The Curse of the Specialist

Common and unusual problems

I am fortunate to have had little need for medical attention in my life so far, but recently I’ve been able to observe the great cogs of the NHS turning (oh so slowly) for someone close to me with a rare and chronic condition. The monolithic organisation is littered with specialists who may have the knowledge to help. The trick, I have learnt, is to get referred to the right one: only then do positive interventions start to happen.

However, navigating the system is different for common complaints, where the diagnosis and treatment is quite straight forward. If I break a bone, there is an X-ray, some sort of cast or bandaging, and then you wait it out while your body heals itself. For more complex breaks there may be additional interventions such as physiotherapy, however the system works quite well as long as variations from the norm are minor. Henry Ford’s flow production principles can be applied at scale if the products are homogeneous. In other words, if the medical problem is a common complaint there will be a standardized approach to moving the patient through the system.

Whilst the human body does appear to malfunction in common ways for the most part, it also misfires in strange, unexpected ways. When confronted with novelty, the NHS cannot apply mass production techniques; instead it turns to specialists.

Diagnoses and treatment of novel conditions

The diagnoses stage of an unusual condition is problematic. Our system guide is the humble GP: the general practitioner. GPs may not have come across the condition before, therefore must observe the symptoms and decide which of the body’s systems is malfunctioning. Tests may be commissioned to help this initial diagnosis. This assessment leads to a referral to a specialist. It is the job of the specialist to confirm the initial diagnosis, and establish with more precision the nature of the condition and appropriate treatment.

There are some false-starts in this approach. The specialist may determine that the initial diagnosis was incorrect and refer back to the GP or on to a specialist in another field. The patient may end up bouncing around the system like in a pinball machine.

However, there is a more problematic trap which I shall term the ‘specialist perspective’.

A specialist is an expert who has focused their attention on developing a mental model of a very narrowly focused domain. The leading specialists in a field will know more than anyone else about this domain and will be pushing the boundaries of this knowledge.

There are obvious benefits to specialists, not least that you have someone treating you that knows as much as there is to know about a particular aspect of human physiology. However, the drawback is that their reference points are clustered, therefore they view the world in a particular way – a specific way. The human body is incredibly complex and interconnected, but the specialist views this complex system through the lens of their specialism: the specialist perspective.

In practice, this means that a specialist in muscular dysfunction will be more likely to perceive a complex set of symptoms as being caused by a muscular problem, a respiratory specialist will diagnose the patient with a respiratory problem, and a psychologist will uncover some trauma or trait which underpins the physical symptoms. I have seen this happen – each specialist is confident that their diagnosis is right and that their treatment will resolve the condition. It is not that the specialist is ‘wrong’, per se, just that they are perceiving the problem from a particular standpoint.

It is possible that in some cases finding the right specialist will lead to a resolution – the condition is an isolated, treatable one. However, it seems likely that most conditions will not be as simple as that. Problems which arise from complex systems will likely have multiple, ambiguous causes which have, over time, resulted in unexpected effects, and  which combine in unique ways to ultimately present as a knotty, messy, confusing range of symptoms. Specialists may unpick one part of the knot and enable the system to untangle itself and regain a healthy homeostasis – complex systems have such emergent properties – but they never fully comprehend the whole.

The curse of the specialist is that their comprehension is coloured by their depth of expertise. Their reference points are clustered, creating a ‘specialist perspective’ which enables insights not available to the generalist, but creates a barrier to the holistic overview.

Specialists and the manifestation of complexity

I would like to discuss the curse of the specialist in relation to schools also, but before I do it is worth abstracting some ideas which I believe carry across domains:

  • Complex systems (such as the human body) have the capacity to reach homeostasis (stability), although intervention might be needed if there is a particular state which we prefer or we want to hurry things along.
  • Common ‘malfunctions’ arise from complex systems which can be dealt with by fairly routine interventions, overseen by generalists.
  • Rare and unique problems arise from complexity which require specialist insights to understand and resolve.
  • Specialists will interpret symptoms against clustered reference points (a specialist mental model) and will prescribe interventions through the prism of this domain.
  • Specialist interventions may be effective if the problem is localised and specific, or if the intervention happens to ‘unstick’ the system sufficiently for the system to self-heal.
  • Specialist diagnoses are not necessarily ‘wrong’, and specialist interventions might be effective, however other diagnoses and prescriptions may also have utility and value. A generalist will need the expertise to temper specialist perspectives and take a more holistic view. Multiple perspectives will provide a more nuanced view of the ‘problem state’ and lead to strategic intervention.
  • The role of intervention in complex systems is to nudge the system towards the desired state. Complexity has the property that it will tend towards stability, but not necessarily the homeostatic state desired.

Specialist perspectives in schools

Allen and White (2019) discuss specialist perspectives in schools and the various ways problems in schools are defined here. They point to the effect described above, whereby the prescribed intervention arises out of the way the problem is defined:

Each definition… smuggles within it a solution. The way in which it is framed tends to highlight a root cause. This implicitly points towards a course of action most likely to tackle said cause.

I summarise Allen and White’s arguments on this phenomena here, and describe how this manifests in schools in terms of how leaders with specific job roles and specialisms define and prescribe solutions to complex problems. This is problematic as the ‘perfect solutions’ proposed are often simplistic and not respectful of complexity. As a result, the naive interventions of leaders make problems worse, not better, and further solutions are needed to ‘fix’ the unintended consequences of the last solution (see Taleb’s Anti-fragile for more on this).

I have been fairly critical of the problems arising from narrow and simplistic responses to complexity – particularly managerial and generic leadership approaches – and Allen and White are even bleaker in their portrayal of the ‘waves of destruction’ caused by naive interventionism. However, I’d like to focus here on the some positives of a specialist perspective and how we can begin to overcome the curse of the specialist.

Emergent order and stability

Complex systems are paradoxical in that they have a tendency towards disorder (entropy), but order and stability emerge from the chaos (homeostasis). This is evident in our universe – the ultimate observable complex system – where, despite a constant deconstruction of any order we impose (the sandcastle blowing away in the wind), order and stability emerge in the form of living and mechanical systems (blooming flowers, swarms of insects, the formation of planets and birth of solar systems).

Schools are (to an obviously lesser extent) also complex systems that will exhibit the property of emergent order and stability. If left alone, the equilibrium reached may not be desirable to us, but randomness will result in behaviours we recognise as patterns and rules.

Those suffering from chronic pain can be considered to be in a stable state, but it is a state we are not satisfied with. Specialist intervention may shift this state to a more acceptable equilibrium. As noted above, it is probably not the case that the intervention ‘cures’ the problem, but that it allows the human body to self-heal by unlocking one part of the defective system.

Similarly, if the status quo in schools is undesirable, the right intervention may set off a chain of events such that a new (different) ordered state emerges. It would be naive for those making the intervention to ever believe that they were in control of complexity; that they designed and engineered this altered state. Expertise is not omnipotent or omniscient: expertise is knowing which levers to pull to increase the liklihood that more preferable states will emerge.

The right specialist, making the right intervention at the right time, might nudge the system into a new, more desirable state. However, the curse of the specialist means that they will be prejudiced in their diagnosis of the problem and  choice of intervention. Furthermore, multiple specialists, if left to their own devices, will prescribe multiple interventions which will combine in unpredictable ways to create further complexity and unexpected effects.

The generalist

The expertise of the headteacher lies in moderating the naive interventions of those with specialist perspectives. Of course your data manager wants to implement a new data system to improve management information; your professional development coordinator will want to use INSET day to up-skill teachers; your pastoral lead will have a new set of rules which, if followed, will reset behaviour. It is not that any of these interventions are ‘wrong’, per se, just that they address the problem as viewed from a particular standpoint.

The chief generalist must have an understanding of complexity. Generalists draw upon multiple perspectives, including those of other generalists as well as the available specialists, to deepen their understanding of the ways in which the emergent state of the system is undesirable and the levers which will nudge the system towards a more desirable equilibrium. Specialist perspectives are vital but must be tethered by the generalist so that naive interventions are not allowed to proliferate.

It is in the interplay between the generalist and specialist(s) that informed leadership emerges. The generalist is cursed with never knowing everything they need to know. The specialist is cursed with a biased perspective which favours a particular interpretation of the system. In denial of complexity, this might result in ill-informed and disjointed intervention. However, I remain hopeful that we might find better ways of uniting the generalist and specialist, and in doing so create a more intelligent form of leadership.

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