How We Naturally Live
Back in my days of running a private foundation in the Midwest, I had a friend who was a respected cardiac surgeon in a highly successful group practice. One day I complained to him about a recurring pain in my knee, and asked him what he thought it was.
"How would I know?" he replied dismissively. "I just do hearts and lungs. I don’t do knees. You’d have to talk to a knee orthopod about that."
But of course. He was "just a tailor," as he described himself on more than one occasion. He did one thing – one ensemble of things – and did it exceedingly well. He didn’t bother to keep up on other body parts, how they connect to each other, or general health issues like the flu and creaky joints.
"It’s hard enough to stay current in my own field, let alone to know what’s going on in other
specialties," he said. "You pretty much have to specialize now. The generalist is dead."
Fifteen years ago I thought that was hyperbole, but these days I’m not so sure. In small towns and
rural areas you might still find the jack-of-all-trades doc – if you can find a doc at all – but in the
urban and suburban areas even the family physician is becoming a specialist. More of what we used to
view as "general" medicine is moving downstream to nurse practitioners, physician assistants
and others, who continue to move upstream in knowledge and practice and chip away at what was once the
sole province of physicians.
Physicians don’t specialize because they want to. They specialize because they have to.
The "art" of the general physician-as-healer is being "algorithmized" into a
technical bag of tricks, fueled by stunning advances in science and technology and sold to consumers
who are looking for a quick health fix. The result is more specialization, more fragmentation of
interests and approaches, more regulation and more brokers.
But here’s the twist: What we have carved up and carved out in the name of better science and
efficiency we are now compelled to integrate, also in the name of science and efficiency.
The mind and body are of one piece. Now that we’ve erected separate and distinct kingdoms for the
treatment of each, should we not integrate them at the basic level of primary care?
The medical, social and psychological dimensions of aging and chronic diseases are hardly separate
and distinct, yet we have made them so. Should we not now integrate them in a team model of chronic
And how shall we go about this integration? With more specialists, brokers and programs, of course.
We’ll have integrationists, preventionists, integrated data management systems, integrated health
plans, new "carve outs" for integrated public health assistance – we’ll even have integrated
regulations and standards to account for it all.
This sounds cynical and flip on the surface, but it’s underlying logic is consistent not only with
the history of medicine in America, but also with technological progress generally, which disassembles
the natural "whole" of human experience into its constituent parts and then reassembles it
in a reproducible ensemble of products and techniques.
In health care, these techniques are reintroduced into the patient’s experience and made to appear
completely "natural." To cite just one example, for thousands of years women figured out how
to have babies and breast feed them. Now, they prepare for childbirth with a regimen of routine visits
and techniques as if they didn’t have a clue what to do, and the whole artificial process appears
completely normal to them.
As the artificial replaces the natural – engulfs it, really – we lose the ability to distinguish
between the two and often come to prefer the artificial because we can control its variability and
reproduce it at will. So it is that we expect to see one specialist for depression, another for
childbirth, yet another for health insurance, and so on. We’ve learned the routine, and so have the
In all of its glorious fragmentation, it’s really a completely integrated and artificial whole.
It’s how we naturally live these days.
Feedback? Send it my way: Roger.Hughes@slhi.org.
*The Drift reflects the views of the author, and does not represent the official view of SLHI’s Board of Trustees and staff.