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Indian J Community Med
Indian J Community Med
IJCM
Indian J Community Med
Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine
0970-0218
1998-3581
Wolters Kluwer - Medknow India

IJCM-49-567
10.4103/ijcm.ijcm_731_23
View Point
Super-Speciality in India: A Boon or Bane?
Kumari Shivanee
Reddy BSC
Malik Yogendra 1
Math Suresh B.
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
1 Department of Forensic Medicine and Toxicology, Bhagat Phool Singh Govt. Medical College for Women, Sonepat, Haryana, India
Address for correspondence: Dr. Shivanee Kumari, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka, India. E-mail: dr.shivaneekumari@gmail.com
Jul-Aug 2024
09 7 2024
49 4 567570
25 10 2023
08 4 2024
Copyright: © 2024 Indian Journal of Community Medicine
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
In the past few decades, super-specialization has gained popularity in many medical disciplines. It provides professionals with a sturdy platform for advanced research and helps to deliver focused and extensive care in the fields of trauma and critical care, which can translate into good clinical outcomes for patients. Although this drift may bring about novel research opportunities, it may limit the number of doctors attending to the basic healthcare needs of the population. India is still struggling to provide primary healthcare services to its population. Super-specialization is a highly technology-driven industry, the costs of which our public health system cannot endure in the present settings. The current demand in India, where basic priorities are yet to be met, is to increase health awareness, provide basic healthcare facilities, and generate interest among medical professionals in providing general health services, especially in rural areas.

Medical professionals
primary healthcare
public health
rural health
super-specialization
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pmcBACKGROUND

Majority of the Indian population (nearly 65%) reside in rural areas of the country, where they have limited access to basic medical facilities. Key health problems faced by them include malnutrition, acute respiratory infections, tuberculosis, Human Immunodeficiency Virus (HIV), diarrhoea and other communicable diseases.[1] Common mental disorders (CMDs) like depression and anxiety hold considerable importance in the field of public health.[2] Prioritizing these, the country implemented various national-level programs with a focus on primary healthcare for universal health coverage. Over the years, the National Medical Commission (NMC) increased the number of Bachelor of Medicine, Bachelor of Surgery (MBBS) and Doctor of Medicine/Doctor of Surgery (MD/MS) seats and the government deputed doctors in different areas of the country to cater to the healthcare needs of the population.[3] In the past few decades, however, super-specialization has gained popularity in many medical disciplines.[4] On one hand, this drift may bring about novel research opportunities, but on the other hand, it may limit the number of doctors attending to the basic healthcare needs of the population.[5] In this article, the authors would like to discuss, from the perspective of public health, relative advantages [Figure 1] and disadvantages [Figure 2] of the exponentially growing super-specialization trends in the country.

Figure 1 Advantages of super-speciality training

Figure 2 Disadvantages of super-speciality training from a public health perspective

DISCUSSION

Boon

Super-specialization provides professionals with a sturdy platform for advanced research. It allows specialists to keep themselves up-to-date with the latest developments, which can be very beneficial for patients suffering from rare or uncommon diseases.[6] In addition, nowadays, doctors are increasingly drawn towards super-speciality fields for advanced clinical, training and teaching experiences, as well as for lucrative remunerations and profits.[78] It helps to provide focused and extensive care in the fields of trauma and critical care, which can translate into good clinical outcomes for patients.[9]

Current status (public health perspective)

According to recent data of 2023 shared by the Union Minister of State for Health and Family Welfare, there are 101,043 MBBS and 45,471 MD/MS/Post-graduate (PG) Diploma available in India, which is a drastic increase from 35,202 MBBS and 13,043 MD/MS/PG Diploma seats in 2009. Super-speciality seats have also increased from 1,850 in 2017 to 4,997 in 2023.[10]

As per the Rural Health Statistics 2021-22, almost two-third of the country’s population resides in rural areas and yet only 33% of the total health workers and 27% of doctors are available in rural areas. Even though the number of health centres has increased in rural areas, the shortage of doctors in Community Health Centres has risen from 45% in 2005 to 80% in 2021. The Primary Health Centres in urban areas have a deficit of 9.8%.[11]

Considering these figures, India is still struggling to provide primary health care services to its population. The needs and priorities of the country as well as the availability of resources guide the development of any medical speciality.[4] As such, although super-specialization provides new research opportunities and modern clinical advances, it may not be the overriding need of the country as of now since the basic medical needs of the majority of the population still need to be addressed.

Bane

Missing out on what’s common

Super-speciality provides depth of knowledge on a specific part of medicine, but limits the breadth of understanding. A deep understanding of a narrow aspect can help in the management of few selective complex cases, but it creates the risk of neglecting common disorders. This situation can typically arise when individuals visit a super-specialist directly for their ailment rather than a general doctor. In such situations, there is a tendency to a conduct variety of tests to specifically rule out any problems related to that super-speciality.[6] As John Heywood says, “Can’t see the woods for the trees,” common disorders that may be detected with simple clinical judgment may get overlooked while super-specialist centres run a series of multiple tests and investigations to detect a disorder that is not usually seen in our population.[5] The increase in super-speciality education in our country can gradually lead to the generation of more and more doctors who know more about a particular system but are less focused on common illnesses.[12]

Case scenario

We would like to refer to cases from Great Ormand Street Children’s Hospital in London, which serves as a referral centre for children from several European countries seeking treatment for endocrinological conditions. After multiple investigations for endocrinological causes, they are often found to be suffering from diseases like Celiac disease or chronic kidney disease, after which they are referred to a General Physician. Hence, the Hospital has formed a protocol, mandating that all faculty members engage in General Paediatrics for a minimum of three months annually. This requirement aims to provide them with regular opportunities to gain experience in identifying prevalent problems in children, thereby reducing the need for multiple investigations.[6]

Tedious process for the patient

While numerous super-specialities have made remarkable advances in various areas within their area, humanism has often been sidelined. Socrates has said, “It is impossible for the part to be well, if the whole is not well.[13]” Super-specialist care has led to compartmentalization of services, which can be very exhausting for the patient. When a patient presents to the hospital, it is not always possible to identify the relevant speciality right away. This process requires clinicians who understand a wide range of specialities. However, general medicine has been shelved in recent decades, due to which patients are being pushed pillar to post for even a simple healthcare problem.

Case scenario

A 65-year-old man with pain abdomen goes to a gastro-enterologist for his ailment. On investigation, it is also found that he has Hypertension and Diabetes Mellitus, after which he is referred to a cardiologist and endocrinologist respectively for management of the comorbidities. Both of these illnesses could have been easily handled at a one-stop level by the family physician or general doctor, and referred to a super-specialist based on necessity. An alternative approach would be to have every super-specialist available round-the-clock in a hospital to be able to deal with acute problems arising from any system. However, this option is not pragmatic, costly and poses additional problems.[5]

Costly affair

Earlier, super-specialization emerged as a means to provide advanced research and specialized care in terms of critical care, trauma services, cardiology, etc., Gradually, technological advances led to further innovative treatment options like cosmetic surgery (plastic surgery), joint replacement surgery (orthopaedic surgery), bariatric surgery (abdominal surgery) and so on.[1] In metropolitan cities of India, a lot of hospitals have been started over the last two decades for such dedicated super-specialist care. When a patient visits these centres, a lot of additional services are also offered to them, leading to heavy cost escalations.[5]

In our country, on one hand we have underdiagnosed and never treated patients at the primary care level and on the other hand, excessively investigated and over-diagnosed patients at the metropolitan city level. In a resource-limited nation like ours, such costly and time-consuming processes can be very detrimental to the public and place a heavy toll on the public health structure. Super-speciality facilities in the present era may progressively transform into a service only available to the privileged few. In addition, with growing sophistication of technology and the commercialization of super-specialization, professionals may become increasingly dependent on technology/instruments to reach a diagnosis, unlike the traditional medicinal practice.

Case scenario

A patient presenting with a fracture to a trauma centre is offered expensive alternatives to immobilization rather than the conventional Plaster of Paris (PoP) cast, which is easy on the pocket and reliable for healing. In addition, during admission, when the patient is found to have comorbidities like thyroid disease, diabetes, or hypertension, super-specialist doctors are called from other centres to treat them. This results in additional financial strain on the patient.[6]

Strained doctor-patient relationship

Earlier, the doctor-patient relationship relied on faith and trust. However, in the last two decades, this relationship between doctor and patient is slowly transforming into a business model like a consumer and a service provider.[1]

Case scenario

An 18-year-old female visited a cardiologist for palpitations. After waiting an hour for her turn, she was advised to do an Electrocardiogram (ECG) and was subsequently referred to a psychiatrist. A study done at a medical college in Pune revealed that even for minor ailments, patients seek super-specialist consultation. Consequently, the heightened workload of super-specialists hinders doctors from allocating sufficient time to address individual problems, thereby impeding the establishment of rapport and confidence.[14]

Moving away from core skills

General physicians and surgeons usually rely on in-depth history, sharp clinical skills and minimal investigations to pick up a diagnosis. However, with the increased numbered of super-speciality hospitals and excess patient load, professionals are inclined towards advanced technology and investigations to diagnose and treat their patients. As such, the medical fraternity is moving away from their core skill of history taking and general physical examination, which is indispensability for any physician.[6] With the continuing drift, it appears that in the time to come, we will have a situation where doctors are not united by MBBS, but rather divided by the multiple super-specialities. General skills, which are the heart and soul of medicine, may get sacrificed at the cost of acquiring specific ones.

Case scenario

A middle-aged male presented with chest pain, and underwent a hemogram, renal and liver functions, Electrocardiogram (ECG), Treadmill Test (TMT), X-ray, Echocardiogram, Angiography, and Computed Tomography (CT) scan. Despite all these tests, dry pleurisy was missed, which could have easily been detected with a thorough chest examination.[6]

Quality of education

Our education system mimics established patterns from the developed world, where super-specialization is a norm. Nevertheless, these countries possess the necessary infrastructure and public demand to sustain the system.[15] In our country, however, the infrastructure and human resource needed for training in advanced super-speciality courses is still developing day by day. Many new medical colleges have also started such courses. There may be overlap in course curriculums for speciality and super-speciality subjects, and also overlap between the syllabus of different super-specialities. Yet, till date, there is a dearth of data regarding the quality of education and research being provided in the various institutes. Unfortunately, many medical students start preparing for MD/MS exams from the first year of MBBS, without focusing on general skills. Similarly, many PG students start preparing for super-speciality during the early years of post-graduates. This has been catalysed by many coaching centres preparing students to crack the entrance exams and not focusing on inculcating skills.

Litigations

The division of specialities into super-specialities also gives rise to the question: Can surgeons evaluate cases of sub-dural haemorrhage? Or is it only the domain of a Neurosurgeon? The legal ramifications of such circumstances are of interest. The fragmentation of expertise into increasingly smaller groups could lead to more serious and varied legal disputes in court.[16] The fragmentation of expertise into more and more minute groups could lead to more grave and diverse litigations in court.[16]

A study done in our country showed that super-speciality hospitals have been implicated in medical negligence in 65% of the cases. The major reason behind such litigations was the lack of good communication skills between the doctor, patient and caregivers.[14]

Case scenario

In 2010, Krishna Rao, filed a complaint against Nikhil Super Speciality Hospital. In the light of the medical negligence, the hospital disbursed a compensation of 2 lakh rupees.[17]

CONCLUSION

Although it is good to adapt ideas from organised health systems prevailing abroad, it is inappropriate to implement them without a thorough assessment of the needs, priorities and feasibilities of our own country. The current demand in India, where basic priorities are yet to be met, is to increase health awareness, provide basic healthcare facilities, and generate interest among medical professionals in providing general health services.[3] Super-specialization is a highly technology-driven industry,[1] the costs of which our public health system cannot endure in the present settings—at a time when national level programs are still being implemented on an urgent basis to provide basic healthcare to all. Moreover, not all patients need to be seen by a super-specialist. Only rare or treatment-resistant cases may require higher specialisation and more intensive care. In India, it may be more pragmatic to wait till required number of doctors are available for basic services at all levels in the country before increasing the number of super-specialists.[6] Super-speciality is research-oriented and technology-driven. It should be reserved at the national institute level. Currently, our country’s primary focus is on public health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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