Physician Ponders Evolving Medical Procedures

Last week I was discussing a patient case with a younger colleague. The patient was developing recurrent pleural effusions and needed them tapped for symptom relief. My colleague discussed the balance of working with pulmonology, gastroenterology, and interventional radiology to manage care. Because the underlying cause was end-stage liver disease, pulmonology deferred to GI. GI doesn't do thoracentesis, so interventional radiology needed to perform the procedure once everyone else agreed it needed to be done. This process got me thinking, would this have happened 10 years ago?

I recalled a similar patient I had as a resident 15 years ago. Because I trained in a community hospital where patient management was almost solely up to family medicine, internal medicine, and pediatrics, we didn't have specialists readily available. Even if we did, back then you did not consult a pulmonologist to do a thoracentesis. You did it yourself. I remembered that we relished a patient like this when we were in training because it was a pretty "easy tap" and allowed us to hone our skills with minimal risk to the patient.

Even in the community where I practice, remote from a tertiary care facility, I no longer do a number of procedures I was trained to do and do not independently manage many types of patients I used to routinely manage. Medicine has changed, even in the relatively short amount of time (or so it seems) since I trained. In the balance between specialization and continuity, there is a definite tilt favoring depth over breadth. There is some good science behind this. Some surgical procedures demonstrate lower complication rates when performed by high-volume centers compared with lower-volume centers. Skills do get rusty over time with lack of use, and technology can assist us in delivering better care with increased patient safety.

My patient from residency with the recurrent pleural effusion needed someone with the technical competency to insert the needle into the right intercostal space without puncturing a blood vessel or lung. He also needed someone who knew him well enough to determine when the next thoracentesis was needed. Someone who was familiar enough with him that he was comfortable with the plan of care, a physician who understood the big picture of his health and well-being.

In the desire to provide specialized, competent, and safe care, physicians have appropriately emphasized expertise and competence. I fear we have downplayed other important components along the way. As a result, we have transitioned from training environments in which we "learned on" patients to those in which we can only approach patients once we are thoroughly "learned." 

The emphasis on expertise and competence has not been equally matched by the emphasis on continuity and a holistic approach. As a result, physicians have compartmentalized patients into organs, diseases, and specialties. Because of this, our patients face the challenge of potentially receiving expert procedural care without the balance of a comprehensive view of their whole being.