Medicine has become so narrowly specialised that clinicians focused on a single organ system are losing the ability to diagnose outside their core area, it has been claimed.
The inability to make a broad differential diagnosis in the face of uncertainty is becoming a real concern in an era when patients are becoming older and have more co-morbidities, argues Associate Professor of Medicine Ian Scott in an opinion piece for the MJA.
Single-domain specialists tend to be less experienced and skilled than generalists at managing the diagnostic pathway for patients presenting with complex problems and co-morbidities, writes Professor Scott, Director of the Department of Internal Medicine and Clinical Epidemiology at Princess Alexandra Hospital in Brisbane.
“Clinicians trained as generalists seem better at navigating this complex mixture of issues than single content domain specialists. Lack of experience in diagnosing and managing such patients may explain more cross-referrals to other specialists, longer stays and higher resource use incurred by single domain specialists compared with generalists within hospital settings,” he says
Single-domain specialists are prone to generating diagnostic hypotheses relevant to their own specialty, even though a diagnosis outside it may be equally or more valid, he says.
Other forms of cognitive bias such as premature closure compound the problem, he writes, pointing to one study which found that half of all patient-initiated second opinion requests to specialists related to diagnosis and of these, 15% involved a change in diagnosis.
“Further, when diagnostic errors made by one doctor are recognised by other doctors who subsequently see the patient, such errors are rarely communicated back to the original doctor for fear of endangering professional relationships”, he writes.
Evidence also suggests patients under a single-domain specialist may be left undertreated for a second disorder unrelated to their primary condition, he notes.
If the condition remains undiagnosed, the specialist may opt for a “best guess” as to which organ system is affected in order to make a cross referral, writes Professor Scott.