Missing the bigger picture

The COVID-19 pandemic has exposed the shortcomings of excessive subspecialisation

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Prof Marcel Levi MD
Excessive subspecialisation in medicine is not a sustainable model for healthcare going forward, as has been shown by the learnings to date from the COVID-19 pandemic, according to Prof Marcel Levi MD, Chief Executive of University College London Hospitals, UK. Giving the Keynote Lecture entitled ‘Tackling the COVID-19 crisis: professionals in the lead’ during the opening session of the 38th Congress of the ESCRS, Prof Levi said it was important to learn from what had happened during the first wave of the pandemic, not just in relation to how to deal with the virus going forward, but also its lessons in general. He noted that there was massive redeployment of medical staff during the first wave of the pandemic in many countries, in order to deal with patients who contracted the virus and to protect other patients and staff. This situation proved very challenging for many healthcare workers not used to being out of their comfort zone. “We are now extremely subspecialised. We know fantastically well how to do our jobs but it is still very difficult to do someone else’s job,” he said. In older patients presenting with many medical comorbidities this is a real issue for clinicians, Prof Levi said, questioning if it is feasible to have a doctor for every individual ailment in one patient. Giving a hypothetical example, he said if an ophthalmologist only deals with one part of the eye and their patient has an issue with another part of the eye, that is not much use to the patient. “In the highly specialised medical model of the 21st Century there is a different doctor for every disease,” he said. While acknowledging that this is positive in many ways such as ensuring expert care, “hyper specialisation” can lead to “forgetting that a patient is more than a collection of organs or parts of organs and that there is actually a bigger picture to address”, Prof Levi maintained. “So many people, including myself, believe we need to rethink our model of subspecialisation. Of course we need specialists in the highly advanced medicine of the 21st Century, but the need also remains to have a broad base of better understanding of medicine in general, of your specialty and maybe across more than one specialty/subspecialty, to properly address these implications. Prof Levi suggested that clinicians should move away from over-focusing on one small disease area, and aim to instead be “super specialists, who are a little more capable of doing a bit more than their highly specialised area”. LEADERSHIP He also spoke about the key role of clinicians in leadership and the need for managers and clinicians to work better together, collaboratively, as has happened during the pandemic. During the first wave of COVID-19 cases, doctors, nurses and other healthcare workers had to step up and lead the response to COVID-19, Prof Levi pointed out. “We asked the professionals to take the lead, we just told them what we needed and they had plenty of ideas about how to do it. We said ‘you do not need permission, just get on with it’. Of course there were managers but in a much more supportive role. Effort was not enough; it was all about results, and it was actually quite effective. And I think it should teach us that this leadership model in hospitals should be adopted much more frequently and could offer an answer to many of the problems we face in healthcare in general.” Prof Levi said that managers speak a different language, which “doctors and nurses do not really understand or want to understand”, but they really should become more involved in leadership. “It is not about power, it is about influence,” he commented, comparing hospital medicine to a symphony orchestra with many talented musicians who have a conductor with influence over them who is responsible for the end result. He acknowledged that sometimes healthcare workers are reluctant to take a leadership role: “but from my personal experience I can tell you that actually having a leadership role in the hospital, being a professional, is really very, very gratifying. It is not about observing what is happening but actually making things happen yourself.” Looking at the continuing challenge of COVID-19, Prof Levi said there had been significant learning from the first wave of the pandemic, including how to reconfigure services at short notice as well as the increased use of telemedicine. Summarising his lessons from the pandemic, Prof Levi said: “‘I think what we’ve learned from this pandemic is that we need to bring together these two worlds; put professionals in the lead, put managers in a supportive role and then we can achieve the most fantastic things much to the benefit of our patients and also to ourselves.” Marcel Levi: marcel.levi@nhs.net