Medical specialization

Medicine, like any other profession, has its individual subject areas or specialisms. The speed with which medical and allied discoveries are made is tremendously high and so the need to specialize and super-specialize stands to reason. No individual doctor can hold in his mind all of medical knowledge, particularly with the information explosion through medical journals, mailings, computer databanks and the mass media. To provide the best service possible, most doctors and allied health professionals, after a basic grounding in general medicine, train in and concentrate on one aspect or specialism. In other words, they become specialists. A specialism may be medical care of a part or system of the body, such as the neurologist who deals with the nervous system; or it may be an aspect of diagnosis or therapy, such as the radiotherapist who is expert in the use of radiation treatments. In most Western countries, both general practitioners and specialists work within a health care system that is organized on two or three levels: primary, secondary and perhaps tertiary care.

Primary care

The family doctor or general practitioner is the primary health physician. He or she is a doctor with a wide knowledge of general medicine. Because people are at their most vulnerable when they are ill, and because worries about health are among the fundamental problems they have to face, the family doctor should be ideally both counsellor and trusted friend. In most countries in the past the general practitioner usually went straight from basic medical training into general practice. In recent years the training a family doctor receives has become more sophisticated, and in a kind of specialism in itself. The candidate undergoes basic medical training, then works as a trainee in various hospital wards. After graduation he can specialize in being a family doctor by working at least a year in a general practice, where he is tutored and assessed in areas as interview technique, note-taking. Case history discussion and overall doctor-patient relationships in the primary care environment. The family doctor is the person at the ‘sharp’ end of the health care system – the one who is consulted at the first sign of a health problem. If the problem is straightforward and within his competence, the family doctor will be able to treat it himself. This is so in about 90 per cent of cases.

Some general practitioners work alone, others work in groups. In a group practice the doctors can cover for each other during holidays and illness, and they can also share the costs and administration of running a practice. The patient of a group practice also profits from this arrangement. He is treated in principle by the same doctor, but during weekends and holidays he may be treated by one of the other doctors who have access to the patient’s file. Every evening before the emergency clinic starts, there is a meeting of the practice doctors about urgent patients. So there is also continuity in the treatment of urgent patients. Ideally. The doctors will have meetings on the management of certain problems, so that their knowledge will increase: of course this also benefits the patient population. On average a group practice has more money to spend on instruments and laboratory equipment than the individual doctor, so that more tests can be performed in the practice instead of the hospital. Besides the family doctor, primary care consists also of other disciplines. The dentist, midwife, physiotherapist and district nurse (who can, if necessary, provide nursing for patients in their own home) are all important members of the primary health care team. The community health physician is also involved, although he does not treat patients. His job is to organize preventative services such as immunization piogrammes. Carry out school and workplace health checks, and monitor and control outbreaks of infectious diseases in the community. «

Secondary care

Sometimes it may be necessary for a general practitioner to refer the patient to another doctor, who has specialist knowledge of the suspected condition, for diagnosis, or treatment, or both. The specialist provides secondary care. Some family doctors themselves have a special interest in, say, paediatrics (the care of infants and children) or geriatrics (problems pertaining to the elderly), especially if they work in a group practice. Such doctors will be able to care for their patients beyond the point at which a family doctor with less specialized knowledge might refer them to a specialist for secondary care. If your family doctor suggests referral to a specialist, or you yourself decide you would like a second opinion, you can, if you have no personal preference, leave it to your family doctor to choose a competent specialist on your behalf. However, especially if you are to undergo an operation or procedure which involves fairly new or complex techniques, you may wish to make enquiries or ask to be referred to a centre where a good number of such operations have already been carried out. In medicine, as in every other field, practice makes perfect. It may not always be possible for you to be referred to the specialist you choose, however. Some specialist hospitals have their own catchment area, and you may of necessity be referred to a specialist at a hospital in your own area. Once you have been referred to a specialist – also called a consultant (more senior) or registrar (less senior) – an appointment will probably be made for you to see him at the outpatient clinic at the hospital where he (or she) works. If necessary he will admit you to hospital for tests or treatment, and until he discharges you, you will be under his care rather than that of your family doctor.

Tertiary care

Occasionally a second-level specialist may refer a patient for ‘third stage’ advice to a unit which has even more specialized facilities or expertise. Here he can be examined by a ‘superspecialist’ with in-dept knowledge and experience of such problems. This is termed tertiary care. Someone who has cancer, for example, may be referred to an oncologist, and someone with a thyroid disorder may be referred to an endocrinologist.

The specialists

Doctors who wish to become specialists in a particular field must spend several years in further training after they have received their basic medical qualifications. Like everyone else, doctors have their own personality, ambitions and dislikes which may fit them best for a particular aspect of medicine.

Certain doctors may be more interested in studying a particular type of disorder than in working primarily with any special group of patients. Those who find an immediate medical challenge more stimulating than the follow-up or long-term care of patients may be drawn towards accident and emergency work in a hospital emergency department, or towards anaesthetics in the operating theatre and delivery wards. There are other, ‘non-clinical’ specialists – doctors who are not directly involved with the patients but who play an important part in their treatment. For instance, pathologists study in the laboratory the way disease processes affect the tissues of the body, spending their time gazing down a microscope at cells instead of examining patients from the bedside.

In most large hospitals the two main branches of specialist work are medicine and surgery. In general, the medical specialists (physicians) are essentially concerned with the diagnosis of disease and its treatment without surgical intervention, that is, treatment principally by drugs. Surgical specialists (surgeons) put patients ‘under the knife’. In most countries, the training for the so-called cutting specialisms involves a series of theoretical exams. These are international. Standardized and obligatory. They ensure that every cutting specialist has a basic knowledge of operation technique, wound healing and so on. The division between medicine and surgery is primarily a historical one and nowadays is not altogether clear-cut. Physicians increasingly use surgical techniques, and surgeons often employ non-surgical methods such as administering drugs in the management of their patients.

Some physicians and surgeons have experience and expertise in a very narrow field. Others – general physicians and general surgeons – have a wide but less specialized knowledge, and deal with a broad range of conditions, although what they are normally called upon to do will depend very much on which other specialists are available in the area at the time. As operating techniques become increasingly sophisticated, there is a tendency for greater surgical specialization, such as microsurgery or neurosurgery. The term ‘general surgery’ in some instances now applies to surgeons who perform the more ‘straightforward’ surgery, such as abdominal operations, while at the same time developing their own degree of expertise in the procedures.

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