Is Being A Specialist Always Better Than Being A Generalist In Your Field?
A friend who works in the Tech industry once told me this story. Tech industries are selecting young men and women in their late teens, teaching them very specialised skills and paying them well. These young people become so good in what they do that they become assets to these companies. However, they do not have any other skills other than the technical skills that they were taught. This is dangerous he said, because if the company goes bust, these highly specialised people will not possess other skills to find other jobs!
A doctor’s Journey in Malaysia
With this story in mind, lets look at the current situation of medical practice in Malaysia. Most medical graduates, do 2 years of housemanship. They then choose a speciality and try to move into this field as quickly as possible. After getting their specialist degree they quickly move to a subspecialty. Upon obtaining the subspecialist degree, they work in this subspecialty for the rest of their lives. Their work is so focused in this subspeciality that they don’t have a broader overview of their speciality. Is this good?
“RANGE” by David Epstein
In the book “Range”, David Epstein argued that being a generalist is as good, if not better, than being a specialist. He quoted an eminent physicist and mathematician, Freeman Dyson. In his paper entitled “ Birds and Frogs”, Dyson wrote that generalist are like birds. Birds fly high in the air and survey broad vistas of mathematics out to the far horizon. Specialists are like frogs. They live in the mud below and see only the flowers that grow nearby. They delight in the details of particular objects, and they solve problems one at a time. He said that science is overflowing with frogs–specialists who are trained only in narrow specialities. This is a hazardous situation for science and for the young people involved.
In the same book “Range”, David Epstein also told the story of Ouderkirk, an inventor and corporate scientist with 3M. In a paper entitled “Balancing breadth and depth of expertise for innovation : A3M story” Ouderkirk and two other researchers set out to study inventors at 3M and wanted to know what profile of inventor made the greatest contributions. They found that both the generalist and specialist have equal number of inventions and patents. The specialist works on a narrow area and only published in that area whereas the generalist works on different domains and brings his knowledge from one domain to another, integrating them and so have patents and inventions in different domains.
Ouderkirk’s group unearthed one more type of inventor. They called them “polymaths,” broad with at least one area of depth. The polymaths had depth in a core area so they had numerous patents in that area—but they were not as deep as the specialists. They also had breadth, even more than the generalists, having worked across dozens of technology classes. Repeatedly, they took expertise accrued in one domain and applied it in a completely new one, which meant they were constantly learning new technologies. Over the course of their careers, the polymaths’ breadth increased markedly as they learned about “the adjacent stuff,” while they actually lost a modicum of depth. They found that these “polymaths” were the most successful in the company with more inventions and patents.”
How Was My Training?
Let me tell you my experience. After doing one year of housemanship at the Kuala Lumpur General Hospital, I worked in the outpatient department of the Hospital Sultanah Aminah Johor Bahru. After that, I worked as a medical officer at the Mersing District Hospital for 1 ½ years. I moved on to Johor Bahru and worked in the chest clinic. After securing a Registrar’s post , I joined the Department of Obstetrics and Gynaecology at the Hospital Sultanah Aminah Johor Bahru. This was a very busy unit. Since there were only 2 consultants and 2 registrars with several medical officers I was exposed to a wide variety of OBGYN cases. Although the main part of my work was Obstetrics, I also had the opportunity to treat a wide variety of gynaecology cases from all different subspecialties namely oncology, reproductive medicine and urogynaecology. Since these subspecialties were not well defined at that time, as a trainee, I did everything. After passing the membership exam of the Royal College of Obstetricians and Gynaecologists, I worked for a year in the UK and returned to Johor Bahru as a specialist. I was also involved in all aspects of OBGYN work. I moved to private practice quite early in my life because of the confidence I had in the skills I acquired working in Hospital Sultanah Aminah Johor Bahru. In private practice, I honed the skills of laparoscopic surgery and later, Reproductive medicine.
Current Medical Training in Malaysia?
Currently, the situation in public and university hospitals is different. When training in the field of OBGYN, exposure to subspecialties is meagre. The reason being, there are already subspecialty trainees and so there is no opportunity for basic speciality trainees to learn subspecialty skills. A friend of mine said that when he was training he had no chance to do any vaginal hysterectomies because these cases were reserved for the urogynaecology trainees. So when someone gets their basic masters degree in OBGYN, the exposure to subspecialties is minimal. They then choose a subspecialty and get experience in that field. Once in a subspecialty, it is difficult to get out to learn skills of another subspecialty. For example a trainee in the field of reproductive medicine will not be able to get any skill that is acquired by a gynaecological oncologist trainee and vice versa.
How I pushed my Laparoscopic surgical skills
I am bringing this up because, when I was performing laparoscopic surgery in the late 1990’s, I realised that it would have been impossible to push my skills further if I did not get the skills of a gynaecological oncologist. Even though I was already doing some gynaecologic oncology work such as open radical hysterectomies, it was not enough for me to do it laparoscopically. So with Dr. Vijay, a gynaecological oncologist, I organised a laparoscopic radical hysterectomy workshop in 2006 and invited Dr Masaaki Ando from Japan to demonstrate this surgery. With my laparoscopic surgical skills and Dr. Vijay’s oncology surgery skills, we embarked on the journey of doing laparoscopic radical hysterectomy for cancers of the cervix and endometrium. This collaboration benefitted both of us, as well as our patients. I became a more skilled laparoscopic surgeon and Dr Vijay in turn, acquired laparoscopic surgical skills. By doing laparoscopic radical hysterectomy, I was able to push my skills to explore the depth of the pelvis enabling me to do more difficult endometriosis cases where all the spaces in the pelvis needed to be opened up.
Similarly, I also had the benefit of working with another laparoscopic surgeon, Dr. Suresh Nair , from Singapore, with a great deal of experience preforming pelvic floor repair. This enabled me to further explore the pelvis in reconstructive pelvic surgery.
Now, how do all these stories tie up? Is being a specialist better than a generalist? Ouderkirk has shown that both generalists and specilaists are important but being a polymaths, someone who is a specialist but also has a broader view of the subject is probably the best. Perhaps as doctors and not mathematicians, we can call them polysubspecialists or in shorter form polysub.
Be a polymath/polysub
I want to be a polymath/polysub. My first love is laparoscopic surgery, but I also have good knowledge of all other fields, which are reproductive medicine, gynaecological oncology, urogynecology and obstetrics. In this way, a patient I see will not be compartmentalised to only one subspecialty. I am constantly looking at expanding my skills by learning from areas adjacent to my field of work. This is something Ouderkirk has suggested. He suggested that to be good in your area of work you should constantly be familiar and be good at “the adjacent stuff”. Since my work deals with the pelvis, I like to see the work of colorectal surgeons and urologists and try to learn their skills so that I will be a better pelvic surgeon. The learning never stops and will continue until the end of my breath.
So what advice can I give young doctors?
- Even though there is a rush to specialise early in life, try to get as much experience laterally in other discipline before zoning into the field of your interest. Later in life you will realise that those skills you acquired during your pre specialisation period will enhance your practice in the field of your choice. If I had to do it all again, I would spend a year working in general surgery, learning to do bowel resection and another year working in urology learning how to repair the bladder and reimplant ureters, before moving onto OBGYN.
- After you have chosen your field and specialised in it, continue learning in the areas that are adjacent to your field. By having good knowledge and skills in these lateral fields, you can outwit your competitors and serve your patients better.
- Never be static in your field. As you dig deeper and deeper and become a true specialist in your field, you will realise that you are loosing some of your inherent skills as you are acquiring these new skills. Try to zoom out to have an overall picture as often as you can. Relook at what skills you are loosing and decide whether you are happy with it.
- Work with others who have skills that you don’t possess. By working with them you can acquire knowledge and skills that will be beneficial to you and your patients.
- Always remember that you are treating the patient and not the symptom.
I would like to thank
My wife Sarojini for editing this article
Dr Gunasegaran for reading this article and giving good suggestion for its improvement