Subspecialization During a Shortage

Elyas Bakhtiari, for HealthLeaders Media, June 5, 2008

Imagine a scenario where a patient comes to the ER needing an emergency laparotomy to address bleeding caused by a large ulcer penetrating the pancreas. The five-person surgical team consists of colorectal and hepatobiliary specialists, a breast surgeon, a minimally invasive surgeon, and a surgical oncologist. The ideal person to handle the operation—a general surgeon—is nowhere to be found.

That was the futuristic picture painted by a recent Wall Street Journal blog post that examined how increasing subspecialization is cutting into the ranks of general surgeons. Since 1992, for example, the number of surgeons pursuing subspecialty fellowships after training has increased from 55% to 70%, and during the same time the number of general surgeons per capita has fallen by 25%.

The effects of subspecialization aren't limited to surgical specialties. Primary care has been struggling for a while to keep medical students from pursuing medical subspecialties that often offer higher pay and better lifestyles. From a new physician's perspective, spending a few extra years in a fellowship is a sound career move.

The trend toward subspecialization has also benefited the industry as a whole in many ways. As treatments have become more complex, highly-focused specialists have been able to expand their respective fields of knowledge and improve patient care. The Hippocratic Oath even instructs physicians to "avoid attempting to do things that other specialists can do better."

But has specialization in medicine gone too far? The "do one thing and do it well" model makes sense when there are enough physicians to cover the entire spectrum of patient care needs. But as we're facing a shortage of physicians in all specialties, the lack of primary care physicians and versatile specialists and surgeons is going to make the burden of meeting tomorrow's healthcare demands tougher.

Subspecialists tend to congregate in large markets where the impact of physician shortages is already minimal. An ophthalmologist specializing in oculoplastics will have a tough time finding many subspecialty-specific procedures at a small hospital in a rural area, for example. And that small hospital has very little need for an oculoplastics specialist. From its perspective, the market needs less, rather than more, specialization. Primary care and general surgery are the lifeblood of rural care, but trends in physician training are shrinking the pool of available candidates and exacerbating the effects of existing shortages.

So how can the trend be reversed? The simplest answer is money. In the short term, that means facilities may have to offer higher salaries to attract primary care physicians, general surgeons, and other traditional specialists. But in the long term, the answer becomes more complicated. The physician payment system is structured to reward physicians for performing specialized procedures, and generalists are also burdened by a higher reliance on Medicare and Medicaid reimbursement. Changing that is beyond the control of an individual hospital or physician practice.

As long as physicians can earn an additional $50,000-$150,000 annually for subspecializing, they'll continue to do the math and perpetuate a trend that amplifies the industry's existing shortage of doctors.

Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at

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