How can we meet the demand for medical generalism?

The career aspiration of most young doctors is to become a specialist.

From the day they walk into medical school they are largely taught by consultants with impressive job titles who have spent most of their career becoming super-specialised in their particular field.

In addition to being culturally groomed for specialisation, rapid advances in medical science and health technology have driven the growth of sub-specialisation. Depth rather than breadth has become the medical paradigm. Specialism holds the key to professional acclaim, prominence and esteem.

Conversely, generalism has bordered on extinction in many of the larger hospitals.

Dr Laurence Buckman, chair of the BMA’s GP committee, comments that “generalism in hospital has largely disappeared – and I am not suggesting that this is a good thing – but I think that the era of the general physician with an interest in something has largely gone. That is not necessarily in the best interests of patients, but it is so”.

The Association of Surgeons goes further saying the term generalist is now “pejorative” and this will not improve unless the general surgeon, general physician and GP are rewarded for their holistic approach to medical care.

The irony of the decline of generalism’s standing is that in hospital medicine – not just primary care – it’s needed now more than ever.

The UK’s ageing population has profound implications for the NHS. Almost 45% of all hospital in-patient treatments in 2009-10 involved people aged 60 or over, and patients aged 60-74 stayed an average seven days in hospital in 2009-10 – 11 if they were aged 75 or over. This compares to an overall average of 5.6 days.

Six out of ten older people are now thought to be living with at least one long-term condition, many of whom have two or more.

Complex needs do not fit neatly into one specialty, and a clear need for doctors who can competently deal with the whole patient begins to emerge.

This mismatch between patient need and doctors’ career aspirations prompted the Royal College of GPs and the Health Foundation to set up high profile commission to review medical generalism with a view to its future development.

The review suggests that the new demographics – 18 million people living with a long-term condition within 20 years – demand a fundamental reappraisal of how medical students are taught to think about illness and disease.

In order to learn how to deal with far greater degrees of complexity and uncertainty than their predecessors would have faced, trainee doctors will need to dwell much less on narrow disease silos and to focus much more on the breadth of possible permutations of co-morbidity.

Professor Sir John Tooke, vice provost (Health) of University College, London, says: “Part of the way of dealing with this is to stop trying to think of medical education as a series of systems or disciplines; it is really thinking of it as a more holistic process and series of care pathways which will involve a range of conditions which happen to present in different ways.

“It is re-thinking how you package the experience.”

A pragmatic first step, however, would be to build more emphasis on generalist skills into the training regime. As the Royal College of Physicians commented, increasing generalist skills in hospitals will complement – not challenge – excellent specialist skills and help to improve patient care overall.

The other significant driver behind the resurgence of medial generalism in hospitals is the demand for increasingly consultant-led, round-the-clock, high quality care. To achieve this, a more equal balance between generalism and specialism will be required.

The commission’s review calls for closer integration between generalist and specialist working. Well-trained staff are most effective in well-designed models of care, it says. To capitalise on the skills and approach of the generalist in either community-based or hospital-based services, models of shared care are needed so that the additional expertise of specialists can be embedded in a predictable and robust way.

But the commission also calls on generalists in both primary and secondary settings to be able to demonstrate the value of what they do and take pride in their professional and public profile. Above all, there is insufficient robust and up-to-date research to be able to evaluate and inform adequately all aspects of generalist practice and its relationship to specialist services, the review concludes.

Other recommendations of note include appraisal systems including assessments of the relationship between generalist and specialist services; development of quality indicators to measure performance over a broader range of patient outcomes; and, a care payment system that recognises the whole person rather than promoting piecemeal treatment.

The Royal College of Physicians called the review “timely” and said it’s crucial to consider whether the medical workforce has the right mix of skills to deliver the highest standard of care to patients.

College president Sir Richard Thompson said: “Patients need doctors with the skills, knowledge and expertise to make rapid diagnoses, find new and innovative ways of treating diseases, and provide holistic, high quality care both in hospitals and the community.

“Patients are increasingly likely to have complex needs that do not fit within one speciality, for almost two-thirds of hospital beds are occupied by people over 65. More doctors must be better placed to respond to these patients’ needs. Whereas specialist care delivers the best outcomes for those with well-demarcated clinical syndromes, we believe that increasing generalist skills in hospitals will complement excellent specialist skills and help to improve the overall care of patients.

“Excellent generalist care must be valued as much as specialist treatment, with doctors encouraged to gain experience in a range of care settings in order to develop a broad base of skills.”

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One Response to “How can we meet the demand for medical generalism?”

  1. Dr Chris Roseveare says:

    I entirely agree with the sentiment bemoaning the loss of the ‘generalist’ from hospital medicine. Specialists have become increasingly ‘specialised’ over the past 2 decades and many consultants have already withdrawn from the general medical on-call rota, particularly in larger hospitals. The development of the new speciality of Acute Internal Medicine (AIM) has provided the opportunity to provide consultant-led ‘holistic’ care for patients admitted as medical emergencies. Acute physicians could also help fill the void for patients who move beyond the Acute Medical Unit (AMU), but whose problem does not fit into a clear speciality category. Trainees in AIM are able to obtain dual accreditation with General Internal Medicine (GIM) by extending their training by one year; most Deaneries have encouraged their AIM trainees to pursue dual accreditation with GIM. During the four year AIM programme, trainees are required to undertake blocks of training in medicine for the elderly, respiratory medicine and cardiology; the additional year provides the opportunity to obtain experience in other in-patient specialities and outpatient clinics. This will provide the broad range of skills and experience which is necessary for the development of a good generalist. These attributes need to be valued by the Health Service. If such training programmes continue to be supported, Acute Physicians, dually accredited in GIM, will be a key part of the hospital workforce in the future.
    Dr Chris Roseveare, President, The Society for Acute Medicine

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