27. Generalists vs. Specialists

July 19, 2016

Two articles have come to my attention that may be more closely related than at first they seem.

The first was the article by Maria Popova about Buckminster Fuller on synergistic thinking:


In which Fuller is very critical of specialist education and thinking.

And the second was a seemingly lighter piece by Sheilamary Koch —

http://exclusive.multibriefs.com/content/for-children-to-be-independent-thinkers-we-must-teach-autonomy/education — which begins:

“When I asked junior high students to look back on their school career and describe the assignment that stood out most for them, most named activities where they were in the driver’s seat. They claimed having the opportunity to take responsibility for their learning motivated them to achieve their best.”

For me, the “Aha!” moment came 30 years ago when I was reading a passage from Marshall McLuhan’s, “The Medium is the Message”. In it the celebrated Canadian professor of communication theory spent a few pages talking about the difference between generalists and specialists.

At the time I was practicing Family Medicine, which had then only recently changed its name from General Practice. I was acutely aware of both the value and the limitation of medical specialization, and had just survived the urgent swerve of the late 1960’s that sought to elevate specialization at the expense of the medical privileges of the general practitioner.

Whereas G.P.’s had, for example, until then performed appendectomies, tonsillectomies, other simple surgeries and had delivered most of the babies born in the United States, there was a powerful political movement, led by the university hospitals that did most of the specialist training and had by that time produced an over-abundance of surgeons, to restrict all but certified specialists from doing even the simplest hands-on procedures.

This movement had purely economic roots, but was clothed in the medical pseudo-logic that it was for the good of patients. Of all the private and public funding available for medical school teaching, overgrown departments of surgery, internal medicine, and obstetrics and gynecology were already consuming lion’s share and were hungry for the rest.

It wasn’t until the Robert Wood Johnson Foundation threw its weight into the struggle that the specialty departments were forced to acknowledge that an ever-growing surplus of surgeons and internists had created a scarcity of G.P.’s and a serious maldistribution of medical services, particularly in rural and inner city areas.

Ironically but not unexpectedly, the solution from medical academia in 1969 was to create yet another official board Certified specialty, the twentieth, called Family Practice, requiring three years of residency training beyond medical school. However, instead of creating Departments of Family Practice equal in stature to the departments of Surgery or Obstetrics and Gynecology, many of the medical schools designated “Divisions” of family practice, within the administrative and budgetary control of the already existing Departments of Internal Medicine. By which they funneled newly available funds designated by federal and private sources solely for family practice training, into an established administrative structure designed to support a specialty that had constituted part of the problem, not part of the solution. Devious buggers.

For the first couple of years after its creation, those of us already in practice were allowed to sit for the exam based upon our experience and independent study, and without the residency training, which I did in 1972, becoming board Certified in Family Practice.  Again ironically, it was the first of three medical specialties in which I became Board Certified. In addition to those three, there were two others in which I became eligible to sit for the exams, but chose not to do because of matters of timing and money. In those two cases I was about to transition into another field, or to retire from practice altogether.

You see the irony: that if a person successfully pursues five medical specialties, is he or she better described as a serial specialist, or rather, a generalist with areas of deeper interest?

I had not thought about that (too damned busy you see) until I ran across the passages from McLuhan, where he described a generalist as one who looks up at what exists and sees it as an environment. But as he or she learns more about it, organizes it and reduces parts of its amorphous complexity into a meaningful story or metaphor, those parts become an artifact of his or her construction. An example would be the beguiling mystery of life reduced to medicine’s story of, “how the body works”. After savoring that for a bit, the generalist again gazes up at what remains: the unexplained, unreduced environment, and begins to think about it, organize it and perceive it as another coherent story or metaphor. Which again becomes an artifact of the mind.

And so the generalist begins to gaze at what remains….. and so on.

As I understood him, McLuhan was saying that the generalist is repeatedly curious about and fascinated by that which he or she does not understand.

The truth is I can’t remember what he said about specialists. Other than that they are moved to learn everything there is to know about one narrow topic.

Thinking in terms suggested by the Popova and Koch articles and using the language of Eric Berne’s Transactional Analysis, whereas the generalist is driven primarily by a natural Child’s unrestrained curiosity about everything, the specialist more resembles the Adapted Child, trying to meet and match the expectations of parents and teachers by learning and repeating everything they seek to teach. Is what governs specialists a fear of being caught not knowing?

But perhaps I am being unfair. Perhaps both apply the same energy. curiosity and intensity, but the difference is in the direction of gaze: that the generalist is looking upward and outward at everything that is, and the specialist merely happens to be looking down and into the depths of a particular phenomenon.

I do remember clearly that in medicine, as a Family Physician it often fell to me to keep in mind the whole picture, and the patient as a whole person, and therefore to use the consultations of the specialists regarding a particular organ or body part within that larger context, to which some specialists were somewhat oblivious. (Others were obviously generalists who happened to be practicing a specialty.)  Clearly both skills are necessary, but the management decisions of the generalist, made in conjunction with the person who is ill, are better.

If Popova’s Fuller is right, that it is a good thing to keep the generalist within each child alive and well, so that there are enough of us that are able to cross-connect information, it seems to me that Koch’s story about science teacher Monserrat Alverado provides useful guidance: encourage independence of study at a much earlier age.  [Ed.  In 2019 I learned from my grandson who paid an extened visit to their schools,  that this constitutes the core of a new, extremely successful, educational practice in Finland.]