Somewhere in a tertiary hospital, a patient with three days of fever waits beneath a sign announcing a “Centre of Excellence.” The patient is frightened; the family has travelled far; the consultant is running late. There may be nothing more than a self-limiting viral illness. Yet an expensive institution is now doing what a competent neighbourhood doctor might have done with a history, an examination, reassurance, and clear instructions about when to return. Meanwhile, someone who truly needs tertiary expertise waits longer.This is not an argument against specialisation. Modern medicine would be unrecognisable without it. It is an argument against turning specialisation into the organising principle of every illness and turning the general practitioner into an obsolete figure. A capable GP is not a lesser specialist. The GP is the physician who knows when not to investigate, when not to prescribe, when to watch, and, crucially, when to refer. That judgement requires knowledge, humility, and continuity, not merely a smaller signboard.We have built a strange economy around the referral. Every additional consultation can mean another journey, another day’s wages lost, another registration fee, another laboratory panel. Repeated investigations sometimes reflect clinical necessity; sometimes they reflect fragmented records, defensive practice, or institutional incentives. Hospitals have substantial fixed costs and require sustainable financing, but a tertiary centre is most valuable when its expensive capacity serves conditions that genuinely need it. India’s health accounts estimated that households paid 43.4% of total health expenditure out of pocket in 2022–23. In that setting, unnecessary escalation is not simply inefficient; it has a human price.A stronger first-contact system should therefore be a clinical and economic priority. Research associates continuity with doctors with lower mortality, although association is not proof of causation. The World Health Organization places accessible, coordinated primary care at the foundation of efficient health systems. The real answer is not to deny access to specialists, but to make the first consultation trustworthy and referral timely, reasoned, and genuinely two-way.Something similar has happened to the meaning of competence. We increasingly ask which degree a doctor holds before asking what the doctor can safely do. Qualifications and scope-of-practice boundaries are indispensable protections. In Poonam Verma v Ashwin Patel, the Supreme Court rightly condemned practice in a medical system for which the practitioner lacked legal qualification. But Jacob Mathew v State of Punjab described the relevant benchmark as an “ordinary competent person exercising ordinary skill.”Neither judgment says that every uncomplicated fever requires a specialist. The danger lies in a culture that confuses credentials with judgement and prudent referral with automatic referral.And perhaps the hunger for another degree is not always academic. Sometimes medicine becomes the only language in which a doctor knows how to measure worth. Years disappear into examinations, hierarchies, conferences, and titles. Friendships thin. Hobbies become embarrassing luxuries. The doctor who once wanted to understand people may gradually have no life beyond treating them. Professional achievement then fills a vacuum that professional achievement itself helped create.Residency can deepen that injury. Hierarchy is necessary for supervision; humiliation is not. Bullying may silence questions, reward imitation over curiosity, and teach young physicians that power is the privilege of passing pain downward. A systematic review estimated that roughly half of residents had experienced bullying, though prevalence varied considerably across studies.6 Not everyone who suffers becomes cruel. But a training culture that normalises degradation should not be surprised when some graduates reproduce it. We risk manufacturing technically accomplished doctors who have forgotten how to be kind.The private suffering is equally troubling. Doctors learn to recognise depression in patients while concealing it in themselves. A meta-analysis found depressive symptoms or depression in 28.8% of resident physicians studied; that figure is not a diagnosis of every third resident, but it is an unmistakable warning.Fear of stigma, breached confidentiality, and career consequences can deter help-seeking.Psychological care for doctors should be confidential, accessible, ordinary and not an admission of professional failure. A profession that attends to everyone’s distress must learn to acknowledge its own.Artificial intelligence will sharpen this choice. It may improve pattern recognition, documentation, and access to knowledge. But as information becomes cheaper, attention, trust, moral judgement, and the ability to sit beside uncertainty become more precious. A machine may help interpret a scan; it cannot bear a family’s grief or assume a clinician’s responsibility.Science is the essence of medicine. Yet its art dies a little whenever a patient becomes a billable episode, a referral replaces thought, or a trainee learns fear instead of wonder. We do not need fewer excellent specialists. We need excellent generalists, wiser institutions, humane teachers, and doctors allowed to remain human. Otherwise, the finest corridors of excellence may lead us further from the people medicine exists to serve.
Disclaimer: Views expressed above are the author’s own.