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December 13, 2000

Generalist vs Specialist Medical Care—Reply

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(22):2873-2874. doi:10.1001/jama.284.22.2869

In Reply: Opinions about the appropriate extent of subspecialization in US medicine, on both sides of the issue, are often vigorously debated. The growth of subspecialization, as I indicated in my Editorial, is undoubtedly based in the scientific progress of recent decades; indeed, the extent to which science has reshaped medical practice is one of the great intellectual and humanistic triumphs of our time.

The issue is not whether we should have subspecialization, but rather how much. The deeper questions are how to make such decisions and whether the progress of science by itself will ultimately provide these answers. Science-based disease management is obviously essential to proper clinical practice, but particular populations and patients may present additional variables. A more general approach may be optimal in the identification of newly presenting disorders and poorly defined symptomatic syndromes. There is also a clear advantage in continuity of care not only over time, but also spanning the various health vicissitudes that individuals may experience. As the US population ages, an increasing proportion of individuals will have diseases in multiple organ systems that will require simultaneous medical management. There will be extension of the already evident need for coherence in clinical care and for someone to make nuanced judgments concerning clinical priorities, including when to exercise technologic restraint in clinical management.