[needlesurgeon]

Hyper-specialization has been an approach taken by the medical establishment. For instance, within the last decade, the "vascular surgery" specialty opened up as a specialty straight out of medical school. Vascular surgery procedures used to be a subset of procedures largely (but not exclusively) performed by general surgeons (neurosurgeons still routinely do carotid endarterectomy procedures, for example). There are murmurs of "Spine surgeon" becoming a separate specialty as well, which is currently performed either by neurosurgeons or orthopedic surgeons (often with dramatically different specialty-biases in their surgical technical and reasoning).

Sub-specialists are needed and are important for a variety of reasons, including realistic demands on training time. If my loved one had a single medical issue, I would certainly wanted them operated on by the person who does nothing but that operation.

Woe is the person with two complex medical issues in a hyper-specialized hospital institution. Consider the situation where someone has two medical problems in direct conflict with each other. For instance: some people can develop chronic subdural hematomas (translated: blood clots on the surface of the brain) which causes neurologic dysfunction. The general advice here is to stop any blot-clotting medication someone is on, to prevent further bleeding or expansion of the cSDH. However, what if that person has an artificial heart valve and needs to be on blood thinners to prevent strokes?

How do we proceed? Ask the neurosurgeon, and the answer is "stop." Ask the cardiologist, and the answer is "don't stop."

Sub-specialization is happening, and it's important. But it turns physicians into finer-grained hammers: so every problem they can hit becomes a nail.

In my opinion, one will always need generalists to make the tough calls and to identify which specialist is required. The only way to train generalists is to know what the outcomes are for both stopping and continuing the blot clotting medication.

[thedoctor79]

I'm not a professional so what I'm saying could be stupid, but I don't see why anti-coagulant medication has to act globally in the organism for something that is a localized issue. I realize the circulatory system is not segmented, however couldn't there be something to be done with the time of action of the anti-coagulant? From my vague recollection, clot formation has something to do with turbulent flow post-valve as well, so improvements might be made in this area as well... try getting a fluid dynamics expert in the team that designs the valves, and I'm not joking. FWIW.

[kensai]

For the cSDH conundrum and similar tough calls, it is indeed complicated, that's why one needs to stick to guidelines or expert opinion. If there are no clear instructions, then the attending's way is the highway. Or your gut feeling. The most important thing in this case is to document your decision and notify patient and relatives.

(resident neurologist here) :)

[heterochromatin]

Hyper specialized internal med sub-subspecialist here.

I unequivocally agree with GP poster about the value of generalists. The systematic devaluation of internal medicine physicians (by this I mean not ABIM subspecialty boarded) is a tragedy.