Seaside, Florida is a neat place to visit. On the gulf coast in between Destin and Panama City, it was built 25 years ago to function as a livable community that happened to be on the beach.When the project was begun, in 1984, the area resembled every other Gulf Coast development:

From the development’s eastern boundary to Panama City, some thirty miles away, the seashore is as crass and chaotic as any in America. Lining the highway on the Gulf of Mexico are economy-grade motels, concrete-block convenience stores, mansard-roofed refreshment stands, shops selling airbrushed T-shirts, and a profusion of cramped housing developments, each built according to a different pat formula–Tudor townhouses, weathered-cedar-shake apartments, stucco-and-tile condominiums, gray clapboard row houses, rustic log cabins, and many others. The state highway department, with unintended irony, has put up signs designating this a “scenic route.”

The developer. Robert Davis,  wanted something special and he hired an architect/planner duo, Andres Duany and Elizabeth Plater-Zyberk, to make the 80 acre site something special. Like all good architects they started with the buildings.

Every house built in Seaside is different, but within the variety is a fundamental orderliness, established by the unifying wooden walls and metal roofs, the substantial porches, the proportions of the windows, and a number of other elements, among them the harmonious colors–a rainbow of pastels.

Important in the appeal of Seaside is the attention to not just the built environment but the common environment

Davis, rejecting the traffic-engineering standards of most municipalities, kept the streets narrow. The pavement is usually eighteen feet wide–“just enough for two cars to pass comfortably.”

Andres Duany was recently in Mobile at the invitation of the Downtown Mobile Alliance. I have read much about the New Urbanism movement which he founded and so was disappointed not to be able to go to his speech. I was delighted to find it posted on  the Alliance website. Duany doesn’t dwell on what he saw here. Instead he speaks to the value of a generalist as a planner. He points out that the zoning specialist focuses on zoning and the planning specialist focuses on planning. If the policy makers allow them to make the rules without input (he’s the expert)  then the city has no character and is built for ease of use of special constituents (such as “big box” stores) and not for the citizens resulting over time in “dead malls.”

What does this have to do with Training Family Doctors? A lot, it turns out. Andres Duany is a self described generalist. He commented that during his ride from the airport he was able to identify the exact corner where the death was occurring. Like a physician, he says, he can predict what will happen, what will happen, and perhaps what it will take to correct the problem. As a generalist, he points out that the work of planning the cities by the “specialists” has left whole areas decaying. While this was not by design there is certainly a cause and effect.

There is a very good article in a recent New England Journal of Medicine (subscription required) entitled “Lessons from the Mammogram Wars.” In it, the authors point out that as a consequence of a panel suggesting that less use of a service (in this case, mammograms) might actually result in not only less cost but in better patient care. They point out the controversy is cause in part because folks who benefit from the increased use of technology (in this case the mammographers) write rules regarding optimum use of the technology and then criticize those who would suggest differently.

The authors point out that part of the problem in medicine is our belief that specialists always act in the interest of the patient alone and another part of the problem is that people want to believe that technology doesn’t lie. Thus, if you the patient have an understanding of an intervention and how the experts determine it should be used then the patient can make an informed purchasing decision without further assistance (A).

Instead, we now know that all interventions have a potential risk and a potential benefit to the patient. In the words of the authors (and illustrated as B in the illustration):

To this end, for most interventions, rather than seeking a single, universal threshold for intervention we should be arguing over a minimum of two distinct thresholds: one above which benefit clearly outweighs the risk of harm, in which case clinicians should recommend a treatment; and one below which concern about harm clearly dominates, in which case clinicians should recommend against that treatment. Between these two thresholds lies a gray area of indeterminate net benefit, in which clinicians should defer to an individual patient’s preferences — including, for example, a woman’s emotional response to her risk of breast cancer — in choosing whether to intervene

To that, I would add the gray area at the end of life for many interventions as well. It is clear that the specialists are expert at designing effective systems for certain situations and when the patient fits into these situations this results in “the best health care in the world.” It has also resulted in expensive and ineffective health care. The addition of the generalist in the mix, both at a policy level as well as at the patient care level. will result in better, more personalized care. Your family physician may not be an expert on mammograms, but let’s allow them to be an expert on “you” and what your wants and desires are. I only hope we can create a a system in urban planning as well as in health care  that values and rewards generalist discussion over blind intervention.

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