How to Balance the lost Art and the Fragmented Science?

In a thought-provoking book,[1] “Range: How Generalists triumph in a Specialized World,” David Epstein has predicted that in a fast changing and complex world, the future belongs to the “Generalist” rather than to the “Specialist.” At first, this appears counterintuitive particularly in the medical field where technological advances are spawning an ever increasing number of specializations, sub-specializations, and sub-sub-specializations. Generalists in medicine are becoming underdogs in the profession. In such an environment, suggesting that generalists will have an edge may be seen as regressive. Medicine evolved as an art and science followed. Art is subtle and subjective, its potential often underestimated. Science is hard and objective, its potential often overestimated. Art sees the big picture, science attempts to solve a puzzle piecemeal, and with sub-specializations, the pieces are becoming smaller and smaller. Consequently, the art, perceived as of lesser impact, is getting suppressed, while the science is getting fragmented. When art ruled, one doctor saw many and diverse group of patients. With ascendency of specializations driven by science, one patient is seen by many doctors. Driven by technological advances, medicine has reached gigantic heights. This has given rise to unrealistic expectations among the people. No doubt medical advances have led to remarkable improvements in health and wellness of people. But there are concerns that the vision and flexibility of this growing faceless industry has contracted and diminished. It should be a matter of concern and introspection for all. Fall of this medical–technological giant can be catastrophic for humanity. Malcolm Gladwell, the Canadian journalist and author, who has studied big business (medicine has become one), provides lessons from the reinterpreted biblical tale of David and Goliath in his book, “David and Goliath, Underdogs, Misfits, and the Art of Battling Giants.”[2] Gladwell states that we get the famous legend of David and Goliath often wrong misinterpreting who had the upper hand in this uneven match. While the traditional view is that David was the underdog, recent research suggests otherwise. Researchers in science and in theology have cleared many misconceptions related to the legend of David and Goliath. A peer-reviewed paper[3], which included a theological reviewer, has a meticulous description of Goliath in original Hebrew texts in the context of current science. It concludes that Goliath suffered from acromegaly caused by the tumor of the pituitary gland. Such tumors increase the secretion of the growth hormone leading to gigantism. The tumors also press on the optic nerve leading to diplopia and severe myopia. Goliath was blind. In the biblical narrative, he is led by the hand to the contest. The big lumbering giant is also clumsy due to his unwieldy armor. David, while no match in size and armor, has advantage of speed and flexibility. He vanquished Goliath with an accurate hit from his sling. Malcolm Gladwell in his book draws parallels with this ancient tale, and today’s monolithic unwieldy business organizations medicine has metamorphosed into. The very qualities which make these organizations impressive, such as size, unlimited resources, and state-of-the-art technology, often weigh down these businesses akin to Goliath’s layers of armor and limit their vision leading to unexpected setbacks. A further handicap, missing in the time of Goliath, is various conflicts of interest, compromising the autonomy of medical professionals. Like the biblical Goliath, medicine today is reaching gigantic heights. The accompanying costs and challenges of sustaining this technology have made individual practice give way to corporate hospitals transforming medicine from a calling to big business propped up by pharmaceutical and other industrial giants. Much armor and many stakeholders have converted it into a faceless growing industry affecting its flexibility and vision to match the public health needs of people in most situations, particularly in developing countries. To save medicine from Goliath’s fate, we require more “gatekeepers,” in the role of David in the profession. They are the generalists or primary care physicians with a simple stethoscope resembling David’s sling. David, the shepherd, became a hero after he defeated Goliath and later became King. Will the general practitioner make a comeback? Will medicine find its soul or the art, again amid the fragmented science? David Epstein in his provocative book recommends late specialization. Perhaps this is more relevant in medicine, where the first step in diagnosis may be as difficult as locating a needle in a haystack. This is where the role of gatekeepers or the general practitioners is vital. The art of picking up a serious case from among the routine cases which crowd the out patient’s department in any busy hospital is as challenging as someone standing on a railway platform looking for one face in the window as the train goes past. Coach after coach pass. If one is distracted or not familiar with the face, or the train picks up speed (one has to hurry in busy OPDs), one is likely to miss what should not be missed. This is primary care medicine, a lost art. It is more difficult than finding a needle in a haystack. The task is more comparable to finding a needle in a moving haystack.[4] The specialist and subspecialist only sees the referred needles (the diagnosed cases), but without the gatekeepers or general practitioners they would be helpless. The greatest challenge, medicine faces today is how to cultivate the art of managing complexity driven by technological advances and find and nurture the right mix of generalists and specialists. Presently, the balance is getting heavily skewed toward specialization. We need to attract more medical graduates to horizontal specialties like family medicine and community medicine. More important is to develop an attitude that generalists are not “underdogs” of medicine. While the super-specialist may excel in the science of medicine, the art is long and acquired by one who has wandered wide, stood on many platforms, and seen many moving trains, and has developed a diverse worldview with a sharp eye to spot the unusual among the mundane. Data availability statement Not applicable. Author contribution AB was responsible for all aspects of the paper such as concept, writing and revisions.

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