Everyone needs to go to the doctor at some point in his or her life. If there is a complicated medical situation, they are referred to a specialized doctor. Sometimes, general practitioners cannot make the right diagnoses. Many patients are lost between different physicians and their views on a specific case. It raises this question: is there an overspecialization problem in medicine? Is it good or bad to have so many specialties and even subspecialties? Does specialization in medicine help to get better care for patients? Does it help physicians to practice more effectively? Is there enough cooperation between physicians?

A medical specialty is a branch of medical practice that is focused on a defined group of patients, diseases, skills, or philosophies. Examples include children (pediatrics), cancer (oncology), laboratory medicine (pathology), or primary care (family medicine). After completing medical school, physicians or surgeons usually further their medical education in a specific specialty of medicine by completing a multiple-year residency to become a specialist. This is a very long and difficult process: it takes around 4-8 years to finish medical school depending on the school and country and then around 3-5 years to specialize in an area depending on the specialty.

Medical specialties can be classified by the following categories:

• Surgical or internal medicine: Surgical medicine generally means that diagnosis and treatment are achieved through major surgical techniques. In internal medicine, the main diagnosis and treatment is never major surgery.
• Age range of patients: The age range of patients seen by any given specialist can be quite variable (pediatrics, geriatrics, etc.).
• Diagnostic or therapeutic: While the diagnostic process is of great importance in all specialties, some specialists perform mainly or only diagnostic examinations, such as pathology, clinical neurophysiology, and radiology.
• Organ-based or technique-based: Many specialties are organ-based. Many symptoms and diseases come from a particular organ. Others are based mainly around a set of techniques, such as radiology, which was originally based around X-rays.

According to the American Board of Medical Specialties, there are 24 different specialties in medicine. Among these, many of them—such as internal medicine, pediatrics, family medicine, dermatology, etc.—have subspecialties. For example, internal medicine has 22 subspecialty areas, and pediatrics has 20 subspecialties. Even some of the doctors who have been specialized in these subspecialties have been specialized in more specific areas like an internal medicine doctor who has been specialized in cardiology and then specialized in cardiac arrhythmias. 

In the past, there weren’t as many specialist doctors, but specialist-driven care has now become a fact of medical practice. In the past decade, the probability that a visit to a physician resulted in a referral to a specialist has nearly doubled, from 5% to more than 9%. Referral rates to specialists are estimated to be at least twice as high in the U.S. as in Britain.

The past half-century has witnessed great changes in American medicine. One of the biggest shifts is this rise of specialists. In 1940, three-quarters of America’s physicians were general practitioners. By 1960, specialists outnumbered generalists, and by 1970 only a quarter of doctors counted themselves general practitioners. There are a multitude of factors causing the increase in specialization, like earning potential, quality of life, and prestige.

Patients with multiple chronic diseases are not an anomaly, and the number of the patients who have more than one disease has been increasing. One of the main causes for the increasing number of patients is because we now have more effective diagnostic techniques. Recently, a group of researchers in Scotland examined the healthcare usage of 1.7 million people, nearly a third of the country. Their findings, published in the prestigious medical science journal The Lancet, suggest that 23% of Scottish people have multimorbidity, roughly the same percentage as in the United States, and that this percentage increases drastically as people age.

By age 65, the average person has two or more chronic diseases, and people living in poverty reach this mark nearly 10 years earlier. As both the percentages of the population living in poverty and over 65 years of age continue to rise, handling patients with multiple chronic ailments become more complicated and requires more specialists.

The researchers looked for differences in treatment and outcomes among Medicare patients hospitalized for heart attack, heart failure, or cardiac arrest when the American Heart Association and American College of Cardiology held their national meetings compared with identical non-meeting dates. Their retrospective data set spanned 10 years (2002 to 2011). They found “substantially” lower adjusted 30-day death rates among high-risk patients with heart failure or cardiac arrest admitted to teaching hospitals during meeting dates. For heart failure, the death rate was 17.5% during meeting times vs 24.8% during non-meeting times. For cardiac arrest, the rates were 59.1% and 69.4%, respectively. For high-risk patients admitted to teaching hospitals with acute myocardial infarction, 30-day mortality rates were similar between meeting and non-meeting dates, at 39.2% and 38.5%. Fewer PCIs (Percutaneous Coronary Intervention—formerly known as angioplasty with stent) were performed during meeting dates (20.8% vs. 28.2%), “without any detriment to survival,” a finding that “suggests potential overuse of PCI in this population,” the authors said in a paper released online on December 22 in JAMA Internal Medicine.

Some researchers resemble the health care system to the “pin factory” model of Adam Smith. According to this model, which Smith tells in an anecdote on the first page of his The Wealth of Nations, the division of labor is the main cause of prosperity. He asserted that ten workers could produce 48,000 pins per day if each of eighteen specialized tasks was assigned to particular workers. Average productivity would be 4,800 pins per worker per day. Without the division of labor, a worker can hardly produce even one pin per day. This example shows the increased productivity and effectiveness after specialization.On the other hand, we also need to see the whole picture especially regarding patients with multiple medical conditions. Otherwise, as in the parable of the blind men and the elephant, we can have only partial diagnosis and cannot provide patients with a wholesome healing.Fethullah Gülen, a contemporary Islamic intellectual, said that the profession of medicine is very important, and it is one of the best and most direct ways to help people and earn God’s pleasure. He also points out the problem of being lost in medical specialization: “We cannot look at a person by separating heart, head, or nervous system from one another… The organism is a whole, and each organ is in connection with the other. Then we need to take a wholistic look – a heart doctor should know the other parts of the body as well as the heart so that she/he can reach more accurate conclusions.”

Information in the medical arena is growing very fast, and technology is rapidly changing. As the technology develops, new techniques are being introduced in thousands of medical publications. It is impossible for doctors to keep up with all of these developments. But they are in a position to evaluate the standards of practice, review advances in technology and science—and changes in regulation and delivery systems—and adapt themselves accordingly. Physicians have to be supported throughout their careers with innovative programs that help early-career physicians further research, connect physicians with emerging scientific studies, and practice relevant continuing medical education, as well as recognizing the work physicians are doing to improve health care safety and quality.

In conclusion, specialization in medicine is very important, but this specialization should not turn into a form of alienation from other departments, and doctors should not miss the general points. They must work in coordination with other doctors through extensive consultation.

References

• Cambridge University Press. (2009). Cambridge academic content dictionary, 2
• https://www.econlib.org/library/topics/highschool/divisionoflaborspecialization.html
• https://en.wikipedia.org/wiki/Medical_specialty
• https://www.abms.org/wp-content/uploads/2020/11/ABMS-Guide-to-Medical-Specialties-2020.pdf
• 2018 May; 10(5): e2720. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067811/
• https://www.theatlantic.com/health/archive/2012/07/our-unsustainable-culture-of-medical-specialization/260504/
• https://www.herkul.org/kirik-testi/husn-u-zan-ve-rahmete-iltica/

Our hands are vital for performing tasks throughout our daily lives and must be taken care of and cleaned regularly. They can easily spread germs, bacteria, or viruses such as Covid-19 (Coronavirus). Coronavirus has spread rapidly throughout the entire world in the past few months and health officials are very adamant that hand hygiene can help prevent further escalation of the virus. The reason is simple; viruses can spread from our hands to other objects that we touch, to which other people can touch those same objects and possibly contract the virus by putting their hands on their face. According to the World Health Organization, proper hand sanitation that uses alcohol-based rub or hot water and soap can kill Coronavirus and other viruses [1].

For some people, such as healthcare professionals, there are actually major consequences for neglecting hand hygiene. For example, the dirty hands of these professionals have a negative impact of 40% in the transport and spread of resistant microorganisms among patients. Hospital infections are actually among one of the main catalysts for increased disability and death rates in hospitals, along with additional healthcare costs [2]. In the United States, 1.7 million patients develop health-related infections every year, and 100,000 of them die. This increases the length of hospital stay by 20 times and the cost of treatment by 5 times [3].

It was not until the 19^th century that we began to understand that infectious diseases can be prevented by washing our hands. In the middle of the same century, the pioneer of antiseptic processes, known as the “savior of mothers,” Hungarian physician Ignaz Semmelweis, showed that microorganisms could be transmitted to patients via the hands of medical staff. This discovery began a new era of hygiene and healthcare. It is now well known that microbes reproduce rapidly, and that it is possible to prevent the spread of disease by keeping the hands and body, which is possible by following personal hygiene rules.

Hand hygiene is maintained in different ways in modern medicine. In daily life, washing hands with soap and water to remove dirt is called “social hand washing.” Common examples include washing after a meal and when visiting the toilet. For this purpose, it is sufficient to rub the hands and fingers for 15 seconds with a non-antimicrobial feature soap, rinse, dry with a disposable towel, and turn off the tap with a towel. Cloth towels used by many people in public places are not considered suitable for hygiene.

The more serious and professional form of hand washing is “hygienic hand washing,” where antimicrobial soaps are used in the washing process before and after contact with patients and bodily fluids. Other hand hygiene methods during surgical operations cover applications where alcohol-based 3-5 ml hand-disinfectant is rubbed until dry along with hand disinfection and surgical hand antisepsis, which includes washing the hands, including the forearms, with chemical solutions such as soaps, isopropanol, chlorhexidine specifically produced for this purpose for 2-3 minutes, and later wearing sterile gloves until the end of any procedures.

The World Health Organization published a guide on proper hand hygienics and explained when, how often, and how healthcare providers should wash their hands [4]. Despite the development of various programs and policies, especially hand hygiene, and increasing material expenditures in the fight against infections observed in health services, the control of infections remains well below the desired level.

Today, research also looks at the effects of hand washing on individual psychology. An experiment carried out by two psychologists from the University of Michigan, Spike W.S. Lee and Norbert Schwarz, shows that hand-washing reduces this classic post-decisional dissonance effect:

In individual sessions, 40 undergraduates browsed 30 CD covers as part of an alleged consumer survey as if they were in a music store. They selected 10 CDs they would like to own and ranked them by preference. Later, the experimenter offered them a choice between their 5th and 6th ranked CDs as a token of appreciation from the sponsor. Following the choice, participants completed an ostensibly unrelated product survey that asked for evaluations of a liquid soap; half merely examined the bottle before answering, whereas others tested the soap by washing their hands. After a filler task, participants ranked the 10 CDs again, allegedly because the sponsor wanted to know what people think about the CDs after leaving the store.

For those who merely examined the soap, the preference for the chosen over the rejected alternative increased from before choice to after choice by an average of 1.9 ranks, replicating the standard dissonance effect. In contrast, for those who washed their hands, preferences were unaffected by their decision. Thus, handwashing significantly reduced the need to justify one’s choice by increasing the perceived difference between alternatives. “Washing one’s hands after making a choice eliminates post-decisional dissonance effects, suggesting that hand-washing psychologically removes traces of the past, including concerns about past decisions” [5].

In another study conducted in 2008, Schnall, et. Al. “hypothesized that physical cleanliness reduces the severity of moral judgments. In support of this idea, they found that individuals make less severe judgments when they are primed with the concept of cleanliness and when they wash their hands after experiencing disgust” [6]. This effect of hand washing, which relieves conscience, is called the “Macbeth Effect.”

Washing hands is one of those simple but compulsory practices we tend to take for granted and lose interest in as we progress in science and education. Simple practices like using each of our hands for different purposes and frequent hand-washing will surely contribute to the fight against healthcare infections and infectious diseases that threaten public health.

There are several traditions of Prophet Muhammad, peace be upon him, in which washing hands is strongly emphasized.

“The blessings of food lie in washing hands before and after eating.”

“Wash your hands after you wake up; you do not know where your hands have moved while you were sleeping.”

The Prophet advised using each hand for different tasks. It is narrated that his wife Aisha said: “The right hand of the Messenger of God (peace be upon him) was for his purification and food, and his left hand was for using the restroom and anything that was dirty.”

Notes

1. “Advice for Public.” World Health Organization, World Health Organization, www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public.
2. Pittet D, Allegranzi B, Storr J, Donaldson L. Clean care is safer care: the global patient safety challenge 2005-2006. Int J Infect Dis. 2006; 10(6): 419–24.
3. Allegranzi B, Storr J, Dziekan G, Leotsakos A, Donaldson L, Pittet D. The first global patient safety challenge “Clean care is safer care”: from launch to current progress and achievements. J Hosp Infect. 2007; 65(Suppl. 2): 115–23.
4. WHO Guidelines on Hand Hygiene in Health Care, www.who.int/gpsc/5may/tools/9789241597906/en/
5. Lee SW, Schwarz N. Washing away postdecisional dissonance. Science. 2010 May 7;328(5979):709. doi: 10.1126/science.1186799.
6. Schnall S, Benton J, Harvey S. With a clean conscience: cleanliness reduces the severity of moral judgments. Psychol Sci. 2008 Dec;19(12):1219-22. doi: 10.1111/j.1467-9280.2008.02227.x. Also see https://psycnet.apa.org/fulltext/2014-20922-011.html in which Johnson, D. J. et. al. suggest that “researchers investigating the connections between cleanliness and morality should therefore use large sample sizes to have the necessary power to detect subtle effects.”