Is there a history in healthcare fragmentation?

So often individuals look back in time and imagine that those much earlier years had a golden quality to them. It is almost always with the passing of time that our imaginations suggest that at some earlier point life was simpler and more fulfilling. The past is often viewed that way in our healthcare experiences too. Critics today point to the fragmentation impacting healthcare as one of the primary lesions contributing to both patient, family and physician dissatisfaction.


My years of practice at the Mayo Clinic provided me with opportunities to read may of the aphorisms of the Mayo brothers, both Charles and Will. One I read just this week again, caught my eye and thoughts as I was working to help solve healthcare fragmentation. During 1928, Charles H. Mayo wrote the following, “If we carry our specialty training too far, uneducated cults slip in.” This was at a time that medicine had two recognized specialties, ophthalmology and otolaryngology, and the American Medicine Association (AMA) published a document for the first time on the “Essentials of Approved Residencies and Fellowships.” This of course was before the Accreditation Council for Graduate Medical Education (ACGME) was established; the ACGME now oversees residency and fellowships in 180 accredited specialty and subspecialty programs. 

When one reflects on the two specialty programs established in 1928, and the number we have 90 years later, it seems that one of the causes of fragmentation may be looking back at us via the 180 ACGME-accredited programs training physicians in narrower and narrower specialty niches. As example, one subspecialty in internal medicine requires training first in the core internal medicine, then in cardiovascular disease (cardiology), then finally in advanced heart failure and transplant cardiology. Having practiced for many years inside large academic healthcare systems with substantial patient care complexity, the need to have true experts in complex organ system care is understandable, yet what is often the risk of that approach, is that the oneness of an integrated human being is set aside, while the diseased organ technical experts are increasingly focused on that single aspect (organ) of the individual. The real risk is that our humanity – as evidenced by our values and goals - is placed second to the diseased organ’s care.  

When we have 180 specialties and subspecialties being trained in 21stcentury medicine, the pull toward narrower and narrower niches of expertise is powerful. Our need is for integration of the human-side of decision making with a true patient (individual) focus. Our individual organs – diseased or not – are simply one part of our integrated whole; that is where our dignity is found.