Rheumatology Fellow Faces Dilemma over Choice to Specialize or Generalize

Half a century ago, Konrad Lorenz, the pioneering animal behavior expert, wrote that “Philosophers are people who know less and less about more and more, until they know nothing about everything. Scientists are people who know more and more about less and less, until they know everything about nothing.” As I start the last year of my fellowship, I’m confronted with the unenviable task of trying to figure out whether I’m becoming a philosopher or a scientist. It’s a dilemma that many fellows, in rheumatology and beyond, have to confront as we start to look at careers beyond our graduate training. Unfortunately, there don’t appear to be any clear-cut answers.

On the one hand, it feels natural for a rheumatology fellow to become a generalist. After all, rheumatologists are supposed to be internists par excellence. We don’t own an organ, but rather look at patients as a whole, and are asked to view diagnostic dilemmas from angles that demand multidisciplinary knowledge. To narrow down one’s knowledge base would be a terrible shame, considering the expansive nature of our mandate. One of the true joys of rheumatology, at least for me, is that you never know who your next patient is going to be. We are also fortunate to live in a time in which there is acknowledgment that advances occur at the boundaries of our different specialties, and so we aren’t compelled to limit ourselves from the get-go.

Conversely, there’s a strong push toward super-specialization. Everyone is looking for the world-renowned expert in something, and rightfully so. Fellow physicians have an opportunity to get in on the ground floor by examining one disease or one process that can elevate them to the stature of a regionally or nationally recognized figure. In the academic world, it makes sense, because publication quantity and quality remain major criteria for tenure and promotion, and monopolizing one aspect can ensure a steady flow of scholarly work. Even in the private world, being the expert on Disease X can lead to more consultations and referrals, and hence money. Regardless, if patients have to be seen, it may be in one’s best interest to pick and choose which types enter your clinic’s doors.

I am still personally torn between being a philosopher and a scientist. Or neither. After all, physicians don’t really fit the mold of either. Even though the terminology suggests that specialists are indeed special, there’s no reason to think that generalists are any less unique and can’t fill their own niches. Pathways, like for aspiring clinical educators or administrators, theoretically allow physicians to focus on one domain while still keeping the breadth of clinical range. Better still, maybe there’s no point in worrying, and we should just let our careers fall into place.