— BOOK AND MEDIA REVIEWS —

Range: Why Generalists Triumph in a Specialized World

Kenneth W. Lin, MD, MPH

Fam Med. 2020;52(5):371-372.

DOI: 10.22454/FamMed.2020.358948

Book Title: Range: Why Generalists Triumph in a Specialized World

Book Author: David Epstein

Publication Information: New York: Riverhead Books, 2019, 352 pp., $28, hardcover

Family physicians have a complicated relationship with generalism. On one hand, what most distinguishes us from other physicians is our ability to manage a broad range of acute and chronic conditions in patients from cradle to grave—to care for the entire patient rather than a single body part or organ system. On the other, we can be acutely sensitive to put downs such as “jack of all trades, master of none,” and often respond that we, too, are specialists–in “the skin and its contents,” in “health care integration,” or in the “whole person.”1 The subtitle of David Epstein’s Range suggests that generalists can outshine specialists in a variety of professions. Although only a few pages directly refer to medical practice, Range nonetheless provides important messages for family medicine educators.

The book begins by questioning the widely held notion that the best way to develop a superstar athlete is through early narrow specialization, with the most famous example being the golfer Tiger Woods. It turns out that the more common narrative is that of Roger Federer, who dabbled in wrestling, swimming, skateboarding, and soccer deep into his teenage years before focusing on tennis. Epstein writes, “The challenge we all face is how to maintain the benefits of breadth, diverse experience, interdisciplinary thinking, and delayed concentration in a world that increasingly incentivizes, even demands, hyperspecialization” (p 13).

Compared to subspecialists, generalists are more likely to be comfortable with conceptual reasoning and applying broad principles to situations outside of previous experience. Epstein recalls an undergraduate chemistry professor who posed test problems that challenged students to make multiple reasonable estimates to come up with ballpark approximations, illustrating the point that “detailed prior knowledge was less important than a way of thinking” (p 52).

To the public, medicine probably appears to be a narrow set of procedures to be mastered through repetition—a view that could also apply to math and music, subjects of two chapters in Range. Practice helps, of course, and for people whose training goes no further than grade school, performing by rote may be the easiest path to generating the correct answers or playing an instrument competently. But Epstein observes that learners acquire a more durable and flexible knowledge base when they first struggle at a subject and work through “desirable difficulties,” which “intentionally sacrifice current performance for future benefit” (p 85).

A later chapter explores how experts make economic and foreign policy forecasts. Epstein contrasts “narrow-view hedgehogs,” who spend their careers on one problem or view all problems through a single discipline-specific lens, with “integrator foxes,” who attain a breadth of expertise and are superior at long-term forecasting. Professionals with range are better equipped to tackle novel problems where familiar tools don’t work, such as the O-ring failure that led to the space shuttle Challenger explosion. Faced with uncertainties surrounding a launch decision on a 40-degree day, NASA managers regressed to what they knew best, which was to demand (nonexistent) data to support the engineers’ suspicion that the O-rings were more likely to fail in cooler weather. Lacking such data, NASA overrode these concerns and approved the fatal launch.

Two examples in Range derived from medicine involve interventional cardiology and arthroscopic knee surgery. Even after randomized, controlled trials demonstrated that patients who underwent stenting for stable coronary artery disease2 or arthroscopic surgery for knee pain and a torn meniscus3 did no better than others who had medical or physical therapy alone, these procedures continue to be performed thousands of times each year. Lacking a generalist’s view of the body as a complex integrated system, cardiologists or orthopedists who focus on “small pieces of a larger jigsaw puzzle in isolation” (p 267) simply can’t believe that their tools don’t work in these situations.

What lessons can family medicine teachers share from Range with their colleagues and students? Even subspecialists benefit from first undergoing generalist training (Roger Federer). Teaching new skills within a broad conceptual framework rather than as disconnected individual tasks may be more difficult for the student, but it creates more lasting knowledge. Breadth has advantages over depth of expertise, particularly in solving novel problems where familiar tools don’t work. Appreciate that the human body is a complex integrated system, and use caution before recommending invasive procedures to fix one malfunctioning piece of the puzzle.

References

  1. Reynolds L. Coping with family medicine put-downs. Can Fam Physician. 2005;51:1081-1082.
  2. Stergiopoulos K, Brown DL. Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172(4):312-319. https://doi.org/10.1001/archinternmed.2011.1484
  3. Sihvonen R, Paavola M, Malmivaara A, et al; Finnish degenerative meniscal lesion study (FIDELITY) group: arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013;369(26):2515-2524. https://doi.org/10.1056/NEJMoa1305189

Lead Author

Kenneth W. Lin, MD, MPH

Affiliations: Georgetown University Medical Center, Washington, DC

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