10 NATURE FAVOURS THE GENERALIST
Modern technology gives people a wonderful opportunity to develop their potential as generalists. It is also essential to the modern world that they do so.
‘Doctor’s thinkin’, ’Perc.’
Percy’s wife, explaining a long silence.
CERTAINLY NOT A BACK MAN
A patient once said to me ‘I hear you are a back man…’.
I hate being labelled, but if I were to choose a label for myself it would certainly not be ‘back man’. Presumably this patient must have met somebody who had improved after I had manipulated his spine. Many GPs do simple manipulations in spite of condemnations by real ‘back men’ who think that GPs can’t possibly do it properly.
People who do wide-ranging, general jobs are instinctively, and without knowing quite why, unwilling to be judged by a single criterion. The label ‘back man’ puts me in the same category as people who spend their whole professional lives doing nothing but treating backs. I am then judged by that criterion and (unless something is very strange indeed) found second rate.
But I don’t feel second rate. I want to say — ‘OK, I may not be the best there is in this field but I have a great deal of related knowledge and experience of the workings of the human body. I know my limitations and on balance, bearing in mind practical considerations of time and cost and convenience, my simple attempts are actually the best course of action for certain patients in certain circumstances. Particularly when the patients may have many other associated problems and I can’t send them off to specialists for all of them without completely losing track of the patient as a whole person…’ But I’ve lost you, haven’t I? You still think I’m a second rate ‘back man’!
GPs are caught in a crossfire of criticism in this particular field, which is why I have chosen it as an extreme example of the problem I am discussing. On one side we have the formidable ranks of the orthopaedic surgeons. These are the doctors who are responsible for the specialist care of patients with back pain.
For fairly obvious reasons orthopaedic surgeons see little of the common, minor back pain that GPs see almost every day and often several times a day. The orthopaedic surgeon’s experience is restricted to a small minority of patients, selected because they have resisted simple rest, pain killers and physiotherapy, and often manipulation as well. So all the great unseen majority don’t enter the specialist’s consciousness at all. As a result the group of patients they see is far more likely to include people with the serious forms of back pain such as severe disc protrusions and tumours. (I don’t dispute for a moment that this concentration is just what is needed to make scientific progress on treating serious conditions. I am referring to the distorted perception of experts when they extrapolate from their situation to that of generalists.)
The distortions do not end here. Nobody knows how manipulation works, there are lots of theories but the general consensus amongst orthopaedic surgeons is that none of them are valid. So, knowing of no mechanism by which manipulation can work they declare that it cannot work. They say, with the certainty of the expert, that the belief that manipulation does work is founded on illusion. And that those patients who believe themselves to have been helped by manipulation would have improved despite it.
Their attitudes are only confirmed when the occasional patient with a spine weakened by disease is made much worse by manipulation, even to the point of paralysis. Such cases are always admitted to hospital under the care of orthopaedic surgeons and feature in the medical literature. They are actually very rare indeed but media scale distortions apply and make them loom disproportionately large.
So there we have the orthopaedic surgeons. They think that any GP who manipulates spines is going through a pointless and dangerous ritual. Firing at us from the opposite flank we have the osteopaths and the chiropractors. Far from doubting the value of manipulation, they make their living by doing it all the time. Legions of patients, some of them doctors and some, I have little doubt, actually orthopaedic surgeons, testify to their effectiveness. But they have their own reason for saying that GP manipulation can’t work. It is because GPs are not ‘trained’ to do it.
They have had years of specialised training, therefore they think they are the only people who should perform manipulations.
I carry on doing occasional manipulations on certain patients, developing my ideas and my technique all the time, always a little uncertain that I am doing the right thing. I am unsure of the mechanism of my actions, but I do acknowledge my limitations fully. I have a life of experience of the ways of the human body and its pathological processes. And I have the trust of the patient. And when the patient, just occasionally, sits up with an incredulous expression and says ‘What have you done? What have you done Doctor, I can move again.’ I sometimes smile to myself and say, in a competent sort of a way, ‘Just a bit of magic.’.
But I wouldn’t dream of calling myself a ‘back man’.
Neither would a discerning three and a half year old called Gregory who pronounced the following recommendation just after I had removed a large splinter from his thumb, ‘I’m vewy impu-wessed Doctor Willis, getting the spu-winta-woff’.
I’m quite sure he didn’t want a back man, ‘thank you vewy much’.
He wanted a ‘generwalist’. And yes, he really was only three and a half. All my stories are true. He had picked up a turn of phrase from his father.
I had got to a late stage in the preparation of the ideas that make up this book without a clear definition of what I meant by the difference between a specialist and a generalist. In particular, I believed that the difference was a matter of degree and was in no sense absolute.
But I now know differently. Reading a book about the great British philosopher of science, Karl Popper, gave me the idea that I could define a generalist quite precisely, not in terms of what he does, but in terms of what he doesn’t do. My definition is as follows.
A generalist never says that something is of no interest to him.
Does that surprise you? Perhaps you don’t believe me. But I can honestly say that I never say that something is ‘Not my field’. There is a continuous spectrum of my ability and knowledge in different fields but at some level, I am prepared to be interested in everything.
My interest extends to reading Karl Popper’s work. And immensely worthwhile that interest has proved to be. It is a good case in point. Imagine we happened to be designing a curriculum for the training of GPs (and people are busily engaged in this particular aspect of progress as I write). If we ask, ‘Shall we include Popper?’, the answer might well be, ‘No’. So then we would have to ask, ‘OK, are we going to exclude Popper then?’ And my answer would have to be, ‘No. Everything is part of the training of a GP. And part of the job description of a GP, for that matter.’
So then you might reply, ‘But we’ve got to do it. Defining curriculae and writing job descriptions are standard modern educational and management techniques!’
So, after all these years, I have found a way of defining what I mean when I say that I am a natural generalist and why, as a general medical practitioner, I set no bounds whatever to what I am prepared to help my patients with. If an old lady needs help with understanding her central heating thermostat, if I am already in her house and I know how to help her, then I regard it as part of my job to do so. Many people do not. Some feel strongly that I should leave such advice to experts. I think that is nonsense.
HOW EVER DO WE DO IT?
One of the things that I learned at school was that the more things I got involved in, the better I could do each of them. It has always puzzled me that this is not more widely acknowledged. I think people just think it is impossible because it seems so obvious that doing two things must be twice as difficult as doing one. They then simply reject the evidence of their own eyes that it is happening all the time.
They find excuses, they think that the reason some children are good at everything (I certainly wasn’t one of them) is because they are simply brilliant. People just can’t admit what they actually see happening, that being good at two things is frequently easier than being good at one. But if they do accept that this is what happens in real life the gate opens and you find you can move into a field full of excellent explanations as to how it happens.
I am going to give some of these explanations now. They are not particularly difficult or mysterious explanations, once you have accepted that there is something to explain. The first takes us back, briefly, to the beginning of the book, when we considered the relationship between the little bits of our memories that fill our conscious attention and the vast, hidden background of our entire experience.
It’s not so much that the experience contained in our minds is large, remember. Or that it is enormously large. Both words certainly apply, but they don’t tell half the story. The truth is that the capacity of our minds is larger than we believe possible. And that we will always underestimate that capacity.
I have tried to give a conception of this size by using the ocean and beaches analogy. But the analogy also shows how the vast bulk of what is in our minds lies hidden and unseen, and how only a tiny part of it can ever appear on the surface at one time. So that is the first explanation: we can do more things than we think we can because the capacity of our minds is larger than we assume — larger than we believe possible.
I said they were going to be simple.
Another commonplace observation which we ignore because we think it can’t be true is that skills improve in the intervals between practices. We are so indoctrinated with the message that it is only the hard work of constant and unremitting practice which can bring improvement and success that we discount the little voice inside us which says, ‘I think my tennis serve is better at the beginning of this season than it was at the end of the last.’
‘Shhh you fool, it can’t be’, we say. But once we get into the habit of listening to these little nudges from our subconscious we find that they are surprisingly reliable guides.
Then we can set about thinking of explanations. One may be that the patterns of co-ordination and control sort themselves out over time and emerge simplified and clarified in some subtle way which is inhibited if we bash on with relentless practice.
Or, because our minds telescope memories of one category of things by collecting them up in the same memory box, we get far more expert through occasional practice than would be expected when we see the events in their literal context. Our total experience of a particular skill, although spread over a long period, is often substantial. And, quite automatically, our minds do exactly what is necessary to maximise the benefit from this distributed experience. They collect it all together in the same box and exclude other things from our attention.
This is how I discovered ‘Willis’ sign for malaria’ — a small thing but mine own. Willis’ sign for malaria is positive when the patient walks into the room and says ‘I’ve got Malaria!’. For the six cases of malaria I have seen during my career I have found it to be an infallible guide. It works because patients with malaria always know they’ve been exposed and haven’t been taking their prophylaxis, or they have had it before. To make this important medical discovery my mind must have selected a rule which all six of my cases, distributed over twenty years or so, had in common. No mean achievement, but quite automatic. All the thousands upon thousands of other disease categories which would have confused the picture and prevented me seeing a pattern were excluded from the ‘malaria’ box.
During the past ten years or so the ‘jogging’ craze has taught a whole generation of adults the previously unsuspected fact that with a minimum of preparation any normally healthy individual can sustain a jog-trot for as long as it takes boredom to overtake them.
All you have to do to get the maximum return for your training effort, with the minimum risk of giving up because of strains and other injuries, is about twenty minutes, three times a week. This is the same for any other sustained, vigorous exercise. Much less, I believe, than most people would have expected.
Compare this with the training programme needed to succeed in competition. It is clear that a great many other things can be done with the time and energy difference, especially since a moderate amount of exercise actually increases your total energy and vitality. So provided you do do other things as well, each at a moderate level, you will obtain a far greater total return of benefit than if you had applied the same amount of energy all on one thing. (But only you will be in a position to judge. Other people will insist on measuring your success by a single parameter!)
The important thing is to know what your objective is. If you want to be the best in the world in some field, and in our present culture many people do, then you have no alternative but to try to exert yourself with greater dedication than anybody else. If you have natural ability of course it helps, but in most fields there will be plenty of people with natural ability.
Single-minded devotion to training has been the common factor necessary for success in numerous competitive activities throughout the latter part of this century. There has been a run-away escalation of training schedules which must certainly have prejudiced other aspects of the development of the individuals involved.
This is bad enough for the few who are successful, whom we hear about, but what about the many who are not and whom we do not hear about? Nobody wants to read stories about people who devote all the daylight hours of their childhoods to perfecting their butterfly stroke only to fail to achieve success.
The alternative objective, which is currently unfashionable, is to be a well-rounded, well balanced, broadly educated and complete human being. A so-called ‘renaissance man’. This sort of person can justifiably enjoy the enormous achievement of coming last in the London Marathon. For this sort of person the law of diminishing returns is transformed into the law of multiple returns.
It is a truly extraordinary fact that we can apply the same delicacy and control with which we steer a car along a winding road to handling a difficult interview with an estranged couple. This is another example of the enormously significant and powerful mechanism of analogy.
In our minds all the different things we do are in one sense separate and in another sense make-up one ‘whole’. Every single thing in our minds merges into this mysterious continuum. This enables our minds to perform a feat which would be an impossible dream for the designers of computers who are restricted to finite units of information. Our minds express everything relative to everything else. Almost any pair of concepts, however ridiculously dissimilar, are scrutinised automatically and common features found. Incredibly, these common features are then used for a mutual enhancement of both the original concepts. This mechanism is exactly what is needed to simplify the task of handling the real world. Everything is dealt with by analogy.
Even when we approach a new task for the first time we begin with a complete set of behaviour patterns which our mind has selected as being most nearly like what it expects the new task to be. This match is often extremely good and even if it isn’t the mind instantly begins to improve it in the light of experience, using other existing patterns as it does so.
Thus practically any skill, and any knowledge is relevant to practically anything else.
The fact that we cannot understand how this happens, that we cannot understand how it could happen, that we couldn’t begin to make a machine to imitate it happening, doesn’t alter the fact that it does happen. All you have to do to prove that it happens is to notice it doing so.
I have no doubt that many of the skills I develop doing things like mending a lock, digging the garden, sailing a boat, acting as a governor at a local school, singing, or even sitting doing nothing on a summer day, are applicable to making me a better doctor. Or a better father, or husband. Somehow it seems obvious and trite to point such things out. But something is happening to our society which makes it necessary to do so.
Perhaps the most obvious of these explanations is the pump-priming effect. This is the burden of well known sayings such as ‘Things that can be done at any time are never done at all’ and ‘If you want something done, get someone who is busy to do it’.
We all know that we are more efficient when something has already got us going. All sorts of jobs get done in a flash once we have got into the swing of things. We develop a momentum and it seems almost effortless just to feed a few extra tasks through the whirling machinery, even when those tasks might have been quite daunting in isolation.
At other times, when we are dull and unmotivated, we get nothing done at all. As my friend and colleague Christopher Everett once pointed out, the thing that takes longest about gardening is getting out of your chair. This same effect is the explanation for the surprising but common experience of doctors that they get most behind time in surgery when they are NOT under pressure. Once again the surprise is an unerring pointer to the significance. You may well share the surprise, but the observation is true.
Just as in the example of jogging, the emphasis on competitiveness and success in the present-day world has led to the tragic belief that something is only worth doing if it can be done successfully. In other words, if it can be done better than other people can do it. To make matters worse, people make their judgement of success on the media scale.
A beneficial side-effect of this has been what is almost certainly a general increase in the standards of performance in numerous fields as people emulate the international superstars. But much of this benefit is off-set by people being made to realise how second-rate their performances are and then wondering whether it is worth the effort.
The word ‘amateur’ of course comes from the Latin verb ‘amo, I love’. An amateur does things for the love of them. As so often happens, the original meaning of a word holds the key to understanding. Do things for the sheer joy of them. Do lots of things. Do them as well as you can, of course, but judge that against your own standards, not some impossible standards set by somebody else.
In case this heresy should be causing too much distress I must qualify it. First by saying that this approach does not exclude the high-flyer from going off down the competitive road. The two approaches are complementary. On the other hand, if the specialist sportsman is finding that his training has become so all-consuming that his life is becoming distorted and narrow, I do think that he should re-examine his values. Certainly those of us who look on from the terraces should have the courage to question those values and not to go on unthinkingly admiring them.
Once again let me emphasise that the reason I am not arguing the case for the pursuit of excellence is not because I don’t think it is a good case. Quite the reverse. The case is so strong and so central to the present day ethos of the world that it does not need arguing. What I am seeking is a healthy balance and to achieve that I must argue the opposing case which is so sadly neglected.
People often say to me, ‘You must spend an awful lot of time keeping up to date!’.
In a sense I do. I see about a dozen medical journals a week, I attend clinical meetings, I discuss diagnoses and treatments with specialists, I continuously look up facts in reference books, etc.
The idea that there are dozens of new advances in medicine which are constantly changing everything is a myth. The important advances in medicine which are likely to be of relevance to a general practitioner in caring for his patients can usually be read in the columns, if not the headlines, of a responsible newspaper. Not only that, but the news of major advances is invariably repeated over and over again in different places.
The main truths of any other discipline can also be obtained relatively simply. This is certainly not to deny the enormous complexity of the knowledge base that is required to understand any particular field at the level you need to contribute to advances in that field. These two things are quite different.
The fact is that when it comes to getting the cream of vital ideas from any specialist field, nature favours the generalist. He can gallop about plundering innumerable fields for their best ideas. Ideas like those of Leonardo da Vinci and Popper and Einstein, which required genius, inspiration, luck and encyclopaedic knowledge of the accumulated ideas of mankind for their origin, are there to be used by everybody else. It may not seem fair, but it is true, and we are very foolish if we do not make use of this fact. In doing so we come to respect the original thinkers even more but that is only incidental.
MAINTAINING A BROAD KNOWLEDGE BASE
Those of us who are fortunate enough to live in the developed world now have a greater freedom of access to the collected knowledge of mankind than any people in history. The selective power of our minds, which evolved in response to the pressures of a very different world, is serving us astonishingly well in making sense of the deluge of information brought to us by technology.
Not only are we exposed to newspapers, books, periodicals, radio, television, films, computer databases, but to educational organisations and techniques of unprecedented refinement and availability. There has never been a time when there were more fascinating and important things going on in the world or when they were better presented to be accessible to the understanding of ordinary people. It would be a terrible irony if this unprecedented situation were to coincide with a general feeling that people should not attempt to dabble in specialist fields.
From my perspective as a doctor I have no doubt whatever that dabbling, or skimming the cream, is entirely legitimate. Provided we are honest with ourselves and with each other. The important thing is to know our limitations. It is far more important for a doctor to know his limitations than it is for him to be terribly clever. Throughout life, being honest is utterly fundamental.
But not only is dabbling legitimate, it is a responsibility, and one which we all share. In the future, more and more of the effort of life is inevitably going to be directed to maintaining the artificial systems, technological and organisational, which make our lives possible. But the hidden oceans formed by the complex ideas which underpin society are held in form which, although it appears to be sophisticated, is ludicrously primitive when compared with the way in which ideas are held in our own minds. In particular, information technology is nowhere near providing any sort of equivalent for the automatic mechanisms which continuously scrutinise the oceans of ideas in our minds for incongruities.
Everything in nature happens for a reason and if we don’t imitate these natural scrutinising processes we will inevitably find out their importance by bitter experience. But maintaining the whole is an unimaginably larger job than watching the frothy fringes upon which society focuses its collective attention. There is only one conceivable way in which we can hope to cope with this huge task and that is to devolve it to the common sense of individual people.
The world will only continue to work if people keep in touch with the breadth of human knowledge at the same time as they pursue their narrow specialist fields. In other words, if we wish to participate in a democracy we must all accept responsibility for educating our common sense.
To do this we have to be able to rely on the information which we skim. And although our minds boggle at the apparent sophistication of contemporary technology for storing, manipulating and communicating information we sometimes forget the simple fact that the whole edifice of information technology is valueless unless the information stored, manipulated and communicated is true.
THE ANSWER TO EVERYTHING
Life is always more complicated than we think it is. We will always underestimate the hidden background to the things that we see on the surface. And that seems, on the face of it, to be a justification for the specialist approach and for the formal scientific method. i.e. If everything is so complicated there is no point in trying to cope with it all and the only possible way forward is by logical reduction and by specialisation.
It is absolutely essential that we try to cope with the general background. And that in order to do so we have to accept that this can only be achieved as an approximation, it cannot be precise and perfect. And although this sort of approach is diametrically opposed to the convergent, materialistic, mechanistic, specialised approach, that does not mean that one is ‘good’ and the other is ‘bad’. Both are necessary. Both must be kept in balance with each other. And there is no way of achieving this balance in a precise, defined, analysed and formally justifiable way. The only way of doing it is by using the profoundly mysterious abilities of the human mind.
So although it is in a sense easier to be a specialist, to choose one mountain and then climb it all the way to the top, the job of being a generalist, who gets to know a little of every mountain, is ultimately the more important one. Specialisation is a tool just as language is a tool. Both are immensely powerful and important tools which we should all use but they are not essential to life. The forming of a general, overall, self-consistent image of the world is essential to life.
If, through our failure to appreciate the importance and the sheer difficulty of that task we undervalue it and attempt to abdicate it to machines and externally imposed rules of society we will find life progressively impoverished just when we think we are making the greatest progress.
Many people feel that that is exactly what is happening today.