Gary Oftedahl: When Being Special is Possibly Partial…

July 19, 2010 at 9:57 am 2 comments

(Warning:  The following may cause some to develop an uncontrolled spike in blood pressure, and incite a feeling of frustration with the author)

We’re all competitive, wanting to be the best.  Heavens, I’m from Minnesota, home of Lake Woebegon, where everyone is above average.  At times, I feel a sense of pride in being in the top 10, and being referenced as coming in 7th is often enough to justify a bit of puffery.  So when a recent Commonwealth Fund report, MIRROR, MIRROR ON THE WALL noted the United States had finished 7th in it’s health system performance in a recent survey, taken out of context, this might sound encouraging.  But we all know the real story is that this ranking places us 7th out of 7 countries.   And it wasn’t even close!!!

The Commonwealth Fund has done us a service by surveying the quality of care in 7 different countries—with many differences in structure and culture, but all facing challenges of cost and quality.  While the U.S. spends approximately twice as much per capita on health care as any of these other countries, we rank last or next to last on all five dimensions measured—quality, access, efficiency, equity, and length of productive lives.

While there are many factors contributing to this ranking, I’d like to focus on a semantic issue, which has likely contributed in great respect to the disparity.   I realize this is potentially likely to incite negative responses, and want to preface that it’s not to minimize the value of anyone’s efforts, but to whimsically raise an issue which needs to be addressed.  It’s about being “special.”   We all want to be special, to be recognized as outstanding in our field, highly accomplished, a “scratch” golfer (I can forget that one), you name the field, I’ll name how to be special.

Let’s apply that to health care.  If I’m a PCP, that term itself is poorly understood by most of the population.  If I’m a generalist, there’s an implicit sense that while I’m perhaps a jack of all trades, I’m not very accomplished in any one area—I’m not “special.”   But if I focus my medical training efforts, become proficient in caring for a very limited but specific area of focus (e.g. skilled at right sided tear duct reconstruction, laparascopic surgery of any sort, expert at managing polycythemia rubra vera), I become known as a “specialist.”  While it’s an oversimplification, and open to criticism, I suggest that subconsciously, being a “specialist” as opposed to a “generalist” has undertones that drive decision making in choosing a career.

And, because we value being special in so many ways, we pay much more for something that is “special.”  We can fool ourselves into thinking that a bottle of wine we paid $30 for tastes much better than a bottle of “three buck Chuck”  (Trader Joe fans know of which I speak).  A hundred dollar tie just has to look better than the one purchased for $7 at a local T J Maxx—it just has to.    Similarly, having my skin growth removed by a dermatologist just has to be worth much more than having it done by my family doctor—doesn’t it?

I’m being whimsical, or perhaps not, but think about the implications if we considered giving what is today called a “specialist” the more appropriate title of a “partialist.”  At the same time, let’s eliminate the underlying negativity toward generalist, but suggest that they’re in fact “comprehensivists.”  To be a comprehensivist requires unique skills mastering many different aspects of the human frailties, exact diagnostic skills, terrific communication capabilities—all important in dealing with the entire panoply of challenges humans confront in our battle with fighting off the relentless effects of aging (commonly referred to as living).

We face a crisis in our health care system.  The Commonwealth Fund report once again presents a clear argument for many of the changes necessary in our system, but one of the principal ones is the need to develop a more robust primary care system—using health care home, technology, patient engagement, and prevention—to address the many failings of our situation.

To assist in addressing this massive challenge, let’s start with attempting to in a small way impact the thought processes of future doctors and health care providers.  Who would want to be a “partialist” as opposed to a “comprehensivist” giving the understanding of what is required?  In addition, we would apply an added value (read payment) to those choosing to tackle the daunting task of being a comprehensivist and assuming the “special” role of managing a person’s total needs.  But today, it’s “special” to be a specialist, from status, recognition, and reimbursement.  It’s a small start, but every great journey starts with a small step—nothing “special” about it.

Entry filed under: General Info, Health Care Redesign. Tags: .

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  • 1. Leonard Kish  |  July 19, 2010 at 11:07 am

    Reminds me of the Russian headline when USSR lost to USA in 2-way competition: “USSR finishes 2nd, USA finishes 2nd to last.”

    You make some great points. We are competitive and status-seeking by nature. I think it was Tom Wolfe who said we spend 50% of our brain power on status: But maybe more than that, we want a quick way to measure value, our own and other’s. It creates better reinforcement.

    I’m currently reading John Hagel et al’s “Power of Pull” ( and in it they discuss that in online communities “the desire for a high reputation is an important motivator for increasing one’s participation” (p. 147). Makes me wonder if online physician communities might someday provide a form of reputation and recognition for primary care as well as others. Imagine physician’s discussing complex cases or scoring on outcomes in online communities as a way to bolster reputations.

    • 2. goftedahl  |  July 25, 2010 at 3:15 pm

      Leonard, Thanks for your thoughts. While I may have been a bit whimsical, and perhaps on the fringe, it is my hope to raise issues which while they may seem trivial to some, could lead to a deeper conversation.

      Thanks for the references, as I’m always interested in different perspectives and insights.


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