To the Editor.—While I wholeheartedly
agree with the comments of Drs Zuger and Sharp1
regarding the need for HIV specialists, their arguments for super-specialized
care also apply to other infectious diseases. As a physician who consults
on all cases of multidrug-resistant tuberculosis in Los Angeles County, California,
I am deeply troubled by the trend toward elimination of categorical tuberculosis
(TB) clinics based on the belief that any primary care physician can treat
this disease. While it is true that many generalists can and do deliver excellent
care to their patients with TB, others may not be able to do so for various
reasons, including a low incidence of TB in their geographic area. Tuberculosis
care, more often than not, is complicated by socioeconomic conditions, psychiatric
disorders, and other circumstances that lead to poor adherence to therapy
and poor treatment outcome. I suspect that most primary care practices have
neither the time nor infrastructure necessary to attend to the public health
issues related to TB, such as finding and screening contacts and delivery
of directly observed therapy. Finally, the treatment of multidrug-resistant
TB requires the skill and expertise that only experience and hands-on training
under knowledgeable mentorship can provide. For these reasons, I believe there
is and will continue to be a need for super specialists, especially as medical
knowledge and technology continue to race ahead at breakneck speed.