I remember one of my medical school professors who was incredulous when I informed him I was going into family medicine. He was an endocrinologist who specialized only in the thyroid. The idea of being responsible for the breadth of medical knowledge was overwhelming to him but exciting to me. When I finished my family medicine residency, I had been trained to take care of sick newborns and critically ill geriatrics patients and had visited my patients in the office, the labor unit, the ICU, their homes, and at nursing homes. I performed thoracentesis and vacuum deliveries, flex sigs, and colposcopies. Fast forward fifteen years and primary care is becoming increasingly specialized. There remain full-spectrum family physicians, but this type of practice is increasingly challenging to balance. There also are outpatient-only practices, family medicine hospitalists, SNFists (who only round in the nursing home), those who only do telehealth and virtual visits, and urgent care specialists. I can’t even remember when any of my patients last had a flex sig, the last patient I delivered will turn six this year, and I would probably be in danger of a medical staff action if I tried to do a thoracentesis in my office like I did years ago. Medicine has changed, and one of the greatest changes is in the increasing specialization of both generalist and specialist practices. As a new generation of physicians graduates residency and fellowship, we are noticing a trend away from general practice—whether that is full spectrum family medicine or general orthopedic surgery. This can be good in many respects. Medicine is extraordinarily complex, and this complexity requires increased focus on a small section of the larger whole. But it also can be problematic. Covering call may be challenging if the patient presents with appendicitis and you are a breast surgeon. It is impossible for most medical communities to provide 24/7 access to super subspecialists. A new balance is required between a holistic view of our patients and sufficient specialization to remain knowledgeable and competent in a professional field that sees a doubling of medical knowledge in several months rather than years. I believe the future of medicine will be all the things we already suspect—more dependent on technology, provided by non-traditional healthcare organizations, and more personalized as we learn how to incorporate genomics into treatment plans. I also believe that beyond the medical content, knowledge, and skill, physicians will need to master the art of the before and the after. We will need to know what happened to our patient before they got to us to a sufficient level of detail that we can seamlessly provide our portion of the care. Similarly, we will need to coordinate and facilitate their care after they leave us. This level of coordination will test and strain our medical establishment. We will have to get better at distilling the key pieces of patient information into a digestible summary so that we no longer rely on the patients to carry their whole health history. Negotiation will be required between physicians to make sure crucial aspects of care are not dropped during hand-offs and transitions. As physicians, we will need to be specialists in both our own medical field but also in the integration of care for our patients. My professor has passed away. He practiced medicine during a different time but still struggled to know everything he needed to about thyroid disease. As a family physician, I never assumed I would know everything about anything except the patient in front of me. In the future, our profession will require us to specialize in more than medical knowledge. We will need to know not only how to care for patients but also how to work together to do so. Source
