Clinical Innovations - Six Innovations -- Innovation Number Two

Introducing New, More Focused and More Productive Medical Specialties

Many are wringing their hands about the plight of primary care doctors. This hand wringing is accompanied by pleas for more generalists and less specialists. This isn't happening because specialists are generally better paid and more productive than generalists. Any medical student or primary care doctor knows this, and they're not going to sit idly by and be placed at the bottom of the socio-economic pile. So, under the radar, many primary care doctors are entering other related fields in search of more income, more time with patients, more control of their destinies, and more satisfaction.

These new fields include the following:

•Hospitalists--The hospitalist’s specialty is now 10 years old, and the number of hospitalists is approaching 15,000. In the eyes of most--patients, hospitals, independent doctors, and hospitalists themselves-- the hospitalist's movement has been an unqualified success. Because hospitalists are on the spot in hospitals to deal with problems that arise there--and because hospitalists are well trained in addressing urgent and clinical care--patient safety improves, complications decrease, hospital stays shorten and busy primary care physicians admitting to the hospital but practicing outside its confine are grateful because they have more free time for themselves and their families.

•Proceduralists--This is a more recent but rapidly emerging specialty. It is a spin-off of the hospitalist’s movement. Proceduralists are hospital-based and are trained to do procedures common in hospitals--tracheotomies, cut-downs to create venous and arterial access, parancenteses and thorancenteses, spinal tapes and diagnostic procedures such as ultrasound. Proceduralists are in demand, not only because of their skills gained from repeatedly performing procedures, but because they can train incoming residents to perform them.

•Palliative physicians--In hospices around the country, a new kind of physician, the palliative physician, is more frequently sighted. After attempts at cure have failed or debilitating diseases have progressed to near death, there is a need for physicians skilled in interacting with nurses, chaplains and other care givers in end-of-life care. These physicians coordinate care for patients with terminal illnesses, comfort the dying, commiserate with spouses and relatives, arrange for care in homes and tend to patients spiritual needs. Palliative physicians to whom I have spoken say this new specialty is a welcome and satisfying relief from the extraordinary demands of a busy primary care practice. It is satisfying because doctors have more time to show compassion, spend more time with patients and be more intimately involved with families of the dying.

•Predictive practitioners--This is as yet an unidentified specialty, and it may simply be part of the future function of existing specialties. But advances in predictive modeling and artificial intelligence may soon make predictive practitioners more common. For example, at Kaiser, an advanced predictive model, the Archimedes Project, has made it possible to predict what clinical interventions are likely to work for diabetic, heart attack, cancer and other chronic diseases. And a new device for simultaneously evaluating cardiac and lung function in patients, who are often asymptomatic but at risk, will soon be introduced to the market. It is called SHAPE (Superior Heart and Pulmonary Evaluation) and has been tested and evaluated at the Mayo Clinic. This device, which is based on heart and lung physiological data, contains a database of thousands of patients; the device permits practitioners to predict with precision the risks of hospitalization or death.