Subspecialisation in medicine

The explosive expansion of scientific knowledge over recent decades has made it difficult for individuals to stay abreast of a single specialty. This, together with specific developments within certain fields, has established a need for expertise at a subspecialist level. The advantages of this development are that clinicians can concentrate their efforts, linking with experts of similar interests, by journals, meetings and networking databases. Similarly, provided a patient reaches the appropriate subspecialist, they can be sure of up-to-date skilled management by a recognised expert in a centre of excellence. The disadvantages of this trend are the obligatory early entry into specialist training and the inevitable decline of the generalist clinician, increasing the risks of inappropriate diagnosis and inappropriate referral. The introduction of a subspecialty will usually increase overall costs and therefore has to be justified by improved quality of care, while not being detrimental to other aspects of health care delivery. The implications at a national level are on undergraduate as well as postgraduate training, and also on the provision of appropriate funding for the sub-specialty and its infrastructure. Although there are many potential pathways for achieving standards of excellence in medical care, subspecialisation provides one of the most appropriate ways of developing, promoting and expanding a field. Such expansion, however, must be accompanied by thorough audit, to justify its independent existence.