A Defense of Generalism

In Medicine, as in other professional fields like law or academics, it’s not easy being a generalist. To paraphrase Rodney Dangerfield, we don’t get no respect!

Medical school professors - themselves mostly subspecialists at tertiary care medical centers where medical schools tend to be located - try to steer their best students toward the specialities. When I expressed an interest in Family Medicine as a medical student at Penn, I was told more than once that I was “too smart” to go into such a broad field.

I must not be that smart, I thought, because I don’t get it. To my mind, the more you have to know, the smarter you have to be.

In my case, it made it easier that there was never any doubt: I am a natural-born generalist through and through. Looking back at my high school yearbook, I see my senior quote from Balzac: I am not deep, but I am very wide. 

In college I majored in History, mainly because it had the least restrictions on the range of courses I could take to satisfy my requirements. My senior thesis was on Camus and Algeria, and it straddled History, Literature, and French. 

After college I worked in photography for a few years, before deciding to apply to med school and pivot from art to science. 

So, no big surprise that I ended up choosing Family Medicine, the field that puts essentially no restrictions on the kinds of patients and diseases that you get to see.

In 1953, the philosopher Isaiah Berlin wrote an essay called, The Hedgehog and The Fox, which he later adapted into what became his most popular book. The title refers to a poetic fragment attributed to the Ancient Greek poet, Archilochus: “A fox knows many things, but a hedgehog knows one big thing.”

Berlin used this dichotomy to divide writers and thinkers into two groups: hedgehogs, who understand the world through the lens of one big idea; and foxes, who understand the world through a diverse collection of ideas.

Whether that’s quite what Archilochus meant is debatable, but the dichotomy provides a useful model for exploring some of the benefits of being a generalist fox (or, dare I say, in the case of Rachel, a foxy generalist?).

To begin with, there is the breadth of training in Family Medicine, where the fox is certainly taught a great many things. 

Family Medicine residents do rotations in Internal Medicine, Pediatrics, Surgery, Obstetrics-Gynecology; as well as months in specialties like Dermatology, Ophthalmology, and Psychiatry among others. 

Electives go even further and can run the gamet - I did a month at the Philadelphia medical examiners office, learning forensics by performing autopsies in cases ranging from murders to motor vehicle accidents (which, let me tell you, put to rest any fantasy of buying a motorcycle).

One outgrowth of this breadth is the generalist fox attitude that you are not there to do your thing, you are there to do what needs to be done. 

The specialist hedgehog can be like the proverbial hammer, to which everything looks like a nail. Studies have shown, for example, that the main variable that predicts the volume of a given surgical procedure is the number of local surgeons who specialize in that procedure. Hmmm….

The generalist fox, by contrast, is trained to adapt. 

Rachel and I once did a stint working on the Zuni reservation in New Mexico. The doctors there were truly inspirational - whether it was delivering babies, draining abscesses, working in the ICU, treating substance abuse, or managing kidney failure (a big problem in that particular population). Like the immigrants in Hamilton, they got the job done.

Also notable are the integrative skills that a generalist fox must develop in order to handle all the variety. How to spot red flags; how to distinguish between benign and malignant symptoms with similar presentations; how to pace a workup; how to order what is necessary; how to not order what is not necessary; when to refer, and to whom; how to manage a clinical team.

Lately, I’ve been hearing a lot of the expression, “not in my wheelhouse” (interesting etymology: a wheelhouse is a batter’s strike zone), meaning outside of my ability, skill, or interest. When it comes to Family Medicine, let’s just say we have a very big wheelhouse.

You know who else has a very big wheelhouse, and who might make an even better metaphor for the generalist than the fox?

Parents.

A parent is the ultimate generalist, as anyone who has ever had one, or is one, knows. Everything is in their wheelhouse, and they have no choice but to become the expert in whatever their child needs. 

And here is where the fox/hedgehog dichotomy breaks down. Because, while parents may be the ultimate generalist foxes, they are simultaneously the ultimate specialist hedgehogs. 

As every Family Doctor or Pediatrician is aware, the parent is the true specialist of the child - the hedgehog who knows one big thing: this pediatric patient.

I see medical generalists in much the same way - as the fox who knows many things, in order to be the hedgehog who knows one big thing: his patients and their community.

In other words, the ultimate goal of the generalist is ecological - to adapt a broad set of skills to a unique clinical environment. For any given population, its needs will vary widely, so you’d better have a lot of range and be able to evolve accordingly.

One of my medical school professors once asked rhetorically, Do you want to be a jack of all trades but master of none?

Close - a master jack of all trades.