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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 disease management?

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 specialists.

In all of its glorious fragmentation, it's really a completely integrated and artificial whole. It's how we naturally live these days.