Episode 1: The Argument For Sub-Specializing

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What's the best way to start an educational platform for electrophysiology, is really working out, what are we doing?

Why am I asking this?

Nowadays, as electrophysiology is growing and growing, and the number of devices, pacemakers, defibrillators are growing and growing, people are slowly subspecializing into electrophysiology and into devices. Therefore, before we start and start discussing in future episodes about different cases about electrophysiology or devices, I constantly ask myself are we breaking this up too much? Is this a sub-subspecialism?

Now before that, when did the whole idea of subspeciality really come about? So all of this comes actually way back when to the medieval times where medicine and surgery were divided up into two different subjects.

Medicine was performed by the learned professional and surgery was actually performed by the bonesetters and carried out by tradesmen and barbers. It was more of a vocation rather than medicine, which was about curing people through diseases from diseases through medicines and through therapies. So already back in the medieval times, we were divided into medicine versus surgery. But really, the subspecialty as we know it today came about in the early 20th century in the USA. Where did it happen? It happened in ophthalmology, the eyes, and pediatrics, children, where they had their own examination boards and their own methods of studying and specialty in those particular fields of medicine.

Now I'm talking about electrophysiology. So what do we have?

We have medicine,

we have a specialty in internal medicine,

we have a subspecialty in cardiology,

and now we have sub-subspeciality in electrophysiology.

How far should this go? How far should we really be breaking this down?

Should we be going further and having a sub-sub-sub into devices and electrophysiology?

Where does it end? So let's look at the pros and the cons of subspecializing.


So when it comes to subspecializing, let's start with a positive side.

Below you can see the slide of the Pros.

So if we look at it in the education context, well, whilst we're striving for excellence and studying and subspecializing, we're actually hoping to gain control in something and maybe dare I even say “mastery” in the body of knowledge that we're subspecializing in. Whether it's devices, whether it's ablations and electrophysiology, whether it's EKGs, we're trying to gain control. What does that allow us?

1.  Academic Progress:

In a world where the niche is key, where you don't just go to a restaurant to have a cup of coffee, you go to a coffee shop and you have specialized niche coffee shops. So when the niche is key, if someone is subspecialized in devices, they'd be able to progress academically within that field.

2.  Scientific Progress:

In the field where the industry has a tight grip on progress. It allows you to push forth scientifically and maybe control the industry and have a doctor maybe decide where, or point the industry in which way it should go by our own personal scientific progress through a niche and subspecializing, understanding of the field.

Well, not only does it affect us educationally, but also economically. If we're subspecializing, we're being able to focus on performing procedures that are maybe more lucrative. For example, if we are being able to perform certain specialized implantations of devices, and we get a high level of proficiency in it 'cause we're subspecialized or sub-subspecialized in it, well then we're being able to work at it at a higher level and maybe even also quicker, therefore it can be more lucrative. In another way though, we can also have pay based on performance health system. Believe it or not, the Portuguese health system, I've heard, have a pay based on performance depending on how well doctors perform in procedures or in the field of medicine is their pay grade. Well, therefore, there's definitely a pro to subspecializing because your performance will be better at what you do better, at what you're subspecialized in. And then again, also in the economic field is discussing accountability. Nowadays, accountability is key. Malpractice insurance, damage settlements, they are all key to people working in the medical system, and to the patients they treat. They wanna know that their doctor performing the procedure is specialized in that procedure. If the doctor isn't subspecialized in the procedure, well, is it possible that he could lay vulnerable to being sued?

Now let's look at the pros of subspecializing from the patient. Well with the patient, he can guarantee that he's getting the best of care, 'cause he's going to a specialist in it. It's also better for the team. Think about it. Within the hospital team, you have one person specialized in devices and one person specialized in ablations and another one specialized in heart failure. You're offering a complete service with specialists. Isn't that better for the patient? And then think about the location. Well, wherever you are, wherever you're giving your service, well if you're rural, you're filling a need by being a specialist. In certain rural locations, they lack specialists in devices so they'll be able to fill a need. And if you're living in the more urban site, well if you've got specialists, that's a top-notch specialist with the best experience, hey, it's more attractive. He can offer the best quality of service. All of this is the pros of subspecializing. It sounds great!

So tell me, are there any negative sides to it? Well, of course, there is.

Below you can see the slide of the Cons.

Well, let's divide it up also starting with education. With education, doctors are nowadays, because of these subspecializing, have to maintain specific board certifications. Each board certification has different requirements, and for different insurance companies, you'd need different board certifications and you need to renew those requirements and those exams. Yes, there's a positive side to that. However, rather than practicing medicine, doctors are having to invest time and money into all these different board certifications. Is it really that necessary? Should they be spending more time going to courses and doing exams than treating patients? Beyond that, when it comes to education, you're limiting yourself and your knowledge base. If you're subspecializing, all you do every day is ablations of atrial fibrillation or implantations of pacemaker and defibrillator devices, well you're limiting yourself into a set knowledge base.

You're a doctor.

You studied medicine.

Years ago, you knew more. You knew dermatology, you knew ophthalmology, you knew the basics. Well, the more you're subspecializing and daily, and day to day, just limiting yourself to your subspecialty, well you're limiting yourself and your knowledge. You're deciding for yourself, potentially at the age of 20, 30, what you're gonna be doing when you're 60 years old. Is that something that you want to limit yourself to? Is that limited knowledge base good for patients? We'll get to that shortly.

If we look at the economic side, more and more team members are necessary for treating the same patient. It's costing the medical systems.

“How many different cardiologists do you need to treat the same patient?”

One is a specialist in devices, one is a specialist in arrhythmia, one is a specialist in heart failure, one is an interventional cardiologist, and that's just cardiologists. These are complicated, complex patients, they have to have specialists in internal medicine and nephrology maybe or diabetes or neurology. How many team members are needed to treat the same patient, costing the medical system? And then go to the next stage, we've got duplication of these providers/services and tests in the community medicine versus the hospital medicine because they've got their device specialists or the cardiologists in the community. And then when they have an acute flare-up of whatever they're going through, they've got their specialists in the hospital. What's the communication like between all these doctors and these team members?

Let's look at it from the patient side.

Who does he turn to?

Who can he turn to because he knows what he's feeling, but does he know is that because of my heart failure? Is that because of my heart rhythm? Is that because of my diabetes? Yes, I'm feeling dizzy, I'm feeling lightheaded. Do I turn to a neurologist? Do I turn to a cardiologist? Where do I go? The bigger the team members, the bigger the teams, I don't know where to turn to as a patient. Now also, maintaining communication between all these different medical providers. Who is it? Is it the family doctor, the general practitioner that tries to keep this group of doctors that treat individual patients together communicating? Is it the patient that's to make sure that his doctors are kept up to date with the different medicines that each doctor's providing? And then look at their location. Well, if someone lives rurally, how many clinics does he have to be a member of to get his complete picture? He's a person. He has many different systems that need treating, especially the older he is. How many different clinics does he have to be attending because he lives rurally to get the complete picture treated? And if he lives urban, who does he choose? Which is the best? Is this urban center, the best for devices, and this one's best for heart failure?

Subspecializing isn't that clear-cut as being great for the patients and not necessarily for the doctor maintaining all these certifications and limiting himself potentially, and certainly not for the medical system.

I say we've got over-fragmentation of care with over-specializing. Where is the limit?

So let's see. Are there benefits?

Here’s a clinical study that happened, not from cardiology but in pediatric urology.

”The increased pediatric subspecialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures.”

They decided to take over 71,000 patients, a nationwide sample based on pediatric urology patients, and they want to see who had the better surgical outcomes. They checked the and pre- and postoperative complication rates and they wanted to see if someone went to a “subspecialist” in pediatric urology, do they have fewer complications? Well, these 71,479 patients that were looked at between 1998 and 2009 showed amazing results and the results that we expected. First of all, specialization was not associated with race or gender or any comorbidities of other illnesses a patient has. It didn't affect the results. However:

1.  Mortality dropped from 1.5% to 0.3%.

2.  Complication rate dropped from 15.5% complications, even minor complications, to 10%. That's a drop in over 5% of complications.

3.  The cost of the procedures dropped from 4% extra to 2%. They actually thought that the cost of procedure might go up by seeing a subspecialist. Actually not. Why did it drop? Because of the complications and the cost effects of the complications dropping, it meant the cost of procedures when you look at it on the global scale also dropped.

4.  How long did the patient stay in the hospital? Well, as you can believe, the hospital length of stay was shorter by 5% to 10%.

So that's it. We're final, right? We should all be subspecializing. Both as a patient, both as medical people, both as doctors, nurses, technicians, we should be subspecializing.

But is the grass really that greener? How far should we be going? Let's go back to us in electrophysiology, in the EKG world, the electricity of the heart, when we have devices and EP ablation subspecializing.

Well, if we think about this, we have nowadays an increase of indications to have devices implanted. The number of patients, therefore, receiving devices or ablations is increasing. Due to these number of people going up, receiving these treatments, and these therapies are helping and the general improvement with a medical system in the modern world today is increasing life expectancy, and therefore, there's an increase of burden of patients on personnel.

So wait a second.

 Maybe we should be sub-subspecializing because we're getting more patients, longer life expectancy, and more of a burden on personnel. Maybe we really should be subspecializing in our world of device and electrophysiology.

Well, what are we checking in devices? In devices, we're checking many different things. (see graphic below)

That's plenty to give us good reason to subspecialize.

Well in EP, is it the same there? Yes. (see graphic below)

Well, if we look at a nice paper that was written (I highly recommend it).

It's called “Specialization, Subspecialization, and Subsubspecialization in Internal Medicine.” This was published in a very small journal (😊), I'm joking, New England Journal of Medicine in 2011, and it says something very straightforward and I highly recommend in reading this paper (again).

I've got a clear reference to it also in my slides, which you see in the video blog of this. It says the following.

“The progress of biomedical science continues to be a major factor in the emergence of new subspecialties.” Yep, you hear it. “Advanced heart failure is examples, including device management in the case of cardiology.” “Creation of these subspecialties reflects the recognition that there are some specific populations of patients who would benefit from the highly focused knowledge and skills obtained through additional training and certification.” You're hearing it. It says straight out in the case of cardiology, with device management, we should be subspecializing and obtaining not only the knowledge, also the certification. It continues further on in the study. “The public values board certification.” After all, you see it on my blog, I did the American board exams, and the European board exams, the public values it. And then it continues and says “clear requirements for a large enough number of patients.” So not only should we be subspecializing though, we should be doing it and being subspecialists in centers with large enough number of patients, 'cause it's all well and good specializing in devices or ablations. But if you have too little number of patients, you shouldn't be doing it. And yes, I'm gonna say something very “politically incorrect” or maybe some people will agree with me it's politically correct. Maybe comment on this in the comments below. Centers that are doing extractions of electrodes of pacemaker devices, if you're not doing large enough number of patients, I a firm believer that you shouldn't be doing it at all, you should leave it to the centers that have the experience. So yes, not only should we be subspecializing, but also the hospitals should subspecializing based on the patient volume.

So let's go back to the question.

Is the grass really greener in electrophysiology?

Well, I'm an extremely firm believer,

“if you will take time to water your own grass, it will be just as green.”

So depending on where you're at in your career and depending on where you're working, the size of your center and what they're performing and the patient population, yes, maybe you should be subspecializing within electrophysiology. But that doesn't mean if you're in a small center that you can forget about ablations and arrhythmias, because no, you still have to maintain knowledge and skills and shouldn't forget about devices and device interrogations because doctors that just do arrhythmias and ablations all day and technicians and nurses that just deal with ablations all day, they don't remember the basics in devices.

So, to sum it up, there's no right answer.

Just like everything in medicine, there's no black and white answer.

 Should we be subspecializing? I'm a personal believer that we should be doing what we're doing best and offer the best service to our patients.

Just to show the dangers of not subspecializing or doing something that you don't know how to do is this:

So yes, it might be difficult, it might be scary. We might feel that we're walking through what they say the valley of the shadow of death, but we cannot fear any evil.

We have to invest in our education and really make sure that we know what we're doing 'cause we owe it to ourselves and we owe it to our patients.

A quote from another paper, just to finish up, a paper called “The case for and against subspecialization in family medicine”. And this was a quote that they brought down by Robert Heinlen. It says the following. “A competent person should be able to, among other skills, change a diaper, balance accounts, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, and analyze a new problem.” "Specialization is for insects”.


So if we're competent, we should actually be able to do a whole list of things as long as it's stuff that we're doing regularly and we do it proficiently.

"Specialization is for insects," it says.

It's for the small, little insect. Well, I wanna bring another side to that, and that's actually from probably what the Bible tells us is the wisest of all men, Solomon, King Solomon. Well, he says, "Go to the ant, you sluggard,(you lazy person)”. Go to the ant “and consider her ways and be wise." In Proverbs, it says we should be considering the ways of the ant.

So maybe we should be subspecializing.

So the jury is sent out.

I would love to hear from you guys what you think.

Please write comments below, like it, share it and please also give me comments on other topics you would like to hear about.
Thank you so much!

COMING UP: Next few weeks, we're gonna be talking about using devices in arrhythmia diagnosis. Some really interesting case studies from devices, displaying that maybe there is a way of working with both worlds together because, in the end, it's all electrophysiology.

Thank you very much for your time and I look forward to learning together with you again next week.