In 2006, Dr. Atul Gawande wrote an article in The New Yorker about maternal care entitled “How Childbirth Went Industrial”. It’s an excellent piece from an author who consistently produces excellent pieces. In it, Gawande charts the rise of the C-section, from its origin as technique so dangerous it was considered tantamount to murder (and consequently banned on living mothers), to its current place as one of the most common surgical procedures carried out in North American hospitals.
The C-section – and epidurals and induced labour – have become so common because obstetrics has become ruthlessly focused on maximizing the Apgar score of newborns. Along the way, the field ditched forceps (possibly better for the mother yet tricky to use or teach), a range of maneuvers for manually freeing trapped babies (likewise difficult), and general anesthetic (genuinely bad for infants, or at least for the Apgar scores of infants).
The C-section has taken the place of much of the specialized knowledge of obstetrics of old, not the least because it is easy to teach and easy for even relatively less skilled doctors to get right. When Gawande wrote the article, there was debate about offering women in their 39th week of pregnancy C-sections as an alternative to waiting for labour. Based on the stats, this hasn’t quite come to pass, but C-sections have become slightly more prevalent since the article was written.
I noticed two laments in the piece. First, Gawande wonders at the consequences of such an essential aspect of the human experience being increasingly (and based off of the studies that show forceps are just as good as C-sections, arguably unnecessarily) medicalized. Second, there’s a sense throughout the article that difficult and hard-won knowledge is being lost.
The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills—the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands. But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.
Medicine would not be the first industry to industrialize. The quasi-mythical King Ludd that gave us the phrase “Luddite” was said to be a weaver, put out of business by the improved mechanical knitting machines. English programs turn out thousands of writers every year, all with an excellent technical command of the English language, but most with none of the emotive power of Gawande. Following the rules is good enough when you’re writing for a corporation that fears to offend, or for technical clarity. But the best writers don’t just know how to follow the rules. They know how and when to break them.
If Gawande was a student of military history, he’d have another metaphor for what is happening to medicine: warriors are being replaced by soldiers.
If you ever find yourself in possession of a spare hour and feel like being lectured breathlessly by a wide-eyed enthusiast, find your local military history buff (you can identify them by their collection of swords or antique guns) and ask them whether there’s any difference between soldiers and warriors.
You can go do this now, or I can fill in, having given this lecture many times myself.
Imagine your favourite (or least favourite) empire from history. You don’t get yourself an empire by collecting bottle caps. To create one, you need some kind of army. To staff your army, you have two options. Warriors, or soldiers.
(Of course, this choice isn’t made just by empires. Their neighbours must necessarily face the same conundrum.)
Warriors are the heroes of movies. They were almost always the product of training that starts at a young age and more often than not were members a special caste. Think medieval European Knights, Japanese Samurai, or the Hashashin fida’i. Warriors were notable for their eponymous mastery of war. A knight was expected to understand strategy and tactics, riding, shooting, fighting (both on foot and mounted), and wrestling. Warriors wanted to live up to their warrior ethos, which normally emphasized certain virtues, like courage and mercy (to other warriors, not to any common peasant drafted to fight them).
Soldiers were whichever conscripts or volunteers someone could get into a reasonable standard of military order. They knew only what they needed to complete their duties: perhaps one or two simple weapons, how to march in formation, how to cook, and how to repair some of their equipment1. Soldiers just wanted to make it through the next battle alive. In service to this, they were often brutally efficient in everything they did. Fighting wasn’t an art to them – it was simple butchery and the simpler and quicker the better. Classic examples of soldiers are the Roman Legionaries, Greek Hoplites, and Napoleon’s Grande Armée.
The techniques that soldiers learned were simple because they needed to be easy to teach to ignorant peasants on a mass scale in a short time. Warriors had their whole childhood for elaborate training.
(Or at least, that’s the standard line. In practice, things were never quite as clear cut as that – veteran soldiers might have been as skilled as any warrior, for example. The general point remains though; one on one, you would always have bet on a warrior over a soldier.)
But when you talk about armies, a funny thing happens. Soldiers dominated2. Individually, they might have been kind of crap at what they did. Taken as a whole though, they were well-coordinated. They looked out for each other. They fought as a team. They didn’t foolishly break ranks, or charge headlong into the enemy. When Germanic warriors came up against Roman soldiers, they were efficiently butchered. The Germans went into battle looking for honour and perhaps a glorious death. The Romans happily gave them the latter and so lived (mostly) to collect their pensions. Whichever empire you thought about above almost certainly employed soldiers, not warriors.
It turns out that discipline and common purpose have counted for rather a lot more in military history than simple strength of arms. Of this particular point, I can think of no better example than the rebellion that followed the Meiji restoration. The few rebel samurai, wonderfully trained and unholy terrors in single combat were easily slaughtered by the Imperial conscripts, who knew little more than which side of a musket to point at the enemy.
The very fact that the samurai didn’t embrace the firing line is a point against them. Their warrior code, which esteemed individual skill, left them no room to adopt this devastating new technology. And no one could command them to take it up, because they were mostly prima donnas where their honour was concerned.
I don’t want to be too hard on warriors. They were actually an efficient solution to the problem of national defence if a population was small and largely agrarian, lacked political cohesion or logistical ability, or was otherwise incapable of supporting a large army. Under these circumstances, polities could not afford to keep a large population under arms at all times. This gave them several choices: they could rely on temporary levies, who would be largely untrained. They could have a large professional army that paid for itself largely through raiding, or they could have a small, elite cadre of professional warriors.
All of these strategies had disadvantages. Levies tended to have very brittle morale, and calling up a large proportion of a population makes even a successfully prosecuted war economically devastating. Raiding tends to make your neighbours really hate you, leading to more conflicts. It can also be very bad for discipline and can backfire on your own population in lean times. Professional warriors will always be dwarfed in numbers by opponents using any other strategy.
Historically, it was never as simple as solely using just one strategy (e.g. European knights were augmented with and eventually supplanted by temporary levies), but there was a clear lean towards one strategy or another in most resource-limited historical polities. It took complex cultural technology and a well-differentiated economy to support a large force of full time soldiers and wherever these pre-conditions were lacking, you just had to make do with what you could get3.
When conditions suddenly call for a struggle – whether that struggle is against a foreign adversary, to boost profits, or to cure disease, it is useful to look at how many societal resources are thrown at the fight. When resources are scarce, we should expect to see a few brilliant generalists, or many poorly trained conscripts. When resources are thick on the ground, the amount that can be spent on brilliant people is quickly saturated and the benefits of training your conscripts quickly accrue. From one direction or another, you’ll approach the concept of soldiers.
Doctors as soldiers, not as warriors is the concept Gawande is brushing up against in his essay. These new doctors will be more standardized, with less room for individual brilliance, but more affordances for working well in teams. The prima donnas will be banished (as they aren’t good team players, even when they’re brilliant). Dr. Gregory House may have been the model doctor in the Victorian Age, or maybe even in the fifties. But I doubt any hospital would want him now. It may be that this standardization is just the thing we need to overcome persistent medical errors, improve outcomes across the board, and make populations healthier. But I can sympathize with the position that it might be causing us to lose something beautiful.
In software development, where I work, a similar trend can be observed. Start-ups aggressively court ambitious generalists, for whom freedom to build things their way is more important than market rate compensation and is a better incentive than even the lottery that is stock-options. At start-ups, you’re likely to see languages that are “fun” to work with, often dynamically typed, even though these languages are often considered less inherently comprehensible than their more “enterprise-friendly” statically typed brethren.
It’s with languages like Java (or its Microsoft clone, C#) and C++ that companies like Google and Amazon build the underlying infrastructure that powers large tracts of the internet. Among the big pure software companies, Facebook is the odd one out for using PHP (and this choice required them to rewrite the code underlying the language from scratch to make it performant enough for their large load).
It’s also at larger companies where team work, design documents, and comprehensibility start to be very important (although there’s room for super-stars at all of the big “tech” companies still; it’s only in companies more removed from tech and therefore outside a lot of the competition for top talent where being a good team player and writing comprehensible code might top brilliance as a qualifier). This isn’t to say that no one hiring for top talent appreciates things like good documentation, or comprehensibility. Merely that it is easy for a culture that esteems individual brilliance to ignore these things are a mark of competence.
Here the logic goes that anyone smart enough for the job will be smart enough to untangle the code of their predecessors. As anyone who’s been involved in the untangling can tell you, there’s a big difference between “smart enough to untangle this mess” and “inclined to wade through this genius’s spaghetti code to get to the part that needs fixing”.
No doubt there exist countless other examples in fields I know nothing about.
The point of gathering all these examples and shoving them into my metaphor is this: I think there exist two important transitions that can occur when a society needs to focus a lot of energy on a problem. The transition from conscripts to soldiers isn’t very interesting, as it’s basically the outcome of a process of continuous improvement.
But the transition from warriors to soldiers is. It’s amazing that we can often get better results by replacing a few highly skilled generalists who apply a lot of hard fought decision making, with a veritable army of less well trained, but highly regimented and organized specialists. It’s a powerful testament to the usefulness of group intelligence. Of course, sometimes (e.g. Google, or the Mongols) you get both, but these are rare happy accidents.
Being able to understand where this transition is occurring helps you understand where we’re putting effort. Understanding when it’s happening within your own sphere of influence can help you weather it.
Also note that this transition doesn’t only go in one direction. As manufacturing becomes less and less prevalent in North America, we may return to the distant past, when manufacturing stuff was only undertaken by very skilled artisans making unique objects.
Note the past tense throughout much of this essay; when I speak about soldiers and warriors, I’m referring only to times before the 1900s. I know comparatively little about how modern armies are set up. ↩
Best of all were the Mongols, who combined the lifelong training of warriors with the discipline and organization of soldiers. When Mongols clashed with European knights in Hungary, their “dishonourable” tactics (feints, followed by feigned retreats and skirmishing) easily took the day. This was all possible through a system of signal flags that allowed Subutai to command the whole battle from a promontory. European leaders were expected to show their bravery by being in the thick of fighting, which gave them no overall control over their lines. ↩
Historically, professional armies with good logistical support could somewhat pay for themselves by expanding an empire, which brought in booty and slaves. This is distinct from raiding (which does not seek to incorporate other territories) and has its own disadvantages (rebellion, over-extension, corruption, massive unemployment among unskilled labourers, etc.). ↩