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By Root 841 0

a body,” he said. It has a skin. It has a skeleton. It has a vascular system—the plumbing. It has a breathing system—the ventilation. It has a nervous system—the wiring. All together, he explained, projects today involve some sixteen different trades. He pulled out the construction plans for a four-hundred-foot-tall skyscraper he was currently building and flipped to the table of contents to show me. Each trade had contributed its own separate section. There were sections for conveying systems (elevators and escalators), mechanical systems (heating, ventilation, plumbing, air conditioning, fire protection), masonry, concrete structures, metal structures, electrical systems, doors and windows, thermal and moisture systems (including waterproofing and insulation), rough and finish carpentry, site work (including excavation, waste and storm water collection, and walkways)—everything right down to the carpeting, painting, landscaping, and rodent control.

All the separate contributions had to be included. Yet they also had to fit together somehow so as to make sense as a whole. And then they had to be executed precisely and in coordination. On the face of it, the complexities seemed overwhelming. To manage them, Salvia said, the entire industry was forced to evolve.

For most of modern history, he explained, going back to medieval times, the dominant way people put up buildings was by going out and hiring Master Builders who designed them, engineered them, and oversaw construction from start to finish, portico to plumbing. Master Builders built Notre Dame, St. Peter’s Basilica, and the United States Capitol building. But by the middle of the twentieth century the Master Builders were dead and gone. The variety and sophistication of advancements in every stage of the construction process had overwhelmed the abilities of any individual to master them.

In the first division of labor, architectural and engineering design split off from construction. Then, piece by piece, each component became further specialized and split off, until there were architects on one side, often with their own areas of sub-specialty, and engineers on another, with their various kinds of expertise; the builders, too, fragmented into their own multiple divisions, ranging from tower crane contractors to finish carpenters. The field looked, in other words, a lot like medicine, with all its specialists and superspecialists.

Yet we in medicine continue to exist in a system created in the Master Builder era—a system in which a lone Master Physician with a prescription pad, an operating room, and a few people to follow his lead plans and executes the entirety of care for a patient, from diagnosis through treatment. We’ve been slow to adapt to the reality that, for example, a third of patients have at least ten specialist physicians actively involved in their care by their last year of life, and probably a score more personnel, ranging from nurse practitioners and physician assistants to pharmacists and home medical aides. And the evidence of how slow we’ve been to adapt is the extraordinarily high rate at which care for patients is duplicated or flawed or completely uncoordinated.

In the construction business, Salvia explained, such failure is not an option. No matter how complex the problems he faced in designing that first shopping mall roof, he very quickly understood that he had no margin for error. Perhaps it’s the large number of people who would die if his roof collapsed under the weight of snow. Or perhaps it’s the huge amount of money that would be lost in the inevitable lawsuits. But, what ever the reason, architects, engineers, and builders were forced long ago—going back to the early part of the last century—to confront the fact that the Master Builder model no longer worked. So they abandoned it. They found a different way to make sure they get things right.

To show me what they do, Salvia had me come to see one of the construction sites where he and his team were working. His firm happened to have a job under way a short, sunny walk from his