Every institution seems to be heading for fragmentation. Let us take stock of the political scene in our country. We daily see the smaller groups of people perceiving the advantages of fragmenting the country for their benefit, into smaller and smaller bits as if we have not had enough of the already existing states in the country. What with all the administrative machinery eating up most of the country’s annual budget, leaving very little for any developmental works, we still want more administrators and expensive ministers in the newer states. Political parties are another good example. Almost every day a new party is born only to die a natural death after making enough money. Larger parties are breaking up every day into all sorts of smaller fragments, named after individuals. This will certainly destroy our democracy in the long run.

Take the example of the human body for our analysis. It is very good in functioning as an organism for nearly seventy odd years if in good shape. If any of the tissues declare independence, in the long run, the whole system will disintegrate and get destroyed. No part of the human body could function in total isolation. The only saving grace for the future is a holistic approach to man’s ills. The latter is not being appreciated, nor is being taught to the young students in the medical schools. This philosophy is not conducive to the new ethos of specialisation and further fragmentation into subspecialties.(1) The key word in the medical field is that of fragmentation of medical knowledge in trying to know more and more about less and less.

Man, in the new set up, is perceived as his body which we see, with all its details of height, weight, body mass index, fat pad thickness, blood chemistry measurements, and many other details that we could measure with our present knowledge. This is called his phenotype (form or shape), which accounts for only 30% of his make up. In addition he has his genome, the genetic make up, forming about 40-60%, and the rest is made up of his consciousness or mind. In our present set up we try to study man (and screen him) by only knowing less than 30% of his make up. Then we take pride in predicting his future based purely on these parameters. Naturally the future predictions go wrong; they should, as they do not know the total initial state of the organism. Time evolution in the dynamic human organism does not follow the linear equations that we use in medicine.(2) For better use of future predictions we must view the body as a whole with, when possible, the knowledge of the genome and the mind.

Take the hospitals of yore for example. Hospitals, derived from the word hospitality, were very good for the sick, but they soon changed to specialist clinics and later became superspecialist in their attitude and have disintegrated in the West. Do we learn our lessons from others’ mistakes ? Never! As we are very clever we want to go through our own mistakes and learn. In the West new hospices have sprung up in place of the old hospitals, again to look after the dying and give dignity to death as well, because death is inevitable, despite the hi-tech medicine that we think we are practising. American hospitals are empty, British hospitals are closing down, the French are opting for the Chinese system of medicine, but we, the proud Indians, are going in for five-star hospitals and try and fragment medical practice into specialties and sub-specialties (superspecialties in Indian English ).

Smaller groups of individuals, calling themselves specialists, try to see the advantages in becoming independent of the previously unified set up, put forward arguments to fragment the system. They claim to do better patient care and give hi-tech specialised service to the specialised sick, belonging to their microspecialty. They forget to look at the whole, and in the bargain, never get the wisdom of keeping the organisation as a whole for the good of the suffering humanity. Human body is never to be seen and corrected in bits and pieces. Let us take the example of one small subspecialty of cancer.

A cancer specialist thinks that the whole of the organisation needs to be his for better patient care. He puts forward arguments to say that cancer treatment and cancer detection are the key to keep man alive on this planet. He fails to see the writing on the wall. Despite all the efforts death rate in cancer has not shown a tendency to go down, although in some small subsection they have achieved some success. Cancer screening is a different story. Mammographic screening of breast cancers in young women is of uncertain effectiveness. (3 & 4) It is still not clear as to which screening method is good enough for ovarian cancer. (5) With these and many other studies about other screening methods, the National Health Service in the UK refuses to invest money in this kind of procedures; but the direct money spinning American hospitals still encourage cancer screening and we, of course, have to follow the Americans. !

The cancer of fragmentation is slowly spreading to graduate medical schools as well, definitely to the detriment of undergraduate teaching. A novice in the field of health care, the innocent undergraduate medical student, does not get the true message of the unity of the human body, and its incapacity to work in bits and pieces. In the new scenario of the plethora of specialties, the novice gets the wrong message, what with the halo around the sub (super) specialist in the teaching hospitals the young graduate student wants to ape him, but naturally. This brings on the dangerous very early subspecialisation craze, not knowing and understanding the human being as a whole. I have seen this adversely affect the basic tenet of the medical profession of "curing rarely, comforting mostly, but consoling always".

Professor Eisenberg, in the USA went through the present medical course, once again at the age of fifty. He resigned his job and took the entry test to the medical school and went through the course in the right royal way. He has been totally disillusioned about the way the young medico is taught the tricks of the trade in the present day hospital set up. One or two American Universities, led by the Minneapolis University, have set up new reorganized departments of general medicine and general surgery to oversee patient care and graduate teaching.

The best bet for the common man in the present set up is to have a good family doctor as his friend, philosopher, and guide. Every one should be guided by his family doctor in matters of health and illness. The specialists should be consulted only when advised by the family doctor. If followed, this method might cut down on the incidence of a new disease called, the Ulysses Syndrome. The latter is due either to diagnostic or therapeutic misadventure. The present day heroic surgeries and other modes of treatment are all fine as long as the hero’s role is played by the poor patient who subjects himself to the procedure.

We must be careful about this new trend for fragmentation. Fragmentation is ultimately inevitable and will destroy any organism or organisation. This is not speculation or bad thinking. It is the rule or a law, called the First Law of Thermodynamics. It is frightening to know the future prospects of the health care industry with the First Law of Thermodynamics in operation. Physics is the king of sciences and the laws of Physics cannot go wrong. I have given the warning. Beware !

Bibliography.

1. Hegde BM, Holistic Living. Book 1992. Bharathiya Vidya Bhavan, Bombay.

2. Hegde BM, Chaos- A new concept in Medicine. Jr. Assos. Physi. India 1996, April ( in Press)

3. Forrest AP & Alexander FE, A question that will not go away- at what age should mammographic examination begin? Jr. Natl. Cancer Inst. 1995; 87: 1195-7.

4. Evans DER, Fentiman IS, Mc Pherson K, et al. Familial breast cancer.Br. Med. Jr. 1994; 308:183-7.

5. Philips J. Is screening for ovarian cancer worthwhile? Jr. Med. Screening 1994;1:206-7.