MEDICAL SUB-SPECIALISATION. WHERE IS THE END?

Recently, that is sometime in mid-September, the American Board of Medical Specialties (ABMS) has approved a proposal to establish a subspecialty certification in "advanced heart failure and transplant cardiology,". What this means is that, you need to be certified to treat advanced heart failure. So now we need to know the simple heart failures that family doctors can treat, the more severe heart failure ( I suppose those that require hospitalisation ) will need a referral to a cardiologist, and now the more advance ones, that the cardiologist will refer to the cardiac advanced heart specialist. Can you see the problem? Firstly, the various tiers must recognise their limitations? That is difficult enough. Then they must refer appropriately. Then in a country like ours, where there is no sub-specialist certification, what is the " Advanced heart failure specialist " going to do in between the lack of referrals. He will end up seeing all and everything. The Americans sure can subdivide and major in the thinniest.
As it is now, we even have problem getting the medical specialist register up and running in Malaysia. We have a voluntary call to register medical specialist. The Government was suppose to amend Medical Act 1971 to incorporate a section on medical specialist and their requirements. This amendment has now been sidelined, in view of the 12GE and the March 8 event. So as of now. each and sundry, with an MBBS, can do whatever he wishes, until he gets a complaint and legal suit ( which is rare, I hope ). In otherwords, in Malaysia presently, the man in the street decides who is a specialist, and soon, the third party payers, like the insurance, will decide who is a specialist. Looking at the present scenario, it will be quite awhile, before we can follow the Americans with sub-sub specialty specialisation.
Looks like the Americans is partly right, and partly wrong. They are right in the sense that the patients with severe heart failure, may require special devices and pacemakers to improve their quality of life, not necessarily their quantity of life. They are not right in the sense that in the outpatients, the cardiac advance heart failure specialist will get so little work that he will soon lose his skill and be no better than the cardiologist. I suppose, if you are talking about inpatient care of the heart failure patients, in the specialised centers, that sees hundreds of heart failure patients a month, than that kind of sub-sub specialisation makes sense. There must also be some economy of scale, to allow them to keep their skills, in advanced heart failure management.
And of course, there is always the issue of cost. Can you imagine the fees that advanced heart failure specialist will charge? And of course, if we carry their arguement about improve specialised medical care, to the extreme, we will soon see specialist in management of the small toe and the bigtoe, and also specialist in the management of the right coronary artery and the left coronary artery. Where is all this leading us? Is it for the better of the patient and the consumer?