An anesthesiologist in my community recently called me for an opinion about some weakness and numbness she’d developed in her lower leg and foot. The physician had a history of multiple sclerosis (MS) but had not been treated for several years. She was seen at a clinic out of town that exclusively diagnosed and treated MS. When I saw her in clinic, I felt that she was suffering from a peripheral nerve issue, specifically peroneal neuropathy, a condition completely unrelated to MS. I suggested imaging and a nerve conduction study as the next step. She already had a follow-up appointment at the MS clinic and was going to see them before she made any other decisions.
A few days later the physician called me in a panic. The MS clinic said her symptoms were due to a “full blown MS exacerbation” and she needed to start infusion treatments. I suggested we go ahead with the imaging and nerve testing anyway. We expedited the MRI of the knee and lumbar spine and completed the nerve conduction study. The testing revealed peroneal neuropathy at the knee and a mass pressing on the peroneal nerve at the fibular head. The physician was taken to surgery for removal of the mass and her symptoms resolved shortly after.
The lesson: Use caution when consulting the physician or practice that specializes in one thing. The adage of if you’ve got a hammer, everything looks like a nail is very true in private specialty medical practices. A practice that super specializes in one specific pathology — such as MS, back pain, low testosterone — is under pressure to find and treat patients with that particular pathology. With no clinical diversity in their practice, their clinical model entirely depends on a high volume of care on a very narrow patient population.
However, if you are a physician with a broad and diverse practice that treats several conditions, then you have the privilege of using strict indications to decide who will benefit from treatment and interventions. There’s much less pressure on you to treat everything like a nail when you’ve got a large toolbox to work with and you can fix several different conditions.
One example of this is orthopaedic surgery. An orthopaedic surgeon that focuses their practice, for example, exclusively on spine surgery, faces tremendous pressure to select patients for surgical intervention. With no clinical diversity in their practice, their clinical model entirely depends on a high volume of surgery on a patient population who have essentially only a narrow handful of conditions. Compare that to an orthopaedic surgeon with a diverse practice that includes general orthopaedic conditions, and participates in general orthopaedic call. The diversity of this practice allows the physician to use their experience and strict, accepted clinical indications to decide who will benefit from surgery.
The same can be said of neurosurgeons. A practice that includes a wide range of clinical conditions including peripheral nerve, brain trauma, brain tumors, tremor, and spine conditions has a solid clinical base that allows them to apply strict evidence-based guidance when deciding how and when to treat patients.
Of course, there are some obvious benefits to referring to a super-specialist. Their depth and experience in some cases can be formidable and invaluable in managing certain conditions. Vascular neurosurgery, for example. Twenty years ago, it was not at all uncommon for community neurosurgeons to manage and treat ruptured and unruptured intracranial aneurysm as part of their routine neurosurgical call responsibilities and practice. Today, intracranial aneurysm treatment is so specialized with advances in open cranial surgery and catheter based endovascular technology, it is accepted practice in neurosurgery that it is only appropriate for patients with intracranial aneurysms and vascular malformations to be treated in centers that exclusively manage vascular conditions of the brain.
Pain management is another example when consolidating the care of one specific patient population likely results in better, more efficient, and more appropriate care. The complexity of medical management, ever tightening controls on narcotic use, evolving understanding of the psycho-social elements of chronic pain, and the specialization and complexity of implantable pain control devices are all reasons to have these patients managed at a pain management specialty practice.
If you’re going to establish a practice that is narrow in scope and focus on a limited disease, here is some advice: You should be prepared to start slow. Be the turtle not the hare. Be selective with your patients, clear in their diagnosis, confident in your treatments. Build slowly with good outcomes, using evidence-based decision-making. That will create a reputation among your referral base as a disease area expert and they will feel confident referring to you to manage that specific condition.
The best compliment I get from primary care doctors is when they tell patients, “I’m sending you to this surgeon, he’s not afraid to tell you that you don’t need surgery.” As a general practitioner or family medicine doctor, it’s important for you to understand what the specialists in your community do well, how they run their practice, and how they select which patients to treat. Pay attention to their outcomes and ask your colleagues how their patients have done with that specialist. You’re looking for a specialist that rigidly adheres to criteria for diagnosis and indications for treatment. Your patient is depending on you to guide them toward a competent specialist. There are times and conditions where a super-specialist is the best course of action for your patient, but be sure they don’t have a myopic view of their specialization.
What are your thoughts on super-specialization?
Dr. Gruber is a neurosurgeon in Paducah, KY. His clinical interests include brain tumor management and robotic spine surgery. Find him on Twitter @DrThomasGruber and LinkedIn. Dr. Gruber is a 2022–2023 Doximity Op-Med Fellow.
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