The Specialists.

Patient demand and advancing medicine create narrowly focused doctors.

When a concert violinist needs W a repair on her instrument, she'd probably consult with fellow violinists for the name of a specialist. And when that concert violinist experiences muscle strain in her wrist, she'd probably do the same thing--and probably be pointed in the direction of the Performing Arts Medicine Clinic.

It started simply enough. Fifteen years ago, after seeing an increasing number of musicians with problems somewhat different than his conventional rheumatology patients, Dr. Kenneth Brandt received support from both the dean of the Indiana University School of Music and the dean of the IU School of Medicine to establish the Performing Arts Medicine Clinic at the IU Medical Center. What resulted was a clinic designed exclusively for the diagnosis and treatment of performance-related health problems experienced by professional, amateur and student performing artists.

"It is much more than a clinic. It is really a performing-arts medicine program that deals with performance-related problems of instrumentalists, vocalists and dancers." The clinic is staffed by a spectrum of health professionals, medical doctors and therapists--many of whom are amateur musicians themselves.

The Performing Arts Medicine Clinic joins the many highly specialized health-care facilities in Indiana that cater to a very particular patient need. According to the American Board of Medical Specialties, there are more than 8,000 board-certified medical specialists in Indiana whose practices range from sleep medicine to hand injuries to wounds that won't heal.

And like many of these Hoosier specialty-care centers, the Performing Arts Medicine Clinic has a global reach. "There is relatively a small number of specialty facilities that do this," says Brandt, a musician himself. "It gets picked up on the Internet, and we get calls from Europe and literally around the globe."

He says the clinic can often identify the problem over the phone in speaking with a prospective patient prior to the first visit because many of the problems are instrument-specific. On the initial visit, the patient brings his or her instrument and can meet simultaneously with a number of clinic's specialists.

"We have a rheumologist, a neurologist, a psychiatrist--kept busy particularly with problems with performance anxiety--a hand therapist, a joint specialist, a dental specialist to deal with the blowers, a pediatrician and a social worker for dealing with chronic problems when that is appropriate," says Brandt. "We see a large number of overuse syndromes, muscle strain, soft-tissue problems, rheumatism and carpal-tunnel syndrome. Patients are self-referred as word gets around about the existence of this facility but they are often referred by other musicians who use the facility."

WHY SPECIALIZE?

Advances in technology and medicine as well as patient demand have caused a trend toward medical specialization in the past few decades. Dr. Deborah C. Givan started out in general pediatrics, then became a pulmonologist and then specialized in pediatric sleep medicine. Now she is director of the Children's Sleep Disorders Center in Indianapolis, the only facility of its type in the Midwest. The center has recently expanded to six beds and still has a waiting list. She says during the last 10 years, new sources of information have increased exponentially the knowledge needed to be a physician.

"It is very hard with the amount of information that is not only being discovered but to have access to it from so many sources and to know all those things, and to know them in detail to help people. It is difficult for any one person," says Givan. "What we've done is created a pyramid of information--where you know a lot about one area, less about other areas."

Since opening in 1987 as one of the first in the nation to specialize in pediatric sleep disorders, the Children's Sleep Disorders Center has tested 15,000 patients. At any given time the center is monitoring about 400 babies and youngsters.

"It is a relatively new area of study both in adult medicine and even more in pediatrics," says Givan. "We were one of the first places in the country to start looking at infantile apnea in children and the use of monitors. When I started as a fellow, I would have to push a piece of equipment around to the bedside to do physiological recordings on infants." When she returned as a faculty member, the equipment had developed to be more tailored for children. "We'd bring the patient to a room rather than vice versa."

From sleep apnea, behavioral sleep disorders to narcolepsy, inadequate sleep can be the culprit behind other pediatric problems such as aggressive behavior, attention-deficit disorder and poor school performance. The physical stress of some sleep disorders can contribute to high blood pressure, among other problems, later in life. "There is some evidence to show that, in part, the high rate of suicides and accidents in teenagers is at least tied to sleep deprivation," says Givan.

At the center, brain waves, oxygen intake, respiratory and abdominal wall movement and other parameters are monitored during sleep. "It is really amazing and rewarding when you help a child to achieve his or her potential, and help parents get some sleep, too. It's amazing how that improves everyone's life--when you get enough sleep," says Givan.

With 12 locations throughout the state, the Indiana Hand Center is an internationally renowned leader in the medical care of the hand--from arthritis to nerve compression problems to emergency trauma and traumatic reconstruction as well as congenital differences.

"The science of medicine has advanced so rapidly that it is impossible for me to master multiple areas. My brain is only so big, and I can only retain so many facts and figures in a certain area," says Dr. Thomas Fischer, managing partner of the Indiana Hand Center. "That's why when my kids get sick, I rely solely upon my friends who are pediatricians, who do this on a daily basis, and know the best thing for a particular sickness, like they rely upon me to take care of their patients with hand injuries."

Fischer notes that after World War II, many physicians found their training was inadequate to care for the badly injured war veterans. As a result, the first generation of surgical specialists began.

The Indiana Hand Centers see 11,000 new patients per year. Some come in for a single visit for education or a singular treatment. Others patients have come in on a routine basis for the last 10 years.

"We combine the arts of orthopedic surgery, plastic surgery, vascular surgery, neurological surgery, pediatric surgery and geriatric surgery into care for a very important piece of the anatomy," says Fischer.

"My senior partners, are well known throughout the world," says Dr. Richard S. Idler, a surgeon at the center. "We have had people on occasion come from overseas seeking our expertise for specific surgical procedures."

SPECIALTIES WITHIN SPECIALTIES

As specialists come together in a specialty medical practice, often there may be even more segmentation among them.

"Even in the field of cardiology, it has gone into further and further specialization," says Jan Ernest, executive director of St. Mary's Heart Institute in Evansville. For example, at her facility there are cardiac physicians who specialize in echocardiography, interventional cardiology, even a specialist in heart rhythm.

"St. Mary's foresaw things occurring in the mid-1980s and formed the Heart Institute to support the development of those various specialties within the field of cardiology," says Ernest.

"In southern Indiana in particular, mortality from heart disease is higher than the rest of the state," says Ernest. "We also serve a market that includes southern Illinois and Kentucky. Those states have some of the highest incidences of cardiovascular disease in the country."

While fulfilling a need in the region, St. Mary's Heart Institute also is a leader in cardiac medicine. "We have the only pediatric cardiology program in the area--a significant sub-specialty," she says of the program which was introduced in 1986. "We did the first minimally invasive surgery. We call it Op-Cad, which is 'off-pump' bypass surgery." Another innovation is endoscopic vein harvesting. Scarring, pain and healing time are greatly reduced, thanks to use of an endoscope.

"When people think of heart disease, they think of heart attacks. But there are a lot of other problems." St. Mary's has a full scope of cardiac inpatient and outpatient services from non-invasive testing like stress testing and echocardiography to invasive-type therapy and diagnostic evaluation as well as full interventional programs and clinical trials.

"Research, we believe, enables us to bring new things to the community and to stay more on the leading edge with our services and treatment of the heart."

DEMAND BRINGS SPECIALIZATION

The St. Joseph Wound Care Center in Fort Wayne serves a tri-state area. It also receives daily calls from around the country as a result of the Internet. "Wound care has become a specialty because there is a definite need," says Beth Sarapata, interim manager of the center. "There are a lot of people who have chronic, non-healing wounds--some wounds lingering for years and years." The fear is, if not properly treated, some non-healing wounds can lead to limb amputation, among other serious problems.

"It is very time-consuming to heal a chronic wound. A lot of intense research testing goes into figuring out why a wound isn't healing. The family physicians refer to us mainly because of the time constraints in their own practices," says Sarapata. The facility logs about 1,700 patient visits a month. Return visits play a big factor, as often it takes more than one visit to heal a wound.

Many of the patients have diabetes, endured radiation treatment, have blood-flow problems or are just bothered with curious, persistent wounds. "We have a smattering of--you name it--really strange infections or funny fungus things. We do a complete work up and find the appropriate antibiotics," says Sarapata.

St. Joseph's Wound Care Center touts Indiana's largest multi-person hyperbaric oxygen chamber with three hyperbaric-certified nurses and two additional certified assistants. Accommodating up to 17 people at a time in 90-minute sessions, the chamber delivers 100 percent oxygen at greater-than-atmospheric pressures to help speed healing in certain treatment plans.

BOTTOM-LINE BENEFITS

One might expect to pay a premium for specialized medical care, but that frequently is not the case, says Kathy Ostrowski, service line manager for neuroscience services at The Methodist Hospitals in Gary and Merrillville. The Neuroscience Institute offers focused care that can be more effective, more convenient for the patient and less costly, she maintains.

How can specialty clinics reduce bottom-line expenses? "We're keeping a lot of our multiple-sclerosis patients out of the hospital," Ostrowski offers as an example. In the past, she explains, some MS treatments required a hospital stay, if only a brief one. The Neuroscience Institute can perform some of the same treatments in an outpatient setting--more convenient and less costly. "In many cases they don't need 24-hour hospitalization."

Convenience also is aided by the fact that the institute brings together into one location many diagnostic and other services relevant to the needs of its patients, who might have MS, chronic pain, headaches or other maladies. And a staff of nurse-practitioners is available to make followup contact more readily available.

PRIMARY DEMANDS

As health-care specialties narrow it becomes more important than ever for primary-care physicians to stay current in advances in specialty care, technology and pharmaceuticals to best direct the patient.

"The role of the primary-care physician complements everything that all the specialty services do, and certainly they are critical in terms of the right level of service at the right time but also putting that service in perspective with everything else being done," notes Stephen A. Freeland, executive director of Primary Care Services at St. Vincent Hospitals and Health Services.

He says primary-care physicians, while needing to be very educated in general medicine, must also have a deep enough understanding of specialty applications and their value to the patient.

"The one thing that's most recognizable in today's health-care delivery system is that the consumer is now wiser because of the Internet," says Freeland. "We're actually seeing the patients coming in having already surfed the 'Net. They are bringing their questions with answers and wanting those things validated. So the Internet has played a major role, not only educating the physician but educating the patient."

"I know the patients are getting good general health care," says Fischer. "Our family practitioners have become more sophisticated in being able to manage long-term disease states and preventative medicine. It's a very symbiotic relationship we have with our other medical partners in this whole process of health care."