Do we need lumpers or splitters in Pulmonary Practice?

Pulmonary Medicine is the subspecialty of internal medicine (even we can call it as super-specialty) that focuses on the diagnosis and management of disorders of the respiratory system, including the lungs, upper airways, thoracic cavity, mediastinum and chest wall. Although most common respiratory problems are treated by general internists and other specialty physicians, those practicing pulmonary medicine (often referred to as “pulmonologists”) are frequently called upon to help diagnose unknown disorders and assist in managing difficult, unusual, or complicated diseases of the respiratory system.  

There is an unfinished debate on the issue of treating pulmonology as a sub- (or super-) specialty of medicine. Why I call it subspecialty is that it is an integral part of internal medicine, not separated, but deals with science of respiratory system. In that count cardiology, neurology, nephrology etc. are also sub-specialties. Basic knowledge of medicine is essential to practice these subspecialties. In the United States, an applicant for a fellowship in pulmonary (or any other sub-specialty) must be previously certified in internal medicine by the American Board of Internal Medicine (ABIM). This is also the case in India for super-specialties, such as Cardiology, Nephrology, Gastroenterology, Neurology and others.

Pulmonologists have expertise in structural, inflammatory, infectious, and neoplastic disorders of the lung parenchyma, pleura and airways, pulmonary vascular disease and its effect on the cardiovascular system, and detection and prevention of occupational and environmental causes of lung disease. Diseases commonly evaluated and treated by pulmonologists include asthma, chronic obstructive lung disease (COPD), lung cancer, interstitial and occupational lung diseases, complex lung and pleural infections including tuberculosis, pulmonary hypertension, and cystic fibrosis. Some pulmonologists focus on sleep-disordered breathing (such as sleep apnea) and may provide diagnostic and therapeutic services in sleep laboratories. 

Even though, we have our subspecialty named as pulmonology or Pulmonary Medicine, there is a trend among our colleagues to further split the specialty. In 1960s and 70s, Internal medicine or general medicine suffered from this splitter syndrome, wherein most of the specialties started separating from the parent discipline and started independent practice. Now almost all diseases are shared by these splinter groups and M D in general medicine is like a “glorified MBBS’. This has a long-lasting impact in a country like India where family practice or general practice (GP) is not mandatory for specialty consultation. This was welcomed by all doctor groups looking at the lucrative names and the fame attached to it, ignoring the fundamental principles of medical practice. The terms used by our colleagues as intensivist or interventionist point to such a phenomenon in pulmonary medicine and I am afraid that history is being repeated.

I am writing this based on my recent experiences while formulating a scientific programme for the just concluded Napcon 2019 at Kochi. As you all know preparing a scientific programme of that magnitude was a herculean task. I have done my level best to invite topics in each subcategory from colleagues working in different capacities. To my surprise I got very good topics worth of three Napcons. I had to spend a lot of time to carefully select the best out of that and to fit in to the scientific programme. Then the task is to allot topics to appropriate faculty. Two organizations representing pulmonologist of India are responsible for conducting Napcon. Preferences in selection of faculty will always be there and as organizing team we must respect these rules. We had about 350 to 400 faculties in the wish list. Out of these some 30% faculties are known to me and the rest are not in my remote sense. Allotting topics to these faculties is always going to be a problem unless their interests and preferences are known. What we have done next is to send e mails to all prospective faculties to inform us about their preferences and choices of topics. Only 20 % faculties responded and since we are bound to respect the timelines also, topics were randomly allocated to faculties.

Now the real problem surfaces, as mails started flowing saying that the topic allotted to them are not according to their interest or field of practice. Few replies really shocked me. One was like this. “The topic allotted to me for a guest lecture is foreign to me. I am in no way related to this topic and I regret to inform that I cannot take up this assignment”. I looked up at the qualification, designation and affiliation of this faculty. He is a fully qualified professor in a reputed national institute teaching both undergraduates and postgraduates.

This really disturbed me a lot. If a section of Pulmonary Medicine is ‘foreign’ to a professor of a medical institute, how the teaching in that department goes. During discussion in a postgraduate symposium, if this topic is brought in what will be the response of this faculty. Forget about postgraduates, undergraduate teaching is to be a little broader and if one aspect is not touched by a faculty, how are we going to complete the teaching.

This is where lumping and splitting comes. Both have its own merits and demerits, especially in science. As per Wikipedia definition, a "lumper" is an individual who takes a gestalt view of a definition, and assigns examples broadly, assuming that differences are not as important as signature similarities. A "splitter" is an individual who takes precise definitions and creates new categories to classify samples that differ in keyways. There are lumpers, who like to group things into broad categories, and there are splitters, who divide things into smaller categories. Splitting often leads to “distinction without difference”, ornamental or fussy categories, and failure to see underlying similarities.

When we look at the history of training in Pulmonary Medicine, it started with a course of diploma in tuberculosis after the degree of under graduation (MBBS) to tackle the problem of tuberculosis. Later, this diploma course was upgraded to the degree of MD (Tuberculosis and Chest Diseases) to tackle the high incidence of pulmonary tuberculosis. As the time went on, when specialized work started then we tried to ignore the basic things and concentrated on sophisticated work. This is the inherent issue when we start splitting everything in small specific compartments. What has happened to tuberculosis now, will happen to pneumonia, asthma or COPD in future.

We should never be ignoring the basic sciences, because we have sophisticated equipments and other paraphernalia to take care of. A pulmonologist these days need to engage with a bit of several other sub-specialties, especially rheumatology and immunology, cardiology and cardiothoracic surgery, environmental and occupational medicine, aviation and diving medicine, oncology, sleep medicine and many others. Respiratory critical care is a major component of pulmonary medicine. It includes the mandatory components of cardio-pulmonary resuscitation, intubation and mechanical respiratory supports. Lungs constitute an important target of damage of most of the life-threatening diseases with mechanical ventilation as the prime focus of critical care management. It is, therefore, important to include critical care as an integral component of pulmonology subspecialty programmes.

Every institute taking up postgraduate training in Pulmonary Medicine should have all facilities to train the students to equip them to meet the challenges of practice. Trained specialists should undergo continuing medical education periodically to abreast their knowledge or participate in hands on workshop to improve their skills. This will prepare them to become a ‘complete specialist’ confident enough to meet any challenges in clinical medicine. It is an insult that a qualified postgraduate is not trained in bronchoscopy or thoracoscopy during their course. Many institutes have now started fellowship in critical care, intervention, allergology etc. to compartmentalize the specialty. Those who acquire this fellowship would love to call them as specialist in that category and their knowledge and practice get narrowed down. This is the main demerit of splitting.

I consider that Pulmonary medicine, whether a subspecialty or super-specialty, remain as a single discipline. We don’t promote splitting it up as intensivist, interventionist, allergologist etc. Tuberculosis shall continue to bother pulmonologists more than the internists and other specialty physicians. Pulmonogists must engage themselves with TB and RNTCP as one of their prime curricular and practice needs. A pulmonologist should also possess the skill to perform diagnostic tests and therapeutic interventions in addition to the cognitive knowledge of diseases and their management. All fellows in pulmonary medicine should be able to identify and manage all pathological conditions related to this specialty and try to get an integrated approach when multiple specialist services are needed. One should be able to treat tuberculosis, ARDS or tracheal tumors with the same spirit and vigor. Let us be lumpers rather than splitters. That is good for the specialty too.

Further reading

1.     1.  Jindal SK. Pulmonary training facilities in medical colleges in India. Indian J Chest Dis & Allied Sci 1989; 31:295-98.  

2.     2.  HS Hira. Training of pulmonary medicine in India. Lung India 2006; 23 (3):132.

3.    3. American Board of Medical Specialties/Internal Medicine/Pulmonary diseases. Available from URL: www.abms.org (Accessed on March 16, 2013).

4.     4. Jindal SK. Pulmonary and critical care medicine: objectives of training (Part I). Lung India 1997; 15:112-14. 

5.      5. Jindal SK. Pulmonary and critical care medicine: curriculum and evaluation (Part II). Lung India 1997; 15:164-67.

6.      6.. Ravindran C: Critical Thinking in Clinical Practice; Pulmon 2006; 8:3:73-75

(Author is presently working as Professor and Head of Pulmonary Medicine in DM Wayanad Institute of Medical Sciences, Wayanad, Kerala. He has worked in the capacity of Principal of Govt Medical College, Kozhikode and Managing Director of Academy of Medicine Sciences, Pariyaram, Kannur. He has 35 years of teaching experience in Pulmonary Medicine. He was the organizing chairman of just concluded Napcon 2019 at Kochi, Kerala)