The Trend Toward New Subspecialties in Medical Training

The trend toward new subspecialties in medical training, often at the fellowship level, seems to be inexorable. In recent years, to mention a few, we have seen the emergence of interventional radiology, feto-maternal medicine, emergency medicine, and sports medicine. There are even ultrasound fellowships within emergency medicine (see: Additional Discussion About "Radiology Without Walls"). At the recent Molecular Summit conference that was held in Philadelphia, Dr. Aaron Baggish of the Division of Cardiology, Massachusetts General Hospital, delivered a lecture entitled Cardiovascular Medicine 2008. In his slide #7, he lists the following six categories of subspecialties in cardiovascular medicine in addition to the generalists:

• Electricians
• Imagers
• Basic scientists
• Interveners
• Heart failure specialists
• Miscellaneous (e.g., aortic disease, congenital, sports, genetics)

A cardiologist friend has suggested yet another emerging category to add to this list: preventive cardiology. In addition, the miscellaneous category above can be viewed as an incubation tank for new and emerging subspecialties in the field. Note the presence of cardiovascular sports medicine, presumably as a new branch of sports medicine. The aortic disease category category above undoubtedly encompasses the new treatment of descending thoracic aortic aneurysms with endovascular stents.

Given this background information, one might wonder why I would have the temerity, or simply bad judgement, to suggest in a series of previous blog notes that pathology, lab medicine, and pathology should consider merging. The trend toward new specialties seems to be moving in the opposite direction -- the splitting of major specialty groups into ever more specialized categories. The answer to this question is that most of the subspecialization activity cited above involves medical disciplines relating to therapeutic intervention. I believe that a merger of pathology, lab medicine, and pathology would cause a coalescence of the diagnostic specialties into a single top-level specialty -- diagnostic medicine with support from a new diagnostic information system (DIS) which would consist of an integrated LIS, RIS, and PACS. Such a merger then puts at the disposal of its practitioners all of the various diagnostic imaging modalities, surgical pathology techniques, and molecular diagnostic tests that are available.

If and when such a merger were to take place, it would be impossible for any single individual to be knowledgeable about the diagnosis of all diseases across all organ systems. I therefore believe that the specialty of diagnostic medicine would immediately cleave into a set of diagnostic subspecialities related to individual organs, organ systems, or general disease categories such as cancer or autoimmune disease.