Editor—Bath et al have argued cogently for a subspecialty of stroke medicine.1 I venture to suggest a modification of their proposal. They state correctly that during the past 20 years knowledge of stroke (its course, pathophysiology, effective interventions, etc) has increased greatly. The knowledge base seems likely to continue to grow in the next few years. It is, however, much less certain that there will be an equivalent widespread improvement in service provision. Something needs to be done about this. The creation of a stroke specialty is one option, and the suggestion needs careful consideration. Three points are perhaps worth making.
Firstly, disease specific specialties within medicine have not found favour in Britain, the preference being for generalism with an interest in a particular system. Secondly, the creation of a subspecialty, as suggested, would have appreciable implications well outside the area of stroke (for example, on training requirements and deployment of hospital beds). Thirdly, the three phases of stroke—prevention, acute care, and rehabilitation—involve different skills. For example, few consultants are fully knowledgeable about the pathophysiology of acute cerebral ischaemia and about rehabilitation.
An opportunity now exists to refashion some parts of medical practice, with an increased emphasis on clinical problems rather than diseases. Such an approach would involve identifying what various diseases have in common with each other. In the field of stroke medicine several points might be worthy of debate:
Prevention—The risk factors for coronary artery disease and stroke are similar. Perhaps what is needed is a locality based cardiovascular disease prevention service dealing with such common problems as hypertension, cardiac arrhythmias, and transient ischaemic attacks.
Acute management—Major hospitals might in future have an acute brain damage unit dealing not only with stroke but also perhaps with traumatic brain injury and acute encephalopathies. Such units should be in a good position to deal with a wide range of problems (for example, cerebral ischaemia, raised intracranial pressure, convulsions, respiratory difficulties, and nutritional problems).
Rehabilitation—Patients with stroke do better when looked after on a stroke unit. But does this need to be a unit only for patients with stroke? Can’t other patients with rehabilitation needs (for example, with brain injury) be looked after on the same ward? Do we really need separate facilities for each category of disease?
Bath et al highlight the need for more medical expertise in the field of stroke. But is a disease oriented specialty the best way of achieving this objective? Data and evidence are needed.