In pieces

Subspecialization

Medical subspecialties have existed for centuries. Ophthalmology and otolaryngology have each laid claim to being the first specialty of the modern era, with their formal establishment in the 19th century.⁸ Furthermore, many generalist physicians are now pursuing primary care subspecialties. And yet, when a physician specializes in one bodily system or organ, they face the risk of finding themselves a technician first, a doctor second.⁹

Those brave generalists who still provide comprehensive family practice care do not have it easy; the demands on them are extraordinary, their schedules are overbooked, and addressing additional concerns during appointments can often result in hesitancy and shame for the patient, and frustration for the family physician.

An incident in my practice highlighting these challenges comes to mind.

I had been treating my patient, a recent newcomer to Canada, over the past few months. We had spent several appointments discussing her health, and I guided her through the nuances of the Canadian health care system.

Notably, she had quite an involved medical history and was seeing several specialists for her conditions. She was often displeased with the physicians she saw and not altogether happy with her health care experience. She also spoke little English.

On this particular day we were scheduled to discuss her recent diagnosis, a rare eye disease—a condition which, frankly, I knew little about.

“How are you?” I began.

“Okay,” she replied.

I had learned to navigate her “okays” with caution.

She proceeded to ask me several detailed questions about her eye condition. Although I am not an ophthalmologist, I answered them to the best of my ability and encouraged her to continue the conversation with her specialist.

There were then other questions and concerns. She was struggling with lung disease and had also recently had an unrelated skin biopsy. She was further annoyed that the biopsy result was still pending at the pathology laboratory.

She found herself running around among doctors and clinics, with few answers.

Her frustration built, minute by minute, exchange by exchange, until it finally broke through. “Skin! Eyes! Lungs! You all see me in pieces, Doctor. Not as a person.”

It was a rare outburst for her.

A longer conversation followed, in which many things were discussed beyond her medical history alone. As we explored these additional aspects of her life, her agitation made more sense to me. At the end of the appointment, there was a palpable sense of relief. She apologized and we moved on.

The salient aspect of this incident was how, in this case, providing detailed medical answers to her questions did little to relieve her fears. She was clearly looking for something else, and I spent the days that followed wondering what that something else is that she—and many other patients—seek from their family physicians.

In Mary Shelley’s classic novel Frankenstein, Dr Frankenstein attempts to create his “monster” as an attractive and handsome specimen, piece by piece. “His limbs were in proportion, and I had selected his features as beautiful.”¹⁰ He takes the most magnificent body parts he can find and puts them together, such that he may create the most beautiful man. Yet this fragmented approach, amalgamating separately beautiful creations, unexpectedly leads to a hideous and frustrated creature. Shelley had originally titled her novel as Frankenstein; Or, the Modern Prometheus—an allusion to the Greek god Prometheus, who stole fire and gave it to humanity, giving them profound knowledge and technology but with unintended consequences.

Have we become the Modern Prometheus? With our fragmented approach to subspecialized medicine à la Dr Frankenstein, we may be headed in a similar direction. Perhaps we cannot simply take our most talented medical minds, hand them an organ or specialty to be responsible for, and let the chips fall where they may.

Certainly, some specialization in medicine is inevitable, and it can lead to miraculous treatments. It is not specialization per se that is at fault. It may well be unreasonable to expect a consultant physician to address unrelated issues if they fall outside the scope of their practice.

The path ahead

So what will guide us as family physicians when the path ahead is unclear? A constructive tactic might be to search for ways to integrate a holistic approach into patient encounters. Before we step into a room to assess chest pain or to address someone’s kidney function, we should take a few seconds and remind ourselves of the patient’s name, their story, where they came from, and where they wish to go.

I believe that family physicians are uniquely positioned to master such an approach.

The development of this emotional intelligence is a skill that future medical curricula must address.^11,12 Dr Nicholas Pimlott has written about reframing the future role of the family physician.¹³ Others have attempted to define the family physician as a specialist generalist.¹⁴

This article is not a criticism of those physicians who choose to subspecialize. They possess remarkable skills. A pulmonologist can allow you to breathe again. An emergency physician can ensure you live to see another day. A radiologist can peer inside of you and report on mysteries that elude the physical examination.

So, what of our identity crisis? What does family medicine bring to the table, and where do we fit in among our talented colleagues? Humbly, I suggest family medicine is the art that, when practised at the highest level, ensures that a sick person never feels as if they are in pieces.