(From The Medical World)
MEDICAL pundits continue to proclaim that the study and practice of medicine is so vast that no single person is able to master the details to a sufficient extent to enable him to practice the different branches into which modern medical practice is subdivided. And the untutored public, knowing all this and accepting without reservation the doctrine thus promulgated, have acquired the urge to seek out a specialist whenever the opportunity offers, and not infrequently in direct opposition to the advice of their own medical attendant.
It is true that the study of medicine is vast and that the practice of medicine demands a wide knowledge, but nevertheless the grand principles upon which medical practice is founded have remained throughout the ages, and are applicable to every department into which medicine is subdivided. And it is those who have mastered these principles that become the most reliable practitioners of their calling. And therein lurks the hidden danger of specialism, for in the feverish search for details the grand principles are liable to be ignored or forgotten.
Specialism, moreover, tends to the development of the narrow view, to the consideration of the particular organ or organs involved, while leaving out of account the organism as a whole, and not least the influence of the psyche.
It is for this reason that the extinction of the general practitioner, or general physician, would be an irreparable disaster, not merely to the practice of medicine, but most of all to the public, who require to be safeguarded in their urge for specialism.
The demand for specialists has reached ridiculous proportions among the laity. A stomach specialist is sought who would not be consulted about liver, in fact, one whose knowledge is not believed to extend to neighbouring organs. A colon specialist is not credited with a knowledge of the rectum. A kidney specialist is supposed to know nothing of the bladder, and the converse is also believed to be true.
Indeed, there is a demand for a specialist in relation to every organ in the body, while the recent demand for “gland specialists” (endocrinologists) serves still further to emphasize the absurd extent to which the public demands are being made. This whole tendency on the part of the public should be checked by those who have the opportunity of influencing public opinion, in order that the public may appreciate the supreme importance of the wider outlook on disease.
Specialism has a place in medical practice, but that place is, and should remain, a subsidiary place. The old division of practitioners into those engaged in general practice and those engaged in consulting practice has to all intents and purposes ceased to exist, not merely because the so-called consultants see patients independently, but still more because of the public demand “to see a specialist,” and, if need be, to continue under his care.
It is clear then that the public should have some guarantee that the specialist has had the training and possesses the experience and the knowledge, to justify his claim to practice in that capacity. This leads one to ask: “What is a Specialist”? The answer is, one who devotes himself to a particular branch of medicine. There is nothing to prevent anyone, however, incompetent, assuming the title of specialist.
And following in the trail of the specialist there is an increasing army of “unqualified specialists” difficult to distinguish when so many members of the medical profession continue to scorn the honoured title of Doctor. Moreover, the qualified and the unqualified dwell side by side in seeming peace and concord, and in the same select area in our great cities.
This state of affairs is eminently unsatisfactory, both from the point of view of the profession and from that of the public, and is calling aloud for remedy. The obvious remedy is that specialists must be properly trained and must be officially recognized as such.
THE TRAINING OF THE SPECIALIST.
The systematic training of specialists in Great Britain is practically non-existent. Much was expected of the unit system when first introduced, and if offers great possibilities, but the number of units in this country is so small as to be almost negligible when considering facilities for special training.
And those who are familiar with the educational standards and the training that are required for specialists on the continent of Europe, and in certain cities in the United States of America, cannot fail to realize the necessity, indeed the urgent demand, for dealing with this important question without delay.
The steady stream of disgruntled sufferers seeking treatment abroad is a sure indication of failure on the part of their advisers at home.
The existence of so many half-baked specialists is leading them not to become exponents of that which applies to a particular speciality but merely to practice “stunts” that are made applicable to a wide range of human suffering. And it is here that they come into direct conflict with the “unqualified specialist”, who has already discovered this to be a lucrative method of imposing on a gullible public.
A system that permits a young graduate, house surgeon one day registered (or not even that), the next, to be appointed to the staff of a hospital or to a special department, and who then settles down to learn his job, meanwhile starting to practice in the “doctors area” as a specialist or consultant, and charging the same fees (or sometimes more) as men of ripe experience, is one that cannot be defended.
And in the interests of the public as well as the medical profession it should be discredited. The remedy is in the hands of the hospital authorities who ought to exact a higher standard of training and experience from candidates for hospital appointments.
After graduation those who intend to qualify as specialists should undergo a further period of intensive training for five years.
A man using a knife for the first time may show that he is a surgeon. Another man may have to work under a master for ten years before he becomes a surgeon. and yet another man may work twenty years and never become a surgeon. A natural aptitude is then a precious possession, for many kinds of specialism. A well-known surgeon, now deceased, once exclaimed to the writer, “Why was I ever a surgeon?” This man seemed to be dogged by ill- luck, or was it technical failure?
He had had abundant opportunity for training, but he lacked aptitude. Surgery was not his vocation. But opportunity must be provided for the young specialist and here one is forced to direct attention to what may be described as the unseemly scramble for beds in the London hospitals. This is where the existing system is thoroughly bad.
The rush to Harley Street is a feature of specialism in London that cannot be overlooked. An address in this locality is believed to have a commercial value and of this full advantage is taken by the house speculator whose enticing bait is effectual in catching the unwary. Rents varying from L150 50 L400 or L500 (often for meagre accommodation) are paid by would-be specialists and other anxious to surround themselves with the Halo of Harley Street.
But the public are beginning to know that all is not well in “Harley Street” and that it is necessary to receive guidance as to whom they should consult. Indeed, an address in this locality is gradually ceasing to have attached to it the importance of former days, while the rapidity of modern transport and inter-communication are daily rendering it unnecessary for the medical luminaries to be crowded into a restricted area.
It is interesting to reflect on the reasons that induce medical practitioners to specialize. some have trained themselves from early days with this object in view, some have a natural aptitude for surgery, others for some special therapy, for example, electrical treatment or radiology. Some have a particular liking for a special branch of medicine or of surgery, for example, neurology, urology or ophthalmology.
Some specialize after failure in other departments of medical practice, others special branch of medicine or of surgery, for example, neurology, urology or ophthalmology. Some specialize after failure in other departments of medical practice, others specialize after success. Some have acquired money and can afford to wait, others are attracted to specialism because they believe it to be more lucrative than general practice. And again, others are attracted to the new specialities because they are not yet overcrowded.
These, then are some of the reasons that prompt men to specialize and it is clear that there will never be a specialist hierarchy in this country until all our specialists have been suitably trained. What is needed is not an increased number of specialists, but fewer specialists, better trained; in other words, a special class of practitioners whom the profession and the public may consult with confidence and who will be well qualified to uphold the great tradition of British medicine.