Introduction

Reviews

Are Specialists Better?

Timothy B. McCall, M.D.

Many books and articles advise medical consumers interested in high quality medical care to seek out the nearest university hospital superspecialist whose area of expertise corresponds to their medical problem. By superspecialists, I mean those doctors who not only have a specialty but who focus their interest on a small area within that specialty. A superspecialist cardiologist, for example, might focus on heart rhythm disturbances. Superspecialists usually work in university medical centers.

I disagree with the standard advice. Rather than routinely consulting superspecialists for every problem that comes along, try to use them only when the specialists your primary care doctor refers you to are baffled or when they diagnose a “superspecialized” problem. Superspecialists are absolutely the best doctors to see for particularly bizarre or complicated problems but not for more common conditions. They are also good doctors to see for second opinions since their perspective may be different from that of their colleagues in private practice or HMOs. Superspecialists tend to stay more up-to-date with advances in medical diagnosis and treatment—at least within their area of interest—than the average doctor. You may or may not want to follow their advice but gaining their perspective on your problem can help you sort out your options.

Because superspecialists are authorities in their particular area of interest, people falsely assume they know a lot in general. They are often primarily researchers who are not be as skilled in the day-to-day practice of medicine as doctors who practice full-time. Many renowned superspecialists I’ve come across have been laughably deficient in their knowledge of general medicine. They are what the Germans would call “Fachidioten,” literally specialist-idiots. The idea is that with increasing specialization, the expert knows more and more about less and less, until finally he or she knows everything about nothing.

If you’ve consulted a primary care doctor and one or more specialists and they can’t figure your problem out or if you’re diagnosed with a rare condition your doctor doesn’t have much experience with, consider seeing a superspecialist. If you can find a superspecialist with a special interest in your case, that doctor may be able to offer invaluable assistance.

In the United States, specialists and especially superspecialists are held in higher regard by both their colleagues and the public. Many American consumers have become accustomed to self-diagnosing their problems, bypassing their primary care doctor if they have one and directly consulting the specialist that seems most appropriate. Many HMO members resent having their access to specialists impeded by primary care “gatekeepers.”

But are specialists better than primary care doctors? Is a hammer better than a screwdriver? It depends on the job. In general, primary care doctors are better at day-to-day medicine. It’s what they’ve trained in and what they’re presumably interested in. Primary care doctors tend to be better at the human side of medicine and at preventive medicine. They are in the best position to coordinate medical care and decide when referral to a specialist, and to which specialist, is advisable. Many patients who decide which specialist they need to see end up guessing wrong, wasting time and money.

Although specialists sometimes restrict their practice to only handle patients with problems in their specialty, some also spend part of their time doing primary care. Some do a good job at it but others lack interest or enthusiasm for general medicine. They may be more interested in patients who have problems in their specialty and may not make the effort to keep up-to-date with advancements in general medical practice.

Compared with primary care doctors, specialists and especially superspecialists tend to intervene more. They order more tests, particularly high-tech tests, prescribe more drugs and hospitalize patients more often. Whether more is better depends on the condition but the general tendency of American physicians has been to intervene too much.

Certain problems are clearly best handled by specialists. Cancer chemotherapy is almost always coordinated by an oncologist. Hard to control cases of diabetes should probably be managed by a endocrinologist. Even in these instances it’s usually still a good idea to have a primary care physician overseeing things. The specialist or specialists can forward their recommendations to the primary care doctor, who can be sure that things aren’t slipping through the cracks.

People who get all their care from various specialists with no one coordinating can suffer. Tests may be unnecessarily repeated. One specialist may order a drug that counteracts the effects of a drug another specialist has prescribed. Some things may be forgotten entirely. If a woman’s cardiologist is taking care of her blood pressure, an orthopedist her arthritic knees and a dermatologist her psoriasis but nobody’s doing a Pap smear or encouraging her to get a mammogram, she isn’t getting optimal care, no matter how “state-of-the-art” each specialist is in his or her own right.

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