These article is adapted from a talk given at the graduation dinner for the residents of the Department of Internal Medicine at Texas Tech University Health Sciences Center in Lubbock on May 27, 2011
Specialization is when people concentrate on one thing or another at which they are good. I will limit my remarks to professional specialization. Of course, if you are going to specialize in something there has to be a demand for it unless you intend to live in a vacuum. In medicine specialization has been getting a bad rap for as long as I can remember, but it is especially widespread today to lament the preponderance of medical specialists versus generalists.
Human diversity is perhaps the most extraordinary characteristic of our species. Consider some of the thing we can do, but only if we specialize in one of them. Because humans can gallop for hours, this is true of no other species, it is possible to run 26 consecutive sub 5 minute miles. But only the best marathon runners in the world can execute this feat. The training required leaves them little time for anything else. Parenthetically, humans are the fastest animals on land if the distance is long enough.
Though scientists and physicians are enamored with the bell shaped curve, human abilities and skills are described by a non-Gaussian distribution like the one below. The average physician is likely near the red vertical line. The further one gets to the right the more specialization is required for the individual so positioned to realize his gifts. The great achievers are very far to the right.
Humans (two to be precise) invented the calculus; but I doubt if either Newton or Leibnitz could run a single sub 5 minute mile. Other human feats picked at random include philosophy, building the Hubble telescope, inventing the alphabet, and the wheel, and the zero. The Mesoamericans who independently invented the zero, along with the Chinese, could not come up with the wheel. Let’s include the stirrup, the Sistine Chapel, Hamlet, the Missa Solemnis, going to the moon, deciphering the genetic code, and inventing the transistor on our list. All require intense specialization to be realized; some by just one man others by huge numbers of specialists (antecedent and contemporary) who devised the components necessary for the construction of a highly complex enterprise.
Adam Smith began Wealth of Nations (1776) with an example of specialization – his famous depiction of the manufacture of a pin. Working by himself and responsible for all aspects of the making of a pin a man could construct, according to Smith, one to twenty pins a day. He broke down the manufacture of a pin to 18 steps which he said could be done by 10 men each specializing in one or two of these operations. This specialization allowed 10 men to make 48,000 pins a day. Thus, the output per man was 4,800. The benefit of this “division of labour” is obvious.
Specialization in medicine has been the rule for at least a century. Nevertheless, for much of that time there has been a constant assault on medical specialization. Everyone has heard the mantra that we need more generalists and fewer specialists. The medical deans and American Association of American Colleges have been making manpower predications about the proper number of physicians and their appropriate distribution for generations. All their proposals have been wrong. Why?
Frederich Hayek provides the answer. The Nobel Prize winning economist’s most important contribution to 20th century thought was that central planning had to fail. Complicated systems, like medicine, are so complex that one man or one group of men no matter how smart or well informed can know but the smallest part of how any system works. Thus it is inevitable that things get away from central planners and that events confound their plans. Once one component of the system is perturbed all the rest respond in infinite and unpredictable ways.
Hayek believed in spontaneous order; ie, let free markets handle human affairs to the greatest extent possible. Language is a good example of spontaneous order. It developed from the bottom up. Attempts to manage it from the top down, like France’s continuous and futile attempts at central control, always fail. English dominates the world without even an attempt to impose order.
Hayek also believed in equality under law, but not in equality of result which is inimical to liberty. He was also aware that people’s natural sense of justice could be a threat to liberty. “We must face the fact that the preservation of individual freedom is incompatible with a full satisfaction of our views of distributive justice.” [Individualism and Economic Order, 1948]
Consider the dismal results from centralized attempts to impose justice. “Minimum wages protected union jobs but made the poor unemployable…Zoning and planning permission has protected rich landlords rather than helping the poor. Rent control makes the poor and the mentally ill unhousable…Regulation of electricity hurt householders by raising electricity costs, as did the ban on nuclear power…The importation of socialism into the third world…stifled growth, enriched large industrialists, and kept the people poor.” [Quoted by James Seaton in his review of Deidre N McCloskey’s The Bourgeois Virtues]
Isaiah Berlin sounded a similar note when discussing the effects of reordering society by those elitists who are convinced that they know the solution to society’s ills. “[T]o make mankind just and happy and creative and harmonious forever—what could be too high a price to pay for that? To make such an omelette, there is surely no limit to the number of eggs that should be broken.” [On the Pursuit of the Ideal, 1988]
In American medicine the distribution of generalists and specialists is 30% and 70% respectively. There are many influential figures in the profession who believe the ratio should be reversed. How this ratio is felt apt is rarely stated. It is found in many other developed countries where access to specialists is not as easy as in the US.
The typical argument for a reversed ratio of generalists to specialists was made recently by Dr Dennis Gottfried. He says, “Our maldistribution of physicians is a major cause of our overpriced, yet underperforming, health care system. Throwing more doctors into the mix will inevitably result in higher costs since American medicine does not obey the usual laws of supply and demand.”
I responded with, “What is the evidence that our current standard of medical practice underperforms? There is none. Statistics like life expectancy and infant mortality are commonly used to gauge medical practice, but in a country as diverse as ours they have little to do with delivery of medical care and everything to do with differences in socio-economic and cultural background. Furthermore, different countries analyze and report their outcome data differently from the way we do making comparisons difficult.
“Why does medicine not obey the usual laws of supply and demand? Because the government doesn’t allow these laws to act. Read the rule book of Medicare and Medicaid. Insurance companies don’t compete because the government through mandates and suspension of anti-trust regulation allows, indeed encourages, them not do so. A diagnostic related group (DRG) is not the stuff of market competition…
“If we were to follow Dr Gottfried’s advice there’s no telling what mischief would follow, but here’s one possible scenario. Remember, when you impose a top down change on a system as complex as medicine the consequences are opaque. Forcing 70% of our graduates into primary care would inevitably leave many of them unhappy. Medicine schools are not deluged with applicants [about 1.9 per slot] as they once were. About half of those who apply are accepted by at least one American medical school. If we force medical graduates to enter a practice they do not find attractive and which pays them less, the number of medical school applicants may fall even more than it has.
“We are opening more medical schools. To maintain the quality of practice now prevalent we will need more applicants not less. That we need more doctors is an assertion, not necessarily a fact. That we need more primary care doctors is an even greater assertion. Both may turn out to be true, but based on the accuracy of past medical manpower predictions I’d bet the other way.
“If we have too many specialists why are they all so busy? They don’t haul in patients from the street; they get them by referral from primary care doctors. Changing the ratio of primary care doctors to specialists is just another name for rationing. If we have more than twice as many primary care doctors taking care of more patients the number of these patients who require specialty referral will increase markedly. But we’ll only have 40% of the specialists we now have (70% of all physicians now, 30% when Dr Gottfried prevails). Draw your own conclusion about waiting lists.”
We owe almost every important advance in any skilled calling to specialization. The great early 20th century mathematician GH Hardy said, “ [I]t is undeniable that a gift for mathematics is one of the most specialized talents, and that mathematicians as a class are not particularly distinguished for general ability or versatility.” [A Mathematician’s Apology, 1940] He could just as well have been discussing physicians.
The current debate over how to structure medicine in this country resolves to which government funded health plan do you prefer. While one is totally top down and the other a voucher system, ultimately they both will topple under the weight of ever increasing medical costs. When the government pays the bill it calls the shots. As I’ve already discussed programs such as these are like drug addiction. They are not subject to moderation.
How medicine and more importantly our patients will weather the enormous bureaucracy that is already imposed on us and which grows larger every year is uncertain, but if physicians don’t get more involved in how their profession is organized further deterioration is certain. The average physician seems as disconnected from the debate over healthcare as a toaster in the desert.
The elite decision makers in American medicine, the editors of the New England Journal of Medicine for example, are devout centralists. In my opinion, they do not represent the average practicing physician. Many of these elites have little or no experience in the day to day practice of their profession. Their opinions were molded by prolonged exposure to non-medical academic elites at our best colleges and universities who are intensely hostile to capitalism and market solutions. Why this is so and how it might be fixed (hint such a solution is very very difficult) is the subject for another day.
