In the training period of specialization in any field, the focus toward acquisition of a skill requires commitment to all the elements that comprise the specialty. This is not only true but is self evident. It is abundantly clear that the more the time, effort and applied intelligence is availed, will result in greater knowledge of the elements needed for superior performance. Narrowing the field of specialization will enable the individual to seek and find higher and higher planes of information leading to superspecialized knowledge on a narrower base, and more and more unique capabilities, but often bound to the tree rather than the forest. In the practice of orthopedic surgery for instance, the knowledge base of generalized medicine and surgery precedes the specialization in order to give a sound foundation to the surgical decision making. Embarking then on progressively exclusive specialization diminishes the time available to renew the broader knowledge base, up to which half of it changes every ten years. The fragmentation of medical specialties and subspecialties has sacrificed general knowledge for specific knowledge. The concept of the ideal orthopedic surgeon of yesteryear is best exemplified by my written examination for Fellow of the Royal College of Surgeons of Canada, (Orthopedics), of 1963. I say this not to recommend it but to show the degree of emphasis at that time. The exam was on four topics, given equal importance. 1. The causes of Essential Hypertension 2. Fractures of the Tibia 3. The mechanism of Renal Tubular Absorption 4. The Embryology of the Spinal Cord. To be granted a Fellow, was to have a broader knowledge. The excellence achieved by repetition and focus on the other hand, in surgical procedures, as in "practise makes perfect" leads to technical success at the cost of openness to the challenge of change and broader learning . In the forty years of orthopedic surgery that I participated in, the progressive narrowing of the individual's scope of his field of work was necessary in order to to maintain the skill-set in a era of rapid progression of knowledge. The value of intraspecialty team practice as provided by closely knit groups, working intimately together, allows for greater discovery and shared insights. The value of new insights provided by interspecialty surgical relationships is often not taken advantage of with the pressure of time but is a potent source of discovery. I have often thought that the ideal surgical model for excellence is threefold, granted equal skill and knowledge brought at the begining of one's surgical career.
1. Close knit group practice in the chosen specialty (ongoing learning from the intraspecialty activity due to cross fertilization)
2. Progressive narrowing of the scope of practice with ageing.
3. Closer connections with the wide range of medical specialties (ongoing learning from contact to interspecialties leading to hitherto unrealized cross fertilization) calculated to counter fragmentation, and avail oneself of the deep well of current medical knowledge and what one can steal to apply to one's own specialty.