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Journal of Postgraduate Medicine, Vol. 54, No. 4, October-December, 2008, pp. 248-249 Editorial Advanced subspecialization in medical subspecialty practice in India: Are we ready for it? Muzumdar DP Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai Code Number: jp08092 Is there a need for endorsing advanced subspecialization in subspecialty practice or can it wait? A vast majority of Indians residing in rural areas have limited or no access to basic medical and surgical facilities. The major health needs of the country are control of malnutrition, acute respiratory infections, tuberculosis, HIV disease, diarrheal diseases and other infectious diseases. In such a situation, the need to focus on advanced subspecialization could easily be questioned. It must be stated that the broad specialties as well as the established subspecialties will continue to play a crucial role in maintaining the balance in medical practice and the importance of these basic services can never be undermined. The infrastructure needed for nurturing advanced subspecialization is mainly available in private rather than public sector hospitals. Few public hospitals have been able to generate advanced subspecialists in a comprehensive manner due to budgetary and human resource constraints. The advanced subspecialization services come at a premium and the long-term viability of such a program needs to be ascertained in terms of monetary recovery and increasing healthcare costs. Barondess et al . have raised concern about the splintering effects of advanced subspecialization and its potential to increase the cost of healthcare delivery.[2] But, on a global background, there is little doubt that the current era is of refinement in subspecialization and that it is here to stay! The need for advanced subspecialization has arisen since one cannot maintain expertise in all aspects of a subspecialty. Earlier, subspecialization came into being to provide advanced and focused care in terms of critical care, trauma services, cardiology etc. However, the rapid pace of globalization and economic upsurge in the recent years as well as technological advances have generated innovative treatment options viz. cosmetic surgery (plastic surgery), joint replacement surgery (orthopedic surgery), bariatric surgery (abdominal surgery) and so on. It has brought a radical change in the manner in which medical subspecialty is perceived by doctors and patients alike. Advanced subspecialization services are largely industry- and technology-driven. Over a period of time, it will certainly create its own identity in the mainstream medical practice. The subspecialists in India have always strived to set high professional standards in various subspecialties. [1] The comprehensive care provided by an advanced subspecialist will be certainly superior to those involved in the management of this disease along with other diseases. There is a possibility that in the long term advanced subspecialization could override the identity of the parent subspecialty. It will be more evident in the metropolitan cities and will slowly pervade centrifugally within the country. The economic development of the region will be the determinant factor for its propagation. It has almost become a trend that advanced training in subspecialty practice is needed in order to be able to sustain and thrive in private or public practice. The subspecialties have become a stepping stone for advanced subspecialization. The path ahead The future subspecialists may be not be in the same comfort zone as their predecessors due to rapidly expanding medical knowledge and technology. With changing practice norms, the insurance segment and professional indemnity are gaining wide coverage and acceptance. [3],[4] The insurance companies (that provide reimbursement for medical expenses and malpractice insurance for professional indemnity) would have a greater say in healthcare and management. The age-old doctor-patient relationship based on faith and trust is metamorphosing into a business relationship between a consumer and a service provider. To ensure that their money′s worth is properly accounted for, the insurance companies would indirectly enforce the defining roles of a subspecialist. It is possible that the hospitals would be more inclined to appoint an advanced subspecialist to deliver appropriate healthcare. If advanced subspecialty practice is here to stay, then it is better that the medical regulatory bodies at the local and national level should take the reins in their stride and focus on these areas. At present, the standard of healthcare across India is highly variable and it is difficult to set guidelines for practice. [5] In the long term, full-term advanced subspecialty practice would be cost-effective since it would be of a high quality with minimal complications. It will in fact reduce patient costs.[6] The rural population is well aware of the health insurance schemes and would be willing to pay and join them.[7] The medical regulatory bodies should lay down norms for advanced subspecialized practice in a tertiary or a regional medical center. The administrative setup of hospitals will have to undergo a sea-change. Indian hospitals may have to implement a gradual change from the British system of vertical hierarchy to the new age American system of horizontal equivalency. Training opportunities for faculty will have to be improved so that younger members could be encouraged to get trained at recognized university departments, here or abroad. This would also have an impact on the training of postgraduate students and resident doctors. They could be sensitized to various advanced subspecialties during their postgraduate course. Fellowships for training in advanced subspecialties could be offered to those interested in further training. In summary, advanced subspecialization in medicine is an offshoot of the rapid advances in diagnostic and therapeutic techniques as well as technology. The process of integration of advanced subspecialization into the medical practice should be smooth and efficient. Due consideration should be given to the wide diversity seen in the Indian patient population and the socioeconomic strata to prevent polarized practice. The benefit of advanced subspecialization should be made available to all sections of the society at a reasonable price. The need for ethical guidelines and regulations for the successful implementation of an advanced subspecialization program cannot be overemphasized. References
Copyright 2008 - Journal of Postgraduate Medicine |
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