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One-fourth of generalists and three-fourths of specialists have a subspecialty within their primary specialty

The rapid expansion of medical knowledge and technology in recent decades has prompted more and more doctors to specialize. According to a recent study, one-fourth of generalists (internists and pediatricians) and three-fourths of specialists now have a subspecialty of expertise in their area. For general internists and pediatricians, subspecialties primarily focused on groups of patients, such as women, the elderly, children with developmental problems, or adolescents. Specialists reported focused expertise in areas specific to their specialty. For example, cardiologists tended to specialize in areas such as echocardiography and electrophysiology. The study was supported in part by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00020).

Focused expertise may secure a niche amid a potential excess of specialists, particularly in hospital and nonrural settings. It also may provide opportunities for additional earnings from referrals and procedures that often accompany such expertise. In fact, one academic medical center now offers a fourth year of internal medicine residency training to enable residents to develop expertise in a subspecialty. Similar trends are evident in pediatrics, with the emergence of fellowship training and certification in fields such as adolescent medicine and behavioral-developmental pediatrics.

Generalists with focused expertise may be particularly useful in managed care organizations or in geographic areas with fewer specialists. For example, a group of primary care doctors, each with complementary expertise, might share knowledge and skills and thus require fewer consultations with specialists. On the other hand, excessive and narrow subspecializing may yield fragmented care and inefficient referral to multiple or inappropriate specialists, cautions Nancy L. Keating, M.D., M.P.H., of Harvard Medical School and Brigham and Women's Hospital. Dr. Keating and her colleagues surveyed 1,370 licensed general internists, pediatricians, cardiologists, infectious disease specialists, and orthopedic surgeons in Massachusetts, who graduated from medical school before 1993.

More details are in "Physicians' reports of focused expertise in clinical practice," by Dr. Keating, Alan M. Zaslavsky, Ph.D., and John Z. Ayanian, M.D., M.P.P., in the Journal of General Internal Medicine 15, 417-420, 2000.

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