Specialists everywhere, but who connects the dots?

Over the past few years, an unmistakable trend has emerged. Indian media increasingly carry advertisements announcing highly specialised, disease-specific hospital units: multiple myeloma units, fatty-liver clinics, headache clinics, diabetic-foot centres, spine centres, sleep clinics and breast-reconstruction units. Increasingly, even an organ or a disease seems too broad a category, with expertise being organised around a specific procedure, an anatomical sub-part or a narrowly defined patient group.Three decades ago, being a specialist was distinction enough. Then came the era of super-specialist departments in hospitals. Now, hospitals in Indian metros have entered a new phase of specialisation, offering disease-specific, procedure-specific and even body-part-specific care.Medical science is built on advancement and progress and much of this trend reflects genuine medical progress. Complex cancers benefit from multidisciplinary teams, while cardiac rhythm disorders require electrophysiologists. Organ transplantation, congenital heart disease, complicated autoimmune disorders and rare cancers demand specialised training, expertise, experience and technical skills. Specialists and super-specialists, therefore, are not the problem.The concern is that this model, whether promoted inadvertently or by design by corporate hospitals, is increasingly undermining the way health services should ideally be organised and delivered.  This calls for serious introspection and urgent policy consideration.The consequences extend beyond professional boundaries: they shape patient journeys, household expenditure, medical education, referral behaviour and, ultimately, the very architecture of healthcare.India’s problem is not that it has too many specialists. In fact, the country remains seriously short of specialists. Government Rural Health Statistics for 2021-22 reported that Community Health Centres had a 79.5% shortfall in four basic specialist categories: surgeons, physicians, paediatricians, and obstetricians and gynaecologists. The shortfall was 83.2% for surgeons, 79.1% for physicians and 81.6% for paediatricians and 74.2% for obstetricians and gynaecologists. Large parts of India still struggle to access even these essential specialists.The real problem is that India has a weak — and gradually weakening — system of general and family physicians. The country also has a poorly structured and often dysfunctional referral system, in which specialist and super-specialist care is accessed in an uncoordinated manner. The proliferation of highly specialised units risks further distorting the availability and utilisation of specialist care, while also contributing to the medicalisation of healthcare.How does this weaken and distort the system?In any well-functioning health system, the foundation is built on primary-care, general and family physicians. In such systems, a good general physician knows when to provide care and when to refer a patient to a specialist. Successful health systems retain strong general practice as the foundation on which specialist medicine sits. As medical practice becomes increasingly specialised, however, several risks emerge.‘Why should we pretend to know medical science?’: SC refuses plea for mandatory NAT testing in blood banksThe United States offers an important warning. It has extraordinary specialist medicine, advanced technologies and world-leading research institutions. Yet the US spends around 17.2% of its GDP on healthcare, compared with an Organisation for Economic Co-operation and Development (OECD) average of about 9.3%, while many of its population health outcomes remain worse than those in several European countries. Its experience demonstrates that technological sophistication and specialist intensity do not automatically produce an efficient, equitable or healthier health system.Real progress is achieved when people receive the care they actually need. Efforts to create and aggressively advertise highly specialised units can encourage people to bypass the referral chain, pushing the system towards direct, fragmented and uncoordinated specialist care. In turn, such fragmentation can lead to unnecessary investigations, excessive procedures and higher healthcare costs.When specialist care is placed on a high pedestal in the hierarchy of medicine, a nuanced point is often forgotten. Knowing almost everything about a narrow field is expertise. But knowing enough across different fields to recognise patterns, reconcile diagnoses, manage multiple conditions, navigate clinical uncertainty and decide when not to intervene is also expertise. That is precisely the expertise of a competent general physician.The cost of fragmented care From the patient’s perspective, excessive specialisation combined with disorganised referral care can be particularly problematic because patients do not arrive neatly divided into medical departments. Consider a 65-year-old with diabetes, hypertension, obesity, fatty liver, knee osteoarthritis, insomnia and anxiety. The Longitudinal Ageing Study in India found that 24.1% of Indians aged 60 years and above had multimorbidity. Yet our healthcare system can easily turn one such person into six different patients: diabetes goes to the endocrinologist, blood pressure to the cardiologist, fatty liver to the hepatologist, knee pain to the orthopaedic surgeon, sleep difficulties to a sleep clinic and anxiety to a psychiatrist. Six excellent specialists do not automatically add up to excellent healthcare.Fragmentation has consequences. Each consultation can generate another investigation, another prescription and another follow-up. Tests may be repeated because medical records remain scattered. Medicines accumulate more easily than they are discontinued. A systematic review of 27 Indian studies found that around 49% of older adults were taking five or more medicines, while nearly one-third were taking 10 or more; potentially inappropriate medication use was reported in 28%. Fragmented care makes medication reconciliation, deprescribing and whole-person clinical judgement considerably harder.Fragmentation also comes with a household bill. Every unnecessary escalation — another specialist consultation, repeated imaging, another laboratory investigation or an additional prescription — can therefore have direct financial consequences for families.A cardiologist should see patients who need cardiac care, not everyone who experiences palpitations. A neurologist should evaluate headaches that require neurological assessment, rather than become the first point of contact for every headache. Good referral systems provide something that India’s largely unstructured outpatient market often lacks: a clear sequence of care. They ensure that specialist expertise is used where it adds the greatest value.The rise of highly specialised units creates another danger: the traditional role of general physicians may gradually be taken over by super-specialists such as cardiologists, haematologists and oncologists. These specialists could then become the first point of contact in the healthcare system and, in turn,  refer patients to even more narrowly focused disease-specific or procedure-specific units.The danger is that we are building the upper floors of medicine while neglecting its foundations.Producing quality doctorsIndia’s expansion of medical education should certainly strengthen specialist capacity, particularly in underserved regions. But equal, and arguably greater, attention must be given to the quality of undergraduate medical education and the clinical competence of graduating doctors. Every MBBS graduate should be capable of managing common illnesses, recognising emergencies, interpreting investigations in their clinical context, practising preventive medicine and knowing when specialist referral adds genuine value.Family medicine, general medicine and primary care must therefore gain greater professional prestige, stronger academic opportunities and greater financial attractiveness. District hospitals need stronger teams of broad-based specialists, while referral pathways across primary, secondary and tertiary facilities should become routine rather than exceptional. Digital health records should enable specialists to communicate with one another instead of creating parallel islands of treatment. Private hospitals, too, should ask whether every new disease-specific unit genuinely responds to an unmet clinical need or, in some cases, simply creates a new market segment.A developed healthcare system cannot be measured only by the number of robotic systems, transplant programmes or increasingly sophisticated ways of subdividing the human body. It must also be judged by its ability to keep people healthy, manage chronic diseases close to home, coordinate care across specialties and protect families from avoidable expenditure.India should certainly build world-class super-speciality medicine. But a pyramid cannot stand on its tip. Before creating a specialist for every organ, disease and procedure, we must ensure that every Indian has access to a competent doctor who can still see the whole patient.(Chandrakant Lahariya is a practising physician and author of “Pill-Free: You Don’t Need Everything You Have Been Prescribed”) (Disclaimer: The views expressed above are the author’s own. They do not necessarily reflect the views of DH.)

Source: Deccan Herald