February 9th, 2020

Should Medical Subspecialists Attend on the General Medical Service?

As I’ve written about many times on this site, one of the highlights of the year for me is when I attend on the medical service — something I’ve been doing pretty much forever.

There’s a wonderful learning exchange that goes on, with my knowledge of ID being repaid in kind by the others on the team — interns, residents, nurses, pharmacists, other attendings — who bring me up to date on current general medicine outside of ID.

(Including the acronyms. Yikes!)

I tried to capture this flow of information by commenting on this highly amusing post by Mayo Clinic’s Dr. Adi Shah — and hence confess was taken aback by this comment from Dr. Stephen Shafran, an ID doctor from Canada:

This is an important perspective, one which we subspecialists should examine carefully. How can we ensure that the care and supervision we provide be as safe as that done by a generalist?

This concern has been on my mind the past few weeks, prompting posting of this poll:

While the results are reassuring, this is hardly scientific — clearly many of the people who participated are ID specialists themselves, and probably many of them also attend on general medicine.

So, where are there actual data? I searched for studies on clinical outcomes for generalist versus subspecialist inpatient attending — and came up with very little.

One study from a single academic medical center suggested that hospitalists had more efficient use of resources (shorter length of stay and costs) than rheumatologists and endocrinologists, but clinical outcomes (readmissions, mortality) were similar. So, is it really unsafe?

As for the trainee experience, this group from UCSF argued strongly that having subspecialists as medical attendings greatly enriches their learning, and might motivate residents to pursue a given subspecialty as a career.

In the absence of definitive information, allow me to list certain strategies that I hope mitigate the safety issues Dr. Shafran raises.

  • Those of us subspecialists who choose to do inpatient medicine generally maintain certification in Internal Medicine as well as our specialty.
  • It’s very much a self-selected population of subspecialists who choose to do general medicine.
  • The subspecialists well-represented on general medicine services have, in their day-to-day activities, a substantial amount of general medicine in their practice — both inpatient and outpatient. There’s a reason you won’t see many subspecialist attendings on medicine who spend most of their time inserting coronary stents or doing ERCPs.
  • Obtaining consults on cases outside of one’s comfort zone is encouraged, and never considered a sign of weakness.

One other thing, perhaps specific to our hospital, is the structure of our medical team. The rotations typically pair us subspecialists with hospitalists or outpatient generalists. While only one doctor can be the attending of record for a given patient, the team has two attendings, both hearing about all cases on rounds. More on this team structure here.

After the above exchange occurred on Twitter, I received the following kind email from Dr. Badar Patel, one of our interns:

The experience I’ve had with subspecialists serving as our general medical attendings have all been extremely positive, and I don’t believe we’ve had safety issues as the Twitter thread would suggest. I am interested in medical education and would love to be involved if an opportunity to study this in a formal manner were to come up.

For a start, he’s created a survey about this issue, and already sent it to our house staff.

If you’re in clinical medicine, we’d be thrilled if you would take it as well — here’s the link. All responses are anonymous. We plan to write up the results in a future perspective piece.

And who knows, maybe we’ll learn something! After all, we all have the same goals — better care for our patients, and a better learning experience for our trainees.

Thoughts, comments, and opinions on this topic most welcome!

7 Responses to “Should Medical Subspecialists Attend on the General Medical Service?”

  1. tom benzoni says:

    People who worry about limitedist-led teams (limited is the correct term; think of lady at term in cardio office who starts to deliver…..) forget that there is a team here.

  2. Great post Dr Sax. I can’t imagine it being unsafe for a sub specialist attending to round on the inpatient service. The relevant specialists are most likely available for consults on difficult cases. Further, it’s probably mostly optional for specialists to do the inpatient service and those Docs not inclined to do general medicine are probably going to opt out. I’ve done 100% ID for almost 7 years (just a little outpatient IM for my HIV patients) and I recently started attending with residents on the inpatient medicine service. It’s been great, both ways I believe. The residents seem to appreciate the extra ID experience. Maintaining IM certification is a must in my opinion though.

  3. John R. Goheen MD says:

    I agree with Dr. Sax. Sub specialists who do general medicine are self selected ie Pulmonologists, Nephrologists, ID, and contribute to the learning experience as well as enhancing their clinical skills.

  4. James Parosa MD says:

    I agree that the subspecialists that attended me at the U of Wisconsin were extremely helpful. I learned more from Dr Dennis Maki than any other attending I ever had. Admittedly his fund of knowledge was unmatched but he also taught a method of evaluation that has stood me well.

  5. Abdu Sharkawy says:

    It is probably too strong a statement to declare any decision to attend on an area outside of one’s specialty on a limited basis as unsafe. Clinical outcomes are determined by a range of factors, including not only individual competence but timeliness of communication with other consultants, adequate follow up, and the ability to connect with a patient in a manner that fosters a relationship of trust and caring. I don’t see how any of these factors are defined by one’s subspecialty as much as they reflect one’s standards of personal and professional integrity. I personally practice a lot of both Internal Medicine and ID and feel privileged in knowing each hat lends value to the other and enriches not only my experience but that of my residents and medical students. I also see subspecialty colleagues who do practice only 1 month a year as general internists and what they lack in current knowledge and evidence based practice is more than offset by dedication, formidable clinical acumen and the practice of the art of Medicine in a truly exemplary manner. That, as much as anything else, makes all the difference to patients and those fortunate enough to be a witness to their talents.

  6. Steve Flecknoe-Brown says:

    When I trained in Internal Medicine (in Australia) you had first to prove that you were a competent Generalist before you could enter sub specialist training. Some years later the move to sub specialist focus gained the upper hand. As a result, newly-minted sub specialists felt quite out of their depth with general internal medicine.
    Now that I work in a rural location I am so grateful for my general medicine training. Here, breadth replaces depth and is just as challenging and rewarding. It is clear that in the developed world the move to sub specialisation has made it harder for rural communities to find general internists, which has created big problems.
    Like Dr Sax, I treasure my time in the general internal medicine program even though my colleagues ask for my help in my sub-specialty. If I had my way I would make attending on the general medicine service a mandatory component of sub specialist practise. But that is a power I do not have.

  7. Anil sharma says:

    Yes, You are right. Great article.


HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

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