Turf wars and silos—Joined at the hip: What can be done?

The traditional organization of medicine over the last century was towards specialization, leading to the creation of departmental ‘‘silos’’ where turf lines were clearly drawn, for example carotid endarterectomy controlled by and limited to vascular surgery. This approach led to tremendous advances and expertise in medicine as the physicians involved were able to concentrate their energy and efforts to master specific areas. However, this silo structure has become ossified and has resulted in turf wars which have come to occupy an increasingly prominent position in the modern landscape of medicine. These turf wars have been driven by several factors. 1. Actual or potential declining reimbursement. During a time of increasing societal and governmental interest in curbing the cost of medical care and the changes in coding and payment structure, this is a very real factor because physician reimbursement is and remains a very tempting target. 2. Changes in training programs with increased interest in organ systems such as the cardiovascular system compared with specific organs alone such as cardiology. 3. Development and widespread application of miniaturization techniques which allow for less invasive approaches compared with traditional open surgical approaches—for example, carotid stenting versus carotid endarterectomy. This has led to different specialities being able to treat the same problem. 4. Advances in imaging which allow subspeciality physicians to perform and interpret images which had previously been the sole purview of radiology.