All Hands on Deck: Learning to “Un-specialize” in the COVID-19 Pandemic

Specialization, as detailed in Adam Smith’s 1776 landmark treatise, Wealth of Nations,¹ has been an enduring trend in labor and economics for centuries. Mirroring evolution in other sectors of the economy, the healthcare workforce has become ever more specialized.² General practitioners and family doctors have ceded ground to a bevy of specialists and subspecialists ranging from pediatric endocrinologists to otolaryngology-neurotologists. Given the growth in medical knowledge over the past century, this specialization seems both necessary and good. This same specialization that serves us in good times, though, leaves us woefully underprepared for an epidemic that will require large numbers of hospitalists/generalists and intensivists, such as the current coronavirus disease 2019 (COVID-19) pandemic.

A bit on terminology before we proceed. For purposes of this paper we define generalists as physicians trained in Internal Medicine, Family Medicine, Pediatrics, or Med/Peds who provide primary hospital care to adults and children. While some may argue that hospitalists are specialists in inpatient care, we would like to focus on hospitalists as generalists who focus on inpatient care and what we have in common with the broader community of generalists. We include as generalists anyone, irrespective of clinical training, who chooses broad primary patient responsibility over the narrower consultative role. There is always a specialist in our midst who knows more about a particular disease or condition; as generalists, most of us appreciate and welcome that expertise.

Sometimes it takes a pandemic like COVID-19 to highlight a tremendous blind spot in our healthcare system that, in retrospect, seems hard to have missed. What do we do when we need more generalists and have only a surplus of specialists, many of whom were involuntarily “furloughed” by canceled elective procedures and postponed clinics? How do we “un-specialize” our specialist workforce?

We will discuss some of the most pressing problems facing hospitals working to ensure adequate staffing for general inpatient units caused by the simultaneous reductions in physician availability (because of illness and/or quarantine) and markedly increased admissions of undifferentiated COVID-19–related illnesses. We will assume that hospitals have already activated all providers practicing in areas most similar to hospital medicine, including generalists who have mixed inpatient/outpatient practices, subspecialists with significant inpatient clinical roles, fellows, and advanced practice providers (APPs) with inpatient experience. The Accreditation Council for Graduate Medical Education released guidance around the roles of physician trainees during the pandemic.³ Despite these measures, though, further workforce augmentation will be vital. To that end, several challenges to clinical staffing are enumerated below, accompanied by strategies to address them.