19th October 1997

Your Health

Becoming extinct: the general physician

By Dr. Sanjiva Wijesinha

On a recent visit to a teaching hospital in the States, I had so much difficulty finding a general physician that I have been wondering whether they are now extinct in those parts.

In today's American hospitals, they have a dazzling array of ologists, each of whom has specialised in some particular ology. Cardiologists, hepatologists, neurologists, rheumatologists - name an organ and like as not there will be an ologist to go with it.

In the old days there were 'physicians with an interest in kidney diseases'; now the hospitals' waterworks departments have become so specialised that one of these days I fear we will have two more kinds of specialists - one for the left kidney and another for the right kidney.

Now all these clever ologists are, I am sure, endowed with tremendous knowledge and are familiar with all the latest research - and each of them must be particularly skilled at examining his or her particular favourite organ. The only problem, I suspect, is that like the King's horses and men, their talents are often limited when it comes to putting the pieces back together again.

Once an ologist has completed the task of examining and investigating the part of the body, be it the heart or the nerves, that he or she finds particularly interesting, the patient is then sent on down the corridor for another ologist to deal with something else.

Or worse, the patient is sent back empty-handed to his family doctor. As one patient I heard reported to his GP, "That famous specialist you referred me to, doctor - once he decided that my liver was not the cause of my problems he seemed to lose interest in me."

When I first started as a junior doctor at the Colombo General Hospital many years ago, I seem to remember there being a lot of general physicians around. True, some of them had special interests in particular diseases, but they were all basically general physicians. Short of delivering a baby or removing an appendix, there wasn't much they couldn't turn their hands to.

The doctor who was interested in liver disease didn't try to pass the buck when faced with a patient having a heart problem, and in those days there was nobody who confined his practice solely to the disorders of the middle ear.

At the tail end of the twentieth century in the over-developed and affluent west most of the general physicians seem to have gone the way of the dinosaurs, with their successors being forced to superspecialise in order to survive.

The general consensus (among the specialists) seems to be that patients are getting a better deal because they can see an expert who is the last word on their particular malfunctioning organ. I suspect however that the general consensus among patients is somewhat different.

It could well be that having available in the hospital an expert in diseases of the spleen means that one will be in very safe hands if one develops a rare disorder of this particular organ - but the vast majority of patients, I am sure, do not suffer from such esoteric ailments. Most of them need to see a physician now and then because age and the inexorable passage of time are causing the various interconnected systems of their bodies to wear out .

Of course, if these patients survive long enough to get really old, they can finally get to see someone called a geriatrician - who has specialised in Gerontology, or the general diseases of old age. The sad fact is that these gerontologists have to confine their generalism to seventy-year olds and above. For those unfortunates who have not yet reached the age of three score years and ten, specialist consultations must take place organ by organ, piece by piece, ologist by painful ologist.

Is it any wonder that modern western medicine costs more than the public can afford?

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