The role of subspecialization in emergency medicine: a rebuttal

Letters

CJEM 2006;8(2):76-77

To the Editor: In the September 2005 issue of CJEM, a Commentary by Sinclair on the role of subspecialization in emergency medicine (EM) outlines the historical development of our specialty and champions the maintenance of our generalist skills.¹ We take exception, however, to the bold headline that subspecialization in EM is the "wrong direction" and to the conclusion that subspecialists "will play a limited role in the future of [emergency medicine]." These statements are misleading, their message inappropriate, and their foundations logically flawed.

Sinclair's primary concern seems to be that the proud generalist tradition of EM might suffer the same fate as internal medicine and general surgery. However, specialization and subsequent subspecialization of labour is a fundamental force behind human progress since time immemorial. Indeed, today's subspecialty may be tomorrow's specialty. Cardiology and orthopedics were once subspecialties of internal medicine and surgery, and their gestation decried by the generalists. EM itself is a specialty created by generalists with a passion for working in the emergency department. For many of the reasons Sinclair concedes, physicians concentrating their practice and intellectual inquiry to a specific field of interest is both inevitable and important to advancing knowledge, educating new physicians, advocating for improvement and ultimately better patient care and outcomes.

EM, with its flexible scheduling, unpredictable case mix, and mobile workforce, is a particularly attractive core specialty for individuals seeking new challenges, including subspecialization. Two relevant examples are the pages of this Journal and the speakers' list for the 2006 International Conference in Emergency Medicine in Halifax, which both demonstrate the recent contributions of EM specialists with additional expertise in a range of fields. These domains include administration, medical education, public health and forensics, in addition to those listed in Sinclair's Commentary. We doubt that Sinclair feels such talented individuals and their trainees "will play a limited role" in our future.

Subspecialists have much to offer. They are a resource, sharing their knowledge and contributing to ongoing discovery. Many act as consultants to colleagues from other specialties, reversing the usual roles and reminding them that emergency physicians really are good at everything, even if they are unwilling to do the specialists' work for them.

In contrast to many other disciplines, however, subspecialized emergency physicians continue to function as generalists. EM, by its very nature, precludes scheduling only patients within a given domain of expertise. This defining feature provides a powerful deterrent to the erosion of core specialty skills. While pediatric EM in large urban centres serves as the singular exception to this truism, most would consider even this subspecialty to be rather generalist-oriented. Our specialty will continue to value those who can deftly manage a high-acuity, high-volume shift. Training programs will continue to emphasize exposure to general EM. We cannot contemplate returning to a system where the triage nurse pages a cardiologist to see the next chest pain patient. We see no sign of fragmentation and devolution of our specialty. Instead, we see a mature, dynamic and evolving specialty that attracts inquisitive and energetic physicians, some of whom will train beyond their core specialty. We are all Emergency Medicine.

Indeed, one might wonder if a bigger threat is too much generalism, and the ongoing dilution of the cases that drew us to EM in the first place. As trauma teams and stroke teams nestle into our resuscitation rooms and patients with acute myocardial infarction bypass us on their way to the cath lab, we spend more of our time providing primary care, arranging urgent nursing home placements and providing ongoing specialist care for patients prematurely discharged home. The solution is not to fear being the last generalists left minding the shop, but to advocate for the interests of our specialty and our patients in a changing world. While many factors have contributed to the shortage of generalist physicians, this is not the inevitable consequence of subspecialization, nor should it be used to restrict the natural growth of our specialty and its practitioners.

Reading Sinclair's Commentary, one is reminded of King Canute, arms held high, commanding the tide to stop rising. Rather than opposing the inevitable evolution of our specialty, we need to encourage progress while promoting and maintaining our core skill set, and while advocating for timely access to appropriately trained and available physicians in all disciplines.

Marco L.A. Sivilotti, MD, MSc
Departments of Emergency Medicine, and of Pharmacology & Toxicology
Queen's University
Kingston, Ont.

Daniel W. Howes, MD
Department of Emergency Medicine, and Critical Care Program
Queen's University
Kingston, Ont.