I’ve been thinking about generalists and specialists lately, and I’m beginning to think that the education field has fetishized specialists and forgotten about the value of generalists.
My thinking on this question has been prodded by a few articles on health care. In January, Atul Gawande published a moving article in The New Yorker about the “herosim of incremental care.” Gawande, a surgeon by training, explains a debate he had with his friend Asaf, an internist, about the relative merits of generalists versus specialists:
[Asaf] showed me studies demonstrating that states with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke. Other studies found that people with a primary-care physician as their usual source of care had lower subsequent five-year mortality rates than others, regardless of their initial health. In the United Kingdom, where family physicians are paid to practice in deprived areas, a ten-per-cent increase in the primary-care supply was shown to improve people’s health so much that you could add ten years to everyone’s life and still not match the benefit…. Further, the more complex a person’s medical needs are the greater the benefit of primary care.
Gawande spends the rest of the article trying to figure out how this works, and he spends time visiting his friend’s clinic:
“It’s the relationship,” they’d say. I began to understand only after I noticed that the doctors, the nurses, and the front-desk staff knew by name almost every patient who came through the door. Often, they had known the patient for years and would know him for years to come. In a single, isolated moment of care for, say, a man who came in with abdominal pain, Asaf looked like nothing special. But once I took in the fact that patient and doctor really knew each other—that the man had visited three months earlier, for back pain, and six months before that, for a flu—I started to realize the significance of their familiarity.
For one thing, it made the man willing to seek medical attention for potentially serious symptoms far sooner, instead of putting it off until it was too late. There is solid evidence behind this. Studies have established that having a regular source of medical care, from a doctor who knows you, has a powerful effect on your willingness to seek care for severe symptoms. This alone appears to be a significant contributor to lower death rates.
Observing the care, I began to grasp how the commitment to seeing people over time leads primary-care clinicians to take an approach to problem-solving that is very different from that of doctors, like me, who provide mainly episodic care.
The summer issue of The Washington Monthly gave more evidence in the case for generalists through Samuel Jay Keyser’s personal story: a sophisticated surgical procedure saved his life, but a team of generalists really helped him take steps toward a productive life.
I find these arguments compelling.
Both Keyser and Gawande point to the growing body of research that health care patients are often better off with a close relationship to one generalist than they are to a poorly coordinated network of specialists. We see this especially in end-of-life care. Patients with hospice and palliative care live longer and cost less to keep alive than those who receive the usual cocktail of specialists and hospitalizations.
Education, however, keeps trending in the opposite direction. There’s been an ever-increasing push to ensure teachers are given specialized training and licenses to fill specialty roles within schools. As a field, we’ve been operating as if more and more specialization will be a good thing, but hardly any of this is linked to actual outcomes for kids. Still, that hasn’t stopped us.
There’s very little evidence behind the specialist trend, and one study I’m aware of points in the opposite direction. When Houston experimented with creating specialized teacher roles in elementary schools, the generalist elementary school teachers who spent all day with their students helped their students learn more than their peers who specialized in only one subject. The author of the study theorized that the generalist teachers who spent more time with their students could better tailor their instruction. We also see this in other studies of teacher credentials, where deeper content knowledge is far from a guarantee of more effective teaching.
To be sure, there are some elements of schooling where having a specialist is clearly better. If one of my children was being tested for a hearing or learning disability, I’d want a specialist to perform the test. But from my conversations in the education space, I’m worried we’ve taken this concept too far and applied it to everything a school does. Whether that’s a good thing or not is worth further investigation.