There are two currents flowing in seemingly opposite directions in medical practice today. One is an increasing movement toward more specialization in the care of patients. The other is the growing understanding that different biological systems are more closely related than previously recognized. There are benefits and drawbacks to both of these trends.
Among the advantages of greater specialization in medicine is the ability of those practicing in the specialty to learn, assimilate, understand, and use the new scientific information that seems to flow constantly in every field. There are so much new data and so many new advances in every medical area that practitioners in a specialty must focus on just their sphere of interest to keep up with it all. Individual patients benefit because their specialist doctors can know and use the very newest and latest findings in delivering care. Society benefits for the same: The best new information is more readily incorporated into the care of people in general.
Among the drawbacks to increasing specialization, however, is the fragmentation of medical care. When doctors practice in silos, so to speak, they have less awareness of problems outside their narrow area of focus, unrecognized problems that nevertheless may impact the presentation or treatment of the illness they are managing.
Another disadvantage related to more specialization in medical care is that patients may have to see more physicians to manage their health. This can involve more inconvenience, greater expense, less integration of care, contrary medical advice, and excess medications with a greater likelihood of drug side effects. It’s the embodiment of the cliche of “one hand not knowing what the other is doing,” or a lack of adequate awareness, knowledge, and communication among parts of the same system.
The other trend, the growing recognition that the biology of the body is not only complicated but highly integrated, is becoming increasingly incorporated into many systems of health care. New examples of specialty integration are evident. Cardio-oncology, a new area of interest, represents the understanding that cardiovascular disease and oncology (cancer) share at least some common risk factors and, perhaps more important, that treatment of one disease, particularly cancer, may have profound effects on the function of the heart. Indeed, there is even a movement among some specialists to create an actual new Board-certified specialty of Cardio-Oncology.
Another new emphasis in medical care is so-called Cardio-obstetrics, reflecting the growing awareness that so many of the physiological changes of pregnancy affect the cardiovascular system, and that various forms of cardiovascular disease have enormous impact on the outcomes of pregnancies. Fifty-or-so years ago, I was in charge of a clinic that dealt with pregnant women who had congenital (inherited) heart disease, structural defects in their own hearts that affected their pregnancies. Today, that narrow focus is expanded to the full panoply of cardiovascular and pregnancy physiology.
These examples — and more are to be expected — of Cardio-Oncology and Cardio-Obstetrics represent a potential reversal of the fragmentation of care that further specialization seems to encourage. They tend now to operate as larger groups or hospital practices like clinics, but could be incorporated into smaller, private practices as well.
There is a further idea, though, that I think deserves a little thought and attention. It’s not a big idea, but it could have a real impact on personal and public health. It requires little or no new administrative actions, no new training, and barely any interruption of the normal flow of patient care in any office or clinic setting. The implementation could impact both disease detection and prevention.
The background for the idea is simple. It is well known that some of the most important underlying factors contributing to serious diseases like heart attack and stroke often go undetected for long periods of time. Two examples are hypertension (high blood pressure) and atrial fibrillation (a disorder of the heart rhythm). Opportunities to detect these abound but are frequently ignored or underused.
Every physician and every nurse know how to measure blood pressure and feel a pulse. Is there a legitimate reason why, at every visit to virtually any medical office (I’ll exclude psychiatrists), a nurse or a physician or a trained technician doesn’t measure the patient’s blood pressure and feel their pulse? This includes not only Internists’ and Primary Care Physicians’ offices, and others where it is routine, but neurologists, otolaryngologists, urologists, gastroenterologists, rheumatologists, even ophthalmologists. Some do this now, but not all, and opportunities are missed.
Detecting elevated blood pressure, including in patients on treatment, is really important. Informing the patient so they can, in turn, inform whoever is managing their blood pressure can enhance control. And in an untreated patient, the information can literally be life-saving if it leads to treatment.
Taking a patient’s pulse for a minute may seem trivial, but the implications could be very significant. Certain arrhythmias, abnormalities of the heart rhythm, notably atrial fibrillation ( A Fib as commonly known) can be predictive of consequences like strokes, which is a feared and often devastating illness. Atrial fibrillation is often very intermittent and even sophisticated monitoring systems may fail to capture it during the period of monitoring. It has been shown that a small percentage of patients with A Fib will be detected during random pulse taking, and these patients are immeasurably well served by finding the arrhythmia and getting them into treatment.
One other small and seemingly minor action by every physician seeing patients for any reason could help overall prevention of illness. If every doctor asked about smoking, or drug use, or seat belt usage, or other patient behaviors seemingly unrelated to the condition under management by the inquiring physician, it could be a constant reminder that these things play roles in overall health. If a urologist asked me about smoking or “recreational” drug use, I’d likely take it a bit more seriously and consider it a little more important, than if I were nagged, as usual, by my primary care doctor. If my rheumatologist asked if I had gotten my flu shot yet, it would have an impact because it would seem more important coming from a physician to whom preventive vaccines should be of no interest.
Integration of medical specialties and collaboration among clinicians with different medical foci are potentially big ideas with big impacts. Introduction of a few easy steps in a medical office visit may be a small idea, but it may also be one with a big impact.
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