The Evolution of Medical Specialism

THE EVOLUTION OF MEDICAL SPECIALISM JOHN M. LUCE and RICHARD L. BYYNY* A due balance and equilibrium ofthe mind ù best preserved by a large and multiform knowledge; but knowledge itselfü best served by an exclusive (or at least paramount) dedication of one man to one science.—Thomas De Quincey [1] A popular debate in today's medical literature concerns the question of whether specialism has had a positive or negative impact on health. Our own view is that specialism is a historically inevitable process which has brought both harm and good, and we believe that physicians can profit more from understanding the evolution of specialism than from trying to quantify its effects. We also feel that as specialism continues to flourish, a new cadre of highly trained generalists is emerging to deal with the medical needs of most patients. In the following article, we discuss this trend along with the history of medical specialism, particularly in the United States, and its impact on health care. We wish to emphasize from the outset that the evolution of medical specialism should not be regarded merely as a progression from the simple to the complex. Although physicians throughout history have limited the scope of their practices in the face of increasing medical knowledge, specialism does not necessarily follow from generalism and actually may have preceded it. Studies of prehistoric societies, cited by Rosen [2], reveal the presence of several types of healers, each with his own attributes. These healers have utilized prayers and counseling, medicaments, or manual procedures and thereby correspond to contemporary practitioners in the fields of psychiatry, medicine, and surgery. A fourth, and probably older field, has dealt with the diseases of women and newborns. Overlapping the modern areas of obstetrics and ?Division of Internal Medicine, Department of Medicine, University of Colorado Medical Center, 4200 E. 9th Avenue, Denver, Colorado 80262. Work sponsored by a grant from the Henry J. Kaiser Family Foundation, Palo Alto, California. We thank Judith A. Luce, M.D., and Lawrence E. Feinberg, M.D., for their editorial assistance and Karen Michelsen for preparing our manuscript.© 1979 by The University of Chicago. 003 1-5982/79/2203-0076$01.00 Perspectives inBiology andMedicine ¦ Spring 1979 | 377 gynecology and pediatrics, this field was developed primarily because sexual taboos prohibited all but a few persons from assisting women in and around their pregnancies [2, pp. 2-5]. The same four areas ofspecialism are referred to in ancient Egyptian medical literature. The oldest known piece of this literature, the Eden Smith Papyrus, dates from the seventeenth century b.c. and is predominandy a surgical document. Its counterpart, the Ebers Papyrus, which was written in the sixteenth century b.c., focuses on diagnostic techniques and pharmaceutical preparations and thus is considered by Major to be the world's first medical text [3, p. 45]. The Greek historian Herodotus was aware of an even further degree of specialism in Egypt than is suggested by these two writings. As he stated, "The art of medicine in Egypt is thus exercised: one physician is confined to the study and management of one disease. There are of course a great number who practice this art; some attend to disorders of the eyes, others to those of the head, some take care of the teeth, others are conversant with all diseases of the bowels, whilst many attend to the cure of maladies which are less conspicuous" [4, p. 84]. Specialism was also an essential aspect of early Greek healing, and in Greece there appeared the first comprehensive explanation of illness as well as the first formal distinction between medicine and surgery. Pythagorus authored the idea that disease results from an imbalance of the four humors (black bile, yellow bile, blood, and phlegm), corresponding to the four elements, and can be corrected more readily through medical than surgical techniques because of the humors' general distribution throughout the body. In keeping with this belief, Pythagorus assigned the philosophic investigation of illness to medical physicians, allotting to surgeons the empirical treatment of largely combat-related injuries. In contrast, Hippocrates tried to separate medicine from philosophy, urging direct observation of patients to augment theoretical discussion. The "Father of Medicine" also...