scratch-mark

Specialization Screws You, One Way or Another

I love my specialist doctor friends who now spend most of their time generalizing.

….At least that’s my take on it. I think it’s a good thing.

~~~

I recall pretty clearly when I first learned there was any such thing as a medical specialist. Before that, I had no idea there was any such thing. I suppose cars are a good example. No matter what the issue, dad would take the car down to the mechanic he habitually used and there would be some assessment, and some fix: and it didn’t matter whether it was pin bearings in a U-joint that needed replacement, a head gasket, valve grinding, or a carburetor rebuild. It got done.

But I’m being unfair.

Owing to the pace at which advancements now accrue, there really is no choice but to specialize. Otherwise, you get half-assed everywhere, right? Self evident? In terms of automobiles, the age of fully integrated generalist is probably over. And it probably should be. Why hold it back by force for sake of nostalgia?

But that accrues to technological advancement, as it is with computers and software. There is simply no single person that can integrate to a level of basic competence. But is the human body getting more complex with every model year, or is knowledge coming from the other direction — i.e., deeper and a more complete understanding, much coming from specialists?

Hmm. I. Don’t. Know. This is perhaps why I tend to pay some attention to smart, no woo-woo holistic practitioners (like Chris Kresser).

But it’s also is what it is. It’s difficult, I think, to argue against the burgeoning medical establishment, as such. They’re operating like any privileged business. And there is effectiveness and real results and I resist efforts to dismiss them.

…They’re far “too big to fail,” so don’t worry.

Back to the beginning. I grew up in the 60s, considering a doctor as someone just a single rung down from God. They knew everything, were expected to know everything, and they always had an out: that upper rung. That was probably enough, Monday through Friday, for most of us; even us kids. But on special occasions, there was talk of seeing a “specialist.” This was a Big Deal. It meant your case was particular, that it merited special attention. You might even die, but you might also be saved.

Now, specialists are as ubiquitous as Ms. Fields in a mall.

I grew up loving this serendipity of life, that whatever may pass, people were being their best and doing their best; and yea, if you didn’t understand they were making a better than average livelihood, then you were just stupid and so should be particularly thankful if your stupid ass got saved. But as I recall. everyone did understand.

We should understand why the manufacturing of ships, automobiles, airplanes, computers and a whole host of increasingly complex appliance and gadgetry gets farmed out. It’s too much for one person or firm to handle, which isn’t even the point, really. It’s clear they can do better for themselves and more quickly, spreading the wealth around to others who are willing to invest and take a risk.

I guess my point is that specialization is really just another way of expressing “division of labor.” So, OK, given that the human body is not getting more complex, we’re just understanding it more, do you want division of labor, or do you want integrative understanding?

~~~

The human body is relatively static. We know more about it, over time, but it is still not an object of industry. The medical profession can help. It has helped. It has done wonders, and I stand against Luddites in this regard.

But it’s not getting more complex, we are simply understanding more. Forgive me, but I think that calls for integration, not deconstruction. I think it calls for deeper, holistic and integrative understanding, not further dis-integration and specialization.

So in this regard, I guardedly stand against the medical profession.

Steve Jobs was perhaps the last self-made entrepreneur that I can imagine, who might die anytime soon. He succeeded to the extent he integrated, combined, made connections, thought about how one thing might relate to another.

Steven Jobs was the furthest thing from a specialist you can get.

Richard Nikoley

I'm Richard Nikoley. Free The Animal began in 2003 and as of 2021, contains 5,000 posts. I blog what I wish...from health, diet, and food to travel and lifestyle; to politics, social antagonism, expat-living location and time independent—while you sleep—income. I celebrate the audacity and hubris to live by your own exclusive authority and take your own chances. Read More

27 Comments

  1. the cottage child on October 6, 2011 at 19:45

    I don’t know if I totally agree – I mean, I do, with regard to the cog in the machine aspect, but no one seems to be much good at anything, really – well, maybe, people are good at chanting and bitching, so there’s that, but no one seems able to focus.

    I want both. Or rather, I expect myself to be both, am raising my children to be both – specialized and general, create and purvey. Meeting the challenge might just require both, anymore. Jobs was a premium example of that, very much worth emulating. It’s an eerie quiet feeling when such a large creative force takes his leave. You’ve remembered him well, here.

  2. Steven Sashen on October 6, 2011 at 23:34

    If you wanted to understand (to some extent) what was going on inside the atom, you wouldn’t consult Galileo, even though he was the the greatest physicist of his time. You wouldn’t even consult Max Plank. And if you wanted to get really deep, you wouldn’t even consult Einstein!

    The universe hasn’t gotten any more complex, but our understanding of it has. And we’ve come to understand that it’s not possible to be a generalist and dig into the specific wells of knowledge that further understanding has revealed to us. My laser physicist friends do not dare tread in the domain of my astrophysicist friends, though either could easily teach an introduction/overview class on physics.

    The human body is the same. It’s not more complex, but our understanding of it is. And our ability to recognize different ways in which it performs sub-optimally has advanced as well.

    If, 50 years ago, you went to your family doctor with certain bacterial infections, you wouldn’t have been diagnosed correctly or treated correctly. There would have been no specialist to refer to… you would have died.

    The increase in specialization is not from a misunderstanding of the human body and it’s illnesses. It’s from increased knowledge and increased opportunity. One reason there weren’t many specialists way-back-when, is that there simply weren’t as many people in the medical profession. Medicine wasn’t a well-paid or financed profession until relatively recently. And the success of the generalist came mostly from the fact that the majority of our medical complaints will naturally heal themselves with time, which is a good thing since the arsenal of tools at the disposal of the older generalist was, at best, limited.

    I have a friend who’s a 76 year old family physician. I asked him, “What percentage of your patients actually need an intervention for their presenting complaint beyond something that was available to the average 19th century doctor?” His answer? “About 20%.” And for that 20%, he needs to refer to people who know more than he possibly can, because there is no integrative understanding of the other 20%. His job is to treat the 80%. The Pareto Principal in action.

    Again, to use the physics metaphor, we can’t currently reconcile Quantum Mechanics and General Relativity. There IS NO integrative understanding. There are some who think there may be, and some who think they’ve found it. But those who claim to have never been able to demonstrate that fact. In the same way, there is no “integrative” medicine that can reliably treat the vast array of symptomology that our massively complex physical organisms demonstrate. There are many integrative practitioners who believe they can treat anything, but they’ve never demonstrated that fact. (Note, by the way that even “integrative” medical professionals specialize — not all of them, for example, believe in or practice accupuncture or homeopathy.)

    Keep in mind that one aspect of evolution is to produce unusual and, therefore, difficult-to-comprehend, genetic variations… so undiagnosable and untreatable illness is actually part of the plan! We now live in a time where we have the luxury of being able to explore those outlier conditions and, even more amazingly, can now treat some of them. The list of treatable conditions that were fatal a mere 20 years ago is not small.

    BTW, I also asked my friend how often he prescribed placebos. “VERY!” was his response. He also told me that if some patients came back, complaining that the placebo didn’t help, he would give them a more expensive and bigger placebo… and more often than not, that would take care of things (again, because time heals most ills).

    I hate to bring up what for some is a sore subject at this time, namely Steve Jobs. Steve was not a specialist; his areas of expertise were limited. Luckily one of them was attracting quality talent. He was a coding generalist. He was a design generalist. He was a fashion singularist ;-). I know a few Apple employees who are currently holding their tongues as SJ gets credit for work that they did.

    More importantly, Steve’s skills did not extend to medicine. He was bad at differentiating between valid medical treatment and mythology, which is why he heeded his naturopaths orders to “treat” his cancer with diet rather than have the highly-reliable surgical intervention which most likely would have left him able to comment on this thread.

    • Richard Nikoley on October 7, 2011 at 07:08

      Steven

      Thanks for all that. I’ll read it again later and may have more to say but for right now to clarify, I was talking strictly of clinical practice. I fully agree that knowledge needs to advance. More later, probably.

  3. Grant on October 7, 2011 at 00:14

    The biggest problem in regards to this issue is epistemological. The epistemology of mainstream, contemporary philosophical thinking doesn’t consider sense perception valid (or, at the very least, necessarily valid). What this means is that there are “specialists” out there who’s ideas and “knowledge” are in contradiction to perceptual evidence, but who retain their status as authorities because the only “evidence” which is accepted is a mind-numblingly complex array of things like statistical analysis, peer review, academic credentials, et cetera (insulation from the consequences of this via direct or indirect government-funding doesn’t hurt either).

    This isn’t to say that any of those things are necessarily invalid either, but only to emphasize that they must not only support direct perceptual experience, but also be confirmed by it sooner or later. Certainly not challenged by it (or presented in such a way so as to avoid being challenged by it eventually). It would be a denial of the perceptual evidence to claim that all specialization that has occured in the last epoch is because of epistemological corruption – much of it certainly is the result of a more detailed understanding of the human body, and that’s a great thing – but it would be equally spurious to deny the perceptual evidence that testifies loudly to the fact that there are a great many “specialists” out there who know everything there is to know about one particular aspect of human biology, but not a lick about how it is influenced or influences the rest of the organism (which actually begs the question: if such person has blinders on to anything outside of his square inch of focus, and yet that square inch is being constantly affected by forces outside of it, how much can he really be properly said to know about his particular field?). It’s as if, in the minds of such people, the simple sentence “yes, but nothing happens in a vaccum” isn’t itself a scientific statement (it is).

    Unfortunately it’s this type of “specialists” who have public’s attention (and the government’s funding), and because of that – in my opinion – the damage their pigeon-holed thinking (and subsequent advice) causes far outweighs whatever value they give.

    • Richard Nikoley on October 7, 2011 at 13:50

      …”contemporary philosophical thinking doesn’t consider sense perception valid…”

      Of course, I suspect you are familiar with the notion of the “stolen concept,” i.e., that you must use your integrated sensory powers to attempt to discredit those same powers.

      Anyway, we have zero choice, logically, but to trust our own senses. Doesn’t mean we should be uncritical in interpretation of conclusions, but it really is all we have. It is our only portal into reality.

      And I favor, ultimately, an effort to integrate and make as many connections and identify as many relationships as possible. I disfavor attempts to dis-integrate , reduce and ignore potential relationships for the purpose of furthering livelihoods at the expense of others.

  4. Razwell on October 7, 2011 at 05:39

    I think Steven Sashen had some good points. (I have a strong interest in space etc. also) . While I respect what he has to say about the hard sciences, medicine specifically is just as much an ART as it is a science. Going to the moon would be an example of hard science. And the hard sciences are more accurate than medicine ever can be or will ever be. People are all so different in how they respond to things. Then, something I recently learned is : Various races sometimes need different medical treatment for heart disease. ( e.g. what is used for a white person might not be used for an asian or black person). I never knew that. There are slight differences in the treatments. And among humans ethnic and race differnces in heart disease and risk profiles. You learn something everyday. :)) I would bet most of the public has no idea about this.

    Doctors learn things on the job they never were taught at their medical universities. I also like D.O.’s
    a lot better than M.D.’s because a D.O. looks at the person more as a whole.

    Yes, I also agree that Steve Jobs *might* be alive today if had chosen the other route. I don’t like hearing about anyone passing away.

  5. rob on October 7, 2011 at 06:32

    These days being a specialist isn’t enough, you have to be a “board certified” specialist

  6. Daniel Kirsner on October 7, 2011 at 21:14

    Very interesting that you ENTJs are anti-specialization–and how unlike your INTJ brethren. I must ponder this further. Arthur Jones, another ENTJ–and a damn brilliant one–was fond of stating that “Specialization is for insects.”

    http://www.arthurjonesexercise.com/First_Half/40.PDF

  7. Samantha Moore on October 7, 2011 at 07:32

    Boring.

    • Richard Nikoley on October 7, 2011 at 07:58

      Then I guess you’re due a refund.

  8. Dan Linehan on October 7, 2011 at 08:19

    There’s so much to learn nowadays, it can take years to become a “highly skilled” generalist.

    I’m just starting to consider myself one, but I’ve also had the luxury of being able to spend hours and hours reading online nearly every day, for the last 10 years or so. I’m not sure how anyone else achieves it.

    I’m 30 and I’m just now feeling like I have an accurate mental map of reality. It took a lot of time and effort to get there.

    I wouldn’t trade my generalist mentality for any one specialty.

    I’ve met too many people over the years who have only done one type of job, and no matter how talented they are, they always seem so trapped to me. There’s that sort of quiet desperation that makes them feel they have to stay where they are, even if they aren’t learning anything new. Thanks but no thanks.

    At this point, I’ve worked in everything from restaurant management to call canter management, to construction to programming. The perspective that comes with having that variety of careers is surprisingly useful.

    • Richard Nikoley on October 7, 2011 at 08:27

      Dan:

      Thank you. You’ve gotten to the spirit of what I had in mind. Yea, when I was a kid I learned how to hunt & fish, work on cars, be a painter and supervise other painters in my dad’s contracting business, then learned some computer programming in college, settling n a bus admin degree with a GENERAL specialty (rather than accounting, finance, management, marketing, etc. — I wanted a general knowledge of all), then did a number of different jobs in the Navy and eventually started my own company and began reading a lot, all the time.

      When I don’t know something I go right to Google and am amazed at how quickly one can become generally familiar with almost any topic in a matter of minutes.

  9. James Howell on October 7, 2011 at 09:12

    1. The demise of the shade tree mechanic: when I was a kid in the sixties, one of my favorite things to do during the summer was to work on some old car I or a friend owned. We did everything from simple brake jobs to complete engine rebuilds. But now? Holy moly, I don’t have a frickin’ clue.

    The following is simplistic but:

    2. Medical specialists: the human body hasn’t changed in the few centuries since medicine became an accepted science. Our knowledge has of course increased but the human body is still the same. I have done a lot of reading in the past couple of years since the idea of a “primal” lifestyle came to my attention and the connection between our modern habits and modern medical specialization stands out. One reads many (anecdotal) stories of this condition or that disease disappearing when a sufferer makes a simple change such as foregoing high-heeled shoes or the simple deletion of, say, processed foods from that person’s menu. Medical problems that did not exist or were very rare are now common thanks to what seems to be the starting point of politicians and “experts” getting involved in our food in the 1970s.

    Of course Big Pharma and Big Agriculture don’t help. Now, I am a capitalist and I do not believe corporations are inherently evil as many of our leftward-leaning citizens believe but the drug and food corporations are not helping matters. I’ve seen commericials for new diabetes drugs and food companies are coming out with “gluten-free” foods that are just as high in carbs, if not higher, than the wheat products and the poor doctor, with all the ambulance chasers out there, is caught in the middle. He/she must specialize, or maybe just pay more than normal attention to, a disease that a few decades ago was rare.

    Because Conventional Wisdom and know-nothing politicians keep us on winding and branching paths, our medical people simply cannot keep up with it all. (A non-thinking public, that also believes in a caring government, doesn’t help of course.) Specialization may be the unintended method of keeping knowledge to a manageable level.

  10. Chandra on October 7, 2011 at 09:16

    I find more and more that the modern general doctor is nothing more than a glorified pharmaceutical pez dispenser for general maladies like colds and flus. If it is anything that might be slightly beyond that, it is immediately spun off to a specialist. A modern doctor does nothing more than can be done in any quick clinic in any pharmacy anywhere. I have become quite disenfranchised with the whole system. The specialists then look @ their own microcosm and fail to accurately access what is going on with the patient because they fail to look @ the whole patient and cannot or will not look outside their own specialty. I find I have the best luck with RNs who can prescribe and take patients over MDs. They seem to listen, treat the patient as a whole, and be better educated IME.

    • Richard Nikoley on October 7, 2011 at 10:06

      Chandra:

      Two stories:

      1) A bit over a year ago I opened a champagne bottle in the French way, with a knife, but even after sweeping down the deck afterward, I still ended up with a tiny shard of glass in the sole of my bare foot later. I could not dig it out. I went to Kaiser but had to go through the primary. He told me bluntly: “I’m a pill doctor, Richard.” So he referred to a podiatrist who painstakingly and very carefully over 30-40 minutes trying several different tools, got it out without having to cut.

      2) Last year when I got my cerivical herniation, I was again sent through the primary. he did a bunch of physical tests, then referred me to the spine guy.

      I don’t dispute there is a need for specialists, but at least in case #1, I would be more than happy as a GP to dig out a piece of glass from a foot. Seems that ought to fall under the category of doctor.

    • rob on October 7, 2011 at 13:25

      With Google you can self-diagnose, figure out what drug you want the doctor to prescribe you, then schedule an appointment, describe the prerequisite symptoms and voila, you have pretty much avoided the medical system altogether.

      I avoid going to doctors at all, usually I just go to an urgent care store, last time was for a burn I got cooking that wasn’t looking like it was healing too good (doctor agreed with my diagnosis, prescribed me some good antibiotics, gave me a bunch of free burn cream and other goodies).

      Not going to doctors will probably bite me in the ass someday when I find out I have a particularly virulent form of ass cancer, but that summabitch was probably fixing to kill me anyway.

    • bob r on October 12, 2011 at 15:11

      “disenfranchised …”: I think “disillusioned” or “disenchanted” might work there but I’m pretty sure disenfranchised, i.e. not allowed a vote, is not the concept you intend to convey.

      [/pedantic mode]

  11. Robert on October 7, 2011 at 11:16

    It would certainly be nice if everybody knew everything, but that is not going to happen. The body is not getting more complex, I agree, but it is already plenty complex that several displines are needed to understand how it works (understanding that is still not complete). A brain specialist knows a lot about brains, but at the cost of knowing less about bones or about intestines. That is just the way it is. I think we do need doctors who have general/big picture view of the body, but we should also accept that their knowledge on the details might be lacking.

    Perhaps in the future computers/machines will diagnose people, computers that could theoretically know everything about the human body. Give them enough data(blood samples, scans etc.) and they might do a better job diagnosing than a human doctor (who simply doesn’t have the time to learn everything about the human body)

    • Richard Nikoley on October 7, 2011 at 12:36

      Robert: I’m arguing for mass generalization and integrative medicine in terms of clinicians, and I’d go so far as to say psych, too.

      There is massive danger, I think, in dis-integrating the human body.

      …I know this is all “boring,” at least to those without a basic brain, or they’re into cartoons or whatever, but we are integrated systems and there’s no escape from dealing with them as such, without consequence.

      • Steven Sashen on October 7, 2011 at 13:24

        But, Richard, when you say: “There is massive danger, I think, in dis-integrating the human body.” you’re implying that there’s a way of treating the body as an “integrated” thing.

        But the body is neither “integrated” nor “disintegrated”. It’s both and neither.

        Some situations highlight the highly complex interrelationship between systems, and other situations allow us to focus on the parts independently of relatedness. And sometimes the “situation” can SOUND the same, but be very different (e.g. some forms of cancer are easily treated by surgical removal, others require a much more nuanced treatment).



      • Richard Nikoley on October 7, 2011 at 13:45

        I’m talking about unbridled reductionism. Some have alluded to that implicitly, if not explicitly already.



    • Richard Nikoley on October 7, 2011 at 12:37

      Oops, that said, learn all you want in the lab and though studies. But then educate the clinicians.

  12. Alexandra on October 7, 2011 at 14:07

    The knowledge that specialists have can help you, it’s those gaps in knowledge from one medical provider to the next that can kill you. My husband was a heart patient and diabetic with one functioning lung (from a surgical error during 3x bypass at age 32.) At age 51 he developed symptoms that he talked to his P.A. about. The P.A. had no clue so decided to send him to a neurologist to be checked. The neurologist ran a few tests and, before the results were even in, decided that my husband needed anticonvulsants and sleeping pills (possibly the worst thing he could have prescribed.) Three weeks later my husband needed an emergency intubation because he was suffering from CO2 narcosis. I spoke with a cardiologist at the hospital and related the chain of events. The cardiologist was shocked that a P.A. (physician’s Assistant) was managing such a complex patient and didn’t understand the symptoms and shocked that the neurologist also failed to recognize the very common symptoms that were presented for what they were, a co2 problem. The cardiologist called the symptoms. “doctor 101” stuff. My husband was never able to breath on his own after that and died within days. We often don’t know what they don’t know until something bad happens. Yet another reason to keep our bodies as healthy as we can.

  13. David Csonka on October 7, 2011 at 14:43

    Well, if medical services are a product, then specializations are a form of product differentiation. Seems like market forces to me.

    • Richard Nikoley on October 7, 2011 at 15:46

      That’s true, David.

      The problem is, humans aren’t cars or computers. Moreover, one car or computer cares not a bit about another.

      • Richard Nikoley on October 7, 2011 at 15:48

        And I wouldn’t even care, so long as there wasn’t so much fraud involved.

        Drug dealers on the street at least possess the virtue of honest dealing that much of the food, drug and medical industries lack.



  14. Anon on October 13, 2011 at 06:19

    Chris Kreeser’ll make you JUMP – JUMP…

Leave a Comment

You must be logged in to post a comment.

YouTube1k
YouTube
Pinterest118k
Pinterest
fb-share-icon
40
45
Follow by Email8k
RSS780