The shifting sands of medical care


Margaret Prendergast knew she would need an operation to get rid of the benign tumor in her uterus that was bleeding and producing punishing pain. Prendergast, a registered nurse, logically presumed it would be her gynecologist who would do the cutting. Or maybe a surgeon.

She never dreamed it would be a radiologist, the sort of specialist who historically spent days cloistered in the hospital basement in a dark, windowless room ruminating over X-rays and MRIs and virtually never venturing into the realm of live patients.

Not only did a radiologist do the operation, he did it without the hysterectomy her gynecologist had said she'd need, using his high-tech imaging equipment to expertly excise three-quarters of the tumor and leave behind only dead cells. Procedures like hers are delighting patients, but they are igniting a turf war between the new army of "interventional radiologists" new army of "interventional radiologists" and the surgeons who had always reigned unchallenged in the operating room.

That's just one in a series of battle lines being drawn as the old divisions between medical specialties become increasingly blurred.

Psychiatrists trained to do therapy are spending their days dispensing drugs, displacing pharmacologists who are the drug experts. Dermatologists used to tending acne and skin cancer are surgically sucking out fat cells and smoothing out wrinkles -- the cosmetic work plastic surgeons were schooled in. Gastroenterologists are being transformed into surgeons, urologists are spending less time on kidney stones and more on impotency, and ophthalmologists are performing laser surgery that makes eyewear obsolete and puts other ophthalmologists out of business.

The world of medical specialization is being turned on its head -- raising doubts about whether specialists are adequately trained in their ever-evolving specialties, pitting doctors who dominated a domain against those pushing their way in, and setting off alarms about whether money drives the system rather than doctors' skills and patients' needs.

Many patients, meanwhile, are uncertain whether to see a radiologist or a surgeon to treat a tumor, and unclear whether they should take their unruly child to a psychiatrist, a pharmacologist or the family pediatrician.

Today's medical specialists are "constantly reinventing themselves. It's happening more than it used to because of the enormous increase in medical knowledge and technical skills," says Dr. John Harrington, dean of the Tufts University Medical School.

Dr. Tom Delbanco has been watching that evolution from his perch as chief of general medicine at Beth Israel Deaconess Medical Center, and it worries him: "Radiologists and pathologists didn't want to deal with people so they went into diagnostic areas, but suddenly they've become interventional. On the other side of the coin, psychiatrists are people who went into a field where they wanted to talk to patients. Now they're suddenly pharmacologists, and they're not always very good at it. I find them making lots of mistakes with drugs.

"They'll all end up being good at what they do," Delbanco adds, "but the transition is what's dangerous."

Medical history is full of examples of breakthroughs in technology and technique putting pressure on doctors to branch out, often onto thin limbs. Joseph E. Murray, the first kidney transplant surgeon, was a plastic surgeon who had done the operation on more than 100 dogs. He made the leap to people effectively enough to be awarded the Nobel Prize. It was the same for the first orthopedic surgeons to do joint replacements and cartilage transplants.

Today, however, the reinvention is happening at supersonic speed, in medicine as in most high-technology fields. And it is not just changing technology that is pushing the pace, but also economic issues.

Insurers have made clear what kinds of medical work they will pay for and what they will not, and doctors have adjusted accordingly, even if that means venturing into uncertain areas. Oncologists, for instance, are trained to examine and counsel patients with cancer, but these days they also often administer chemotherapy themselves and perform other procedures for which they will be more generously reimbursed but about which they are less well-trained.

Dermatologists have pushed the envelope even further, with some devoting large parts of their practices to liposuction, hair transplants and other procedures that patients pay for out of their own pockets.

Psychiatry has been even more radically reshaped by a combination of scientific breakthroughs and shifting reimbursement philosophies.

When Dr. Margaret Ross graduated from medical school in 1974, therapy was the main weapon in a psychiatrist's arsenal and drugs were used only to treat severe cases of disorders like depression. Today Prozac and other antidepressants are being used to treat everything from panic attacks to obsessive-compulsive disorders. Therapy, by contrast, is under siege by researchers who insist it does not work and by insurers who will only pay for a limited number of sessions.

The result, Ross says, is that nearly half the patients she sees as a staff psychiatrist at the Massachusetts Institute of Technology are on some sort of medication and for many of her colleagues it is 80 or 90 percent.

Such changes are exciting for young doctors who were trained in them and like to picture themselves on the cutting edge.

But for some doctors like Ross who have been around longer, the changes can be unsettling. "Psychiatrists today feel less good about what they do," says the 51-year-old therapist, "and fewer people are going into psychiatry. People say the training has become much more administrative, how to get people into hospitals and out. It's not the sort of really intellectually satisfying deep connection with people we used to experience with long-term psychotherapy. I don't want to say it's not satisfying, but it's a very different kind of connection. I'm not sorry I went into it, but I do have my days."

The transition is even harder for doctors in their 60s and 70s. "Older practitioners often feel left out and never recover from their failure to keep up with the technology," says Dr. Joseph Martin, dean of the Harvard Medical School. "Technology does develop more quickly now than it is able to be disseminated to people who can use it in their practices."

Some physicians respond by refocusing on aspects of their specialty where they feel most comfortable and competent. Others take the continuing education courses and other training that, in this era of perpetual change, have taken on new urgency. Some specialists could be shifting focus at the peril of their patients.

"I'm less worried with cognitive practitioners like psychiatrists who really keep up pretty well; it's not that complicated to learn how to use major medications," says Martin. "I worry more about technically sophisticated areas of surgery, radiology and dermatology, where doctors take on a procedure like liposuction without having the true training or ability to recognize complications."

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