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A Generalist in an Age of Specialization

November 6, 2011

Last week I had the opportunity to attend the 6th Canadian Conference on Dementia (CCD) in Montreal.  Like its predecessors it was a fabulous meeting.  The two co-chairs, Ron Keren and Sandra Black, did a phenomenal job, and attracted many of the top people in the field as participants.  I am very interested in dementia, and in fact work in a Memory Clinic in Toronto on a weekly basis.  However, I was clearly several levels below many of the participants in my knowledge and expertise in the field of dementia.  This is in fact not surprising, as I subspecialized in Geriatric Medicine because I wanted to focus on all of a person’s problems, rather than those caused as a result of dysfunction in a single organ system.  However, that more diffuse focus comes at a price.  My hospital just attracted a new behavioural neurologist just out of her research fellowship.  This is in fact her first full time job, and yet she is far ahead of me in the dementia field.  This made me a bit uncomfortable at first, but I have reconciled myself to my place in the field.

However, knowing my own inferior level is one thing.  What would really upset me is the thought that I am providing second rate care for my patients at the memory clinic.  However, I do not think that I am, and my experience is possibly generalizable to other fields.  First, there is evidence going back to the 1980’s from Seattle that general medical optimization of patients (most of whom are elderly) with dementia improves cognitive function, often for a prolonged period.  This is what I bring to the clinic, however, I think I provide good assessments of patients with dementia as their only active issue as well.  How am I able to accomplish this?  By working closely with the experts.  As a group we have decided on a standardized way to approach both the history and cognitive testing.  I am constantly cued to ask the right questions by a template created by a more expert colleague (thank you David Tang-Wai).  But the real power comes from the interprofessional conference after the clinic has ended.  Detailed case discussions with a neurologist, geriatric psychiatrist, and allied health, means that all aspects of the case are reviewed before a diagnosis and plan of action are put in place.  The learning opportunities for the non-expert such as myself are enormous, and are particularly valuable because of their clinical relevance.  I have learned more at these conferences than reading journals or even attending the CCD.

Is this model generalizable?  I think so.  Just considering two of the major issues facing our older patients, diabetes mellitus and congestive heart failure, leads to obvious areas where geriatricians, general internists, and family physicians could work side by side with specialists and make an important contribution, and on occasion even improve the quality of care.  An example of the latter effect would be the work of George Heckman showing the high prevalence of cognitive impairment in a heart failure clinic.  Often treatment failure in such a setting requires alternate means of ensuring medication adherence (dosettes, blister packs, supervision), rather than increasing medication dosage.  The ability to learn from each other can also improve care in other settings as well. 

Still, I had better learn a bit more to avoid embarrassing myself in front of junior colleagues!

Regards,

Barry Goldlist