Ashok Ogra

At some point in life, everyone requires medical attention. While general practitioners (GPs) provide the first line of care, more serious or complex conditions often require the attention of specialists such as cardiologists, pediatricians, oncologists, gastroenterologists, and urologists. The rise of specialization in medicine has enabled doctors to develop in-depth knowledge within specific fields, resulting in more accurate diagnoses and targeted treatments. This progression is a natural outcome of scientific advancement and has significantly improved patient outcomes.

In recent years, however, the trend has moved further into what is now called ‘super-specialization.’ This is where doctors narrow their practice to extremely specific areas within their field.

Orthopedics provides a telling example of how far specialization has advanced. The field now includes subspecialties such as joint replacement, pediatric orthopedics, sports medicine, spine surgery, hand and micro vascular surgery, orthopedic trauma, musculoskeletal oncology, geriatric orthopedics, and regenerative medicine.

Even within ophthalmology, there are subspecialties with few doctors in specialized eye care centers/hospitals only performing cataract surgery, and letting other doctors handle only retina cases. In fact, retinal surgery is now divided further, with some experts focusing solely on the peripheral retina. A patient with a retinal tear may find themselves needing a different specialist simply because the first one does not deal with that exact area.

Dentistry, too, has witnessed a surge in specialization. The Dental Council of India recognizes eleven postgraduate (MDS) specializations .These include Oral and Maxillofacial Surgery, Orthodontics and Dentofacial Orthopedics, Periodontology, Prosthodontics and Crown & Bridge, Conservative Dentistry and Endodontics, Pedodontics and Preventive Dentistry, Oral Medicine and Radiology, Public Health Dentistry, Oral Pathology and Microbiology, Sports Dentistry, and Forensic Odontology.

This kind of compartmentalization is not limited to allopathic medicine alone: even Ayurveda, a system traditionally associated with holistic healing and general care, has embraced this trend. Dr. Sajna Ali of Ayurnava Ayurveda informs that various specializations are now offered under MD and MS three-year courses. For instance, Bala Roga refers to Pediatrics, Kayachikitsa to Internal Medicine, and Prasuti Stri Roga to Gynecology and Obstetrics. Those specializing in surgery earn an MS in Shalya Tantra. Plans are also underway to introduce super-specialized DM programs in areas such as psychiatry, reproductive medicine, orthopedics, oncology, gerontology, and hematology.

While such specialization improves precision and often leads to better outcomes, it can also create silos. Super-specialists often hesitate to step outside their narrowly defined domains, resulting in fragmented care. Patients with multiple health conditions can find themselves navigating a maze of doctors, each focused on a single organ system or disease, with no one looking at the bigger picture. This is especially problematic for elderly patients, who typically require a holistic and coordinated approach to their health. In a typical hospital scenario, a single patient might be managed simultaneously by a cardiologist, a nephrologist, an endocrinologist, a gastroenterologist, and an infectious disease specialist. Despite the individual expertise, no single doctor takes responsibility for the patient’s overall well-being. This lack of integration can result in conflicting recommendations, repeated investigations, and mounting stress and costs for patients and their families.

A report published by The Guardian, London raised concerns about this trend, faulting modern medicine for treating patients as isolated cases rather than as whole individuals. It emphasized the need for medical training that enables doctors to assess patients comprehensively, not just within the narrow boundaries of their specialty.

In earlier decades, physicians tended to be more generalist. They collaborated across specialties, discussed diagnoses and treatments with peers, and often shared responsibility for patient outcomes. Today, however, such collaboration is not just rare but sometimes actively discouraged. An ICU doctor who raises concerns outside their specialty may be seen as overstepping; a urologist who identifies a bladder mass as tuberculosis rather than cancer may be reprimanded for making a diagnosis deemed outside their domain. The result is a rigid compartmentalization of knowledge and authority that sidelines broader clinical insight and promotes excessive testing and referrals.

Despite these drawbacks, super-specialization continues to thrive, and for good reason. Specialists offer a higher degree of accuracy in diagnosis and treatment, which can lead to better patient outcomes, shorter hospital stays, and more efficient interventions. Their focused expertise is especially critical in rare or complex cases where generalists may lack the depth of knowledge required. Moreover, many medical breakthroughs and innovations have emerged precisely because of the intense focus that specialization demands.

However, this fragmentation of care leaves patients in a difficult position. One of the most significant dilemmas they face is how to make informed decisions when they lack the medical background to evaluate or reconcile differing medical opinions.

In addition, there is also the fact that our society is becoming excessively medicalized. And that reminds us of Austrian theologian, philosopher and social critics, Ivan Illich who made a searing critique of modern medicine in his book Limits to Medicine: Medical Nemesis. Published in late 1970s, the book refers to the medical establishment that has evolved into a major threat to health itself. Illich believed that medicine was undermining natural healing processes, eroding personal autonomy, and turning health into a domain monopolized by professionals and institutions.

Noted health expert Vinesh Kumar points out that society increasingly assumes a person is ‘ill until proven healthy.’ Tracing the etymology of the word “health,” he notes that it once meant “whole,” “holy,” “uninjured,” and “to heal.” It is only in the last century that the term has come to signify a clinical absence of disease-a narrow, often mechanistic view.

The need, therefore, is to treat patients as integrated wholes. The human body is not a machine made up of discrete parts; it is an interconnected, dynamic system influenced by biology, psychology, and environment.

India presents a unique case in this regard. Unlike many Western countries that operate through structured referral systems, patients in India often consult specialists directly, bypassing general practitioners altogether.

There is also the issue relating to unethical practice that few doctors indulge in. As pointed out by noted cardiologist Dr.Upendra Kaul, in his critically acclaimed book ‘When The Heart Speaks’: “every referred case for angioplasty and angiography used to get a kickback of Rs.5000 and Rs.15, 000 respectively. In fact, seeing this trend, few doctors went a step further and started paying their referring doctors Rs.1 lakh in advance and adjusting it as and when patients came in an ingenious move.” He reminds doctors that their primary duties are to offer comfort and empathy.

To address these issues, there is growing recognition of the need to re-emphasize the role of generalist physicians. Some countries have introduced dual-training programs to develop doctors who are skilled in both general and specialized medicine. These hybrid practitioners can offer a depth of knowledge along with a breadth of vision, helping to bridge the gap between narrow expertise and holistic care. Strengthening general medicine education, improving interdisciplinary communication, and raising public awareness about the importance of primary care can significantly enhance the quality and coherence of healthcare delivery.

The objective should not be to reject specialization, but to balance it with broad-based, integrated, and compassionate care.

Illich’s critique is ultimately a call to rethink our relationship with medicine-not to discard it, but to reclaim health as something that belongs first and foremost to individuals and communities.

However, where one may disagree with Illich is when he says that “modern medicine is a negation of health. It makes more people sick than it heals.” This is certainly a wide misplaced assumption. The average life span has increased from less than 33 years in 1900 to over 70 years now. How else does one explain the almost elimination of dreaded disease such as polio, measles, rabies, guinea worm, malaria etc.? This is essentially because of huge advancements in medical research and invention of more effective drugs, availability of precise surgical tools and adoption of improved diagnostic tests that are available nowadays.

The way forward therefore lies in integration, not opposition. Specialization must be retained for the advantages it brings, but it must also be tempered by systems that emphasize coordination, primary care, and whole-person understanding.

As the old Chinese proverb says, “If there is a headache, examine the feet.” The lesson is simple: the body-and by extension, healthcare-must be viewed as an interconnected whole. Only then can we fulfill the true promise of medicine. Also, aim must be to enhance HEALTH SPAN rather than focus only on extending LIFE SPAN.

(The author works for reputed Apeejay Education, New Delhi.)