The fight between generalists vs. specialists

Veterinary specialists and generalists have more in common than differences; they shouldn’t be fighting like, well, you know… Photo: Bigstock/kozorog The under-appreciation of general practice is a popular topic over on the human side of the medical profession. Disgruntled GPs—including pediatricians, family doctors, and sometimes OB/GyNs and internists—respectfully bemoan the lack of pay and respect afforded their population. Anyone specifically interested in general medicine is commonly regarded as second-rate due to the less-competitive qualification requirements. It’s often believed that GPs assume their practice roles not out of choice but because they couldn’t qualify for more competitive, higher-paid internships and residencies. In some cases, that is undeniably true. Where else would a wanna-be orthopod, plastic surgeon, dermatologist, or interventional radiologist end up? Among the family doctors who could not hack the competition for these most sought-after specialty groups, though, are plenty of ambitious, hard-driving individuals who could care less about making top dollar if it means they will be stuck doing the same procedures day after day on patients they never get a chance to get to know. Specialization does not equal ambition. Yet, conventional wisdom among the med set implies they’re lazier, dumber, and less competent precisely because there are some among them who would rather be making more money at all costs. Some of this bias also infects veterinary medicine. Who would want to be a GP when they can make at least twice as much as a starting internist and more than three times as much as a veterinary surgeon? Some practice owners tend to get a bit of a pass these days, but small animal and equine associates are typically regarded as run-of-the-mill, less ambitious, exclusively lifestyle-oriented, and generally less competent. The drive to self ID I’ve always been keen to observe how and why veterinarians self-segregate into specialty groups. When I graduated back in 1995, four out of the top five students in our class went right into highly competitive internships and ultimately specialized. Only one went into general practice. Nowadays, you can expect the vast majority of the top 40 percent would be vying for competitive internships. Anything less would be widely considered a waste of all that effort. Self-segregation these days goes further than the binary choice of general vs. specialty medicine. Nowadays, veterinarians seem to think ER practice is also a pathway to better pay—and definitely greater respect—than run-of-the-mill GP-dom. Saving lives in a fast-paced practice is perceived as a more challenging environment where the smarter and more ambitious prefer to be. Generalists, as the thinking goes, are only there because they couldn’t climb any higher on the veterinary totem pole. Sure, the odd vet here and there specifically aspires to practice ownership—and that’s respectable, too—but it’s for those who care about money alone, and not about medicine. Medical ambition is a worthier, more reputable prospect. After all, everyone knows it is the C students who build businesses, right? So goes the thinking of the youngsters I meet these days. As in human medicine, generalists get short shrift. Who are the most heroic? Meanwhile, who does the heavy lifting in veterinary medicine? I argue it’s the generalists who do the bulk of the work and make the biggest difference in the lives of animals. They treat more than just the tippy top of the iceberg of patients who enjoy the great luck of belonging to those who can fork over $10,000 for a TPLO and $20,000 for spinal surgery. It’s impressive work, to be sure, and I have tremendous respect—even awe—for my favorite specialists. However, even they’d agree it is we who have to sort the horses from the zebras. We are the ones who need to carry not just the specialized knowledge of what they can make possible, but the basic understanding that underlies each and every potential diagnosis. In fact, the very best specialists are great not because of the specialized skills and crazy expensive tools they know how to use, but precisely because they’re great generalists, too. When all you have is a hammer (and you know how to wield it expertly), everything starts to look like a nail, doesn’t it? That is when mistakes get made. It’s also a black hole for medical ethics. When you know how to perform an expert TPLO or a perfect hemilaminectomy, it’s tempting to slice just about anything stifle or spinal that comes your way. As we all know, generalists come in all shapes, sizes and willingness to perform ethical gymnastics, too. The thing is, our medicine is more likely to be looked at askance and our abilities assumed to be lesser than. This is particularly true when we fail to refer—which is fair!—but also because, as generalists, it’s assumed we possess inferior skills overall. After all, if we weren’t second-rate we’d have completed residencies and passed our board exams, too. Its own sort of specialty What specialists and others fail to recognize is generalists are specialists, too. As in human medicine, we specialize not only in possessing, maintaining, and carefully curating a broad base of knowledge but in the ability to extract the relevant history from an owner, rule out a wide range of other processes, and sort carefully between the many potential comorbidities. Given our vantage point, we are also specialists in understanding everything in its proper context—where it matters: in the relationship between the patient and their people. I can understand why it is hard for others to appreciate this. After all, “soft skills” get the short shrift, too. For some reason, most medical practitioners tend to appreciate the terra firma, “science-driven” skills we have collected. For example, identifying a disease process after a well-taken history doesn’t get half as much respect as when it’s gleaned from a panel of values or a collection of images. Emergency medicine garners greater respect than standard GP work precisely because it’s perceived as more technical. We are effectively biased against our “people skills,” as if these are any less relevant or meaningful. We’ve all heard it asked, “Do you want a great doctor or do you want one with a good bedside manner?” I’ve said it myself when preparing a client for a prickly specialist visit, but the truth is a truly great doctor is never a jerk. No one is above being difficult to communicate with. Generalists tend to be better communicators because we cultivate the skill. We tend to get more practice in this department. Alas, these instructive and diagnostic tools only rarely earn us the financial remuneration we deserve. Now, I’m not saying generalists are better. I’m just saying we don’t deserve any less respect—or pay—because our skills happen to be broader-based and our training less competitive. Sure, the up-front schooling isn’t as rigorous so it’s only fair we not earn as much in the early half of our careers. However, by the time we’re 20 years in and we generalists have accumulated more of our less technical, but nonetheless “specialized,” expertise, both pay and respect should ideally even out between the two groups, and they don’t. In fact, our earning potential maxes out more quickly than that of our specialist counterparts, and the economic outlook of the specialist thoroughly outpaces that of the generalist at every turn. Some will argue that a specialist’s greater economic investment early on in their careers well justifies the long-term economic disparity between the groups. Here is where I diverge from the conventional wisdom: Specialists may deserve to make more, but not to the extent they do. This brings me full circle back to the notion of respect: respect for experience, respect for softer skills, and respect for the kind of specialized work generalists arguably have to work harder to maintain given the breadth of their knowledge base. I’m sure plenty of you will disagree, especially regarding the economic argument. Thankfully, I’m not alone in my take on the economics. Indeed, there’s a huge body of research into human healthcare delivery that supports this contention and, what’s more, argues it is precisely this disparity that is at the root of human medicine’s current failure to deliver care equitably, affordably, efficiently, and effectively. And veterinary medicine can’t be too far behind. Patty Khuly, VMD, MBA, runs a small animal practice in Miami and is available at drpattykhuly.com. Columnists’ opinions do not necessarily reflect those of VPN Plus+.

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The fight between generalists vs. specialists

A look at the misguided and unfair under-appreciation of general practice in vet med

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