Elementary concepts of medicine: XII. Specialties of medicine, genuine and other

In the preceding essays on concepts of medicine the focus has been on such concepts as are of orientational relevance irrespective of one's specialty in medicine. The predicate in this has been that modern medicine is a set of specialty disciplines, and that cross-specialty concepts constitute an introductory component of the educational preparation for scientific practice of modern medicine – of the preparation within 'the medical common', before studies specific to the student's chosen specialty (Miettinen & Flegel 1992; Miettinen 2001a). Eminent among the cross-specialty concepts is 'naturally' that of medical specialty itself, relevant in the selection of specialty for a start. We have already set forth that a doctor in whatever specialty of medicine, in our opinion, is a learned professional engaging in gnosis and on this basis teaching the client about their own health (Miettinen 2001b; Miettinen & Flegel 2003) – in practice, in this meaning of 'practice'. Our medical dictionaries define the concept of practice specialty as: 'the field of practice of . . . a physician whose practice is limited to a particular branch of medicine or surgery, especially one who, by virtue of advanced training, is certified by a specialty board as being qualified to so limit his practice' (Dorland 1994); or 'the particular subject area or branch of medical science to which one devotes professional attention' (Stedman 1995). As for these two definitions, we first dismiss that reference to surgery in the first definition, as our concern is with specialties of medicine all of which are, by our conception of medicine, concerned with gnosis and its associated teaching of the client (cf. above); and by the same token, we disregard the reference to 'medical science' (Miettinen 2001c) in the second definition. This said, the first definition makes the essence of specialty to be a branch of medicine to which practice may be limited – as a privilege that may require certification of qualification. The second definition seems to accord with this, with branch of medicine expressed by 'particular subject area' and limitation by 'devotion.' We regard this concept of medical specialty as untenable. In other types of profession, and in medicine likewise, we take specialty to be not one of possible focus but of possible special expertise, special competence – with or without certification or other recognition of this virtue when it is actually possessed by someone. A person with special expertise in a given specialty area of medicine has, in that area, a higher degree of expertise than a colleague without that special expertise. In accord with this, the Royal College of Physicians and Surgeons of Canada certifies subspecialists for 'special competence' in their respective specialties (Royal College of Physicians and Surgeons of Canada 2001), and not merely as 'being qualified to so limit his practice' (Dorland 1994) or as having the 'particular subject area . . . to which one devotes professional attention' (Stedman 1995). Mere limiting or devoting one's practice to a given area does not require qualification or certification. Given the concepts of doctor's specialty above, including our conception of it, it is of interest to examine the current set of specialties and subspecialties of 'medicine and surgery'. Those now official in Canada are listed in Table 1. As for the most fundamental specialty distinction in medicine, that between clinical medicine and community medicine, it is striking to note that whereas the former, as such, is nobody's specialty, the latter is. Why is it, we wonder, that with the possible exception of occupational medicine there are no specialties within community medicine? If community medicine is equated with epidemiology, as well it might be, is not infectious disease epidemiology highly differentiated from cancer epidemiology, for example? And whereas type of intervention is a basis of clinical specialties, as in 'physical medicine and rehabilitation', why is it, most notably, that health education is not a specialty of community medicine? The specialty of 'community medicine' can only stand for 'general community medicine'. A related point of note: general clinical medicine should be seen as an important specialty, but it is not among the specialties in Table 1, not as such nor under any misnomer. Another conspicuous feature of that list of specialties is the presence of 'medical biochemistry' and 'medical microbiology'. These fields do have a natural existence, of course; but are they specialty fields for physicians – any more than are, say, medical statistics or health economics? In the framework of medical practice, these two fields are directed to gnostic fact-finding rather than gnosis itself; they are laboratory specialties without direct interface with the client, the latter being characteristic of clinical practice. The same reservation applies to 'diagnostic radiology', though not quite as obviously. The analogy is complete insofar as this specialty supplies diagnosis-relevant facts, including the feature that the facts, in radiology abstracted from images, are derived without direct interface with the client. Confusion arises from a notable cultural aspect of radiology: the radiologist, so different from the biochemist or microbiologist, is prone to translate the specialty's intrinsic facts, divorced from other diagnostically relevant facts, to diagnosis. To the extent that this is diagnosis, it is not clinical but laboratory diagnosis, in this respect akin to diagnosis in the pathology specialties. The important difference is, however, that radiologic facts are not illness-definitional, while pathologic facts commonly are. The several 'surgery' specialties call for attention to the concept of surgery, which is defined in medical dictionaries as: 'that branch of medicine which treats diseases, injuries, and deformities by manual or operative methods' (Dorland 1994); or 'the branch of medicine concerned with the treatment of disease, injury, and deformity by operation or manipulation' (Stedman 1995). So, according to these sources, surgery indeed is not lateral to medicine, contrary to what is implied by 'medicine or surgery' (Dorland 1994), and by 'physicians and surgeons' (Royal College of Physicians and Surgeons of Canada 2001); it is a 'branch' intrinsic to medicine. That its concerns relate to all three of the principal types of illness while the general mantra in medicine is 'disease' represents nothing definitional to surgery, only ingrained error in that general idea. Obviously definitional is the surgical genre of interventions, specifically of treatments according to those definitions; but in what particular sense? The first definition seemingly makes surgery the branch that carries out such treatments, the second the branch that is 'concerned with' such treatments. As for the latter, various non-surgical specialties of medicine are concerned with surgical options in intervention. And as for the former: the surgeon is expressly concerned with gnosis, first and foremost prognosis in respect to the effects of surgical intervention but to some extent with diagnosis also (as in exploratory laparatomy); and besides, the surgeon acts as a doctor, teaching the clinical client about the client's own health, notably its dependence on surgical intervention – and the non-surgical colleague is similarly a recipient of the surgeon's intervention-prognostic teaching. Overall, it is apparent that the concept of medical specialty per se, and secondarily the conceptualization of a justifiable set of specialties, remain in need of serious thought. These topics are important, given that each practitioner of modern medicine actually practises a particular specialty of it.

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