ended question like that, then imagine what all he might find out.
Need to share information
MS has so many vague and often misunderstood or unknown symptoms that go unmentioned that only a neurologist might recognize as a problem. However, how many neurologists bother to explore if they are present? I know ours has never said one word. Why isn’t part of treatment for a condition like MS incorporating an explanation on what could happen or what to report as new symptoms? So many patients have symptoms they never know are related to MS until they come to a website like multiplesclerosis.net and suddenly realize they have a significant symptom.
A comprehensive, team approach to health care
I hope that one day, the medical field will consider treating patients with chronic complex conditions from a comprehensive standpoint using a team approach and a leader to coordinate their efforts. Currently, each specialist does their own thing without talking to others.
The pitfalls of specialized medicine
- Each physician has their treatment goals for the patient’s health that impacts the outcomes of other medical conditions, but they fail to share those goals with other teams treating related aspects of the patient's condition.
- Different teams prescribe medications. Although the medications may impact the entire body, none of the different medical teams discuss changes in medications and how a change in one drug might impact another when a significant drug regiment change is occurring.
- Symptoms are identified that imply complications that cross over between body systems. However, the specialties neglect to share the information among each other; therefore, only one specialty takes appropriate intervention measures.
Why aren't they all sharing information? Maybe that would be just too much like right.
Who can relate? "Just because I could do something last year, last month, last week or yesterday doesn’t mean I can do it today. Also, it doesn’t mean I can’t."