Dog

One worry of mine is the place of general medicine is vanishing.

Of course it remains arguable whether there is a need of general medicine. As Adam Smith pointed out, it would be much more effective to have a division of labour, and each doctor would do better to focus on a small area and excel.

Yes, surgeons are more advanced in their step of differentiation - and there is no difficulty to see the problem of general surgery nowadays. When the first edition of Farquharson's Textbook of Operative Surgery was published in 1954, many surgeons were capable of practising a wide spectrum of operations, and it was possible for a single author to provide comprehensive advice within a single book. In its latest (ninth) edition, ironically edited by the daughter of the original author, there are no less than 24 contributors - and none claim themselves a general surgeon.

And surgery is different. With an inherited emphasis on handicraft, division of labour has the obvious advantage. Of course a surgeon who treats a young woman with recent onset vomiting might do all exotic endoscopic examinations but miss the diagnosis of pregnancy. We laugh at them but, in the future, gastroenterologist may fail in the same way. This argument is just too familiar and I shall not go further.

What troubles me is: physicians' role is often more subtle. Many a time the practice depends on a bird's-eye view of the whole picture and application of common sense that is not common. This patient will die of cancer in three months and there is no point to talk about diabetic control. Salbutamol puff is out for the asthma of this man because he also has severe rheumatoid arthritis of his hands. And the list is endless.

With extensive sub-specialization, who is responsible for practising simple common sense and taking care of cases who are turn away by every specialist ?

Maybe the dogs.

As Geoffrey Vickers said, "Even the dogs may eat of the crumbs which fall from the rich man's table; and in these days, when the rich in knowledge eat such specialized food at such separate tables, only the dogs have a chance of a balanced diet."