Generalism in Medicine
has it a future?
George Freeman
Emeritus professor of general practice
Department of Primary Care and Public Health
seminar 12th October 2011
medical generalism
1. has a past - but specialists are rampant today!
2. an expert generalist or just Jack of all trades?
- special attributes but not a specialism
3. not confined to primary care
4. gatekeeping
5. evidence for – largely from Starfield
6. generalism and the marketplace
7. non-medical generalists
8. Generalism Commission 2011
- recommendations for the future
2
1
history - of specialism
• the archetypal medical practitioner is a
generalist – but specialism goes back at least to
the 5th century BCE (Herodotus)
• specialism took off from mid 18th century starting
with paediatrics in France
• now form majority in all developed medical
economies – less so in UK than most
• generalists have long struggled for ‘parity’
3
2a expert
- or lowest common denominator?
• widely distributed
- generals, general managers
• senior, wise, experienced with overview
• but low status in medicine in recent past
• public perceptions vary a lot (Nickols 1981)
4
2b expert – special attributes
•
•
•
•
broad diagnostic framework
patent centred values
practise in context
output is technical and emotional
• not specific to but most expressed in
general practice
5
3
not confined to primary care
think of
A&E
care of the elderly
acute medical intake
medical managers
secondary care tendency to put generalist at the
front end
contrast primary care with nurse triage
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4
gatekeeping
• gatekeeper role means strong general practice –
both money and prestige
– contrast GP in Belgium and Netherlands
• integral part of most comprehensive or managed
care systems
• GP commissioning is highest form yet
• not always popular with patients
• recent questions about diagnosis
• the Gatekeeper and the Wizard
(Mathers & Hodgkin 1989)
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5
evidence for
Starfield
better care outcomes with more primary care
physicians
international comparisons of
comprehensiveness, family orientation
1. better access
2. better quality of generalist care
3. prevention in primary care
4. better early management
5. primary care is more appropriate care
6. reduction of inappropriate specialist care
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6
generalism and the marketplace
• public faith in ‘expertise’ & ‘science’
• specialists cannot survive unless patients
believe they are better
• AMA has opposed
– public health centres
– public programmes for care of the poor
– Health Maintenance Organisations
• the market place favours specialisation
(Gordon Moore 1992)
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7
non-medical generalists
Nurse Practitioners
• increasing in first contact role
• different training
• run some PCOs
• no evidence of inferiority to GPs
• cheaper? better?
better evidence needed!
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8
Generalism Commission 2011
11 recommendations include
• importance of early accurate diagnosis
• generalism needs continuity of care
• more imaginative use of IT
• revise perverse reward systems
• training
– more general for all; longer for GPs
• boost for academic GP & research
– multi-morbidity; non-medical generalists
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references
Herodotus - see p 49 in
Porter R. The greatest benefit to mankind: a medical history of humanity from
antiquity to the present. Harper Collins, London, 1997.
Nickols FW (1981). Generalist vs Specialist: Whom do I consult?” Performance
& Instruction. Washington, D.C.: National Society for Performance & Instruction.
(Updated version 2003 accessed on line 11.10.2011 via
http://www.nickols.us/generalist.pdf )
Mathers N, Hodgkin. The Gatekeeper and the Wizard: a fairy tale. BMJ
1989;298:172-4
StarfieldB, Shi L, Macinko J. Contribution of Primary Care to Health Systems
and Health. The Millbank Quarterly 2005;83:457-502
Moore GT The case of the disappearing generalist: does it need to be solved?
The Millbank Quarterly 1982;70:361-79
Guiding patients through complexity: modern medical generalism. Report of an
independent commission for the RCGP and the Health Foundation.
http://www.health.org.uk/public/cms/75/76/4299/2763/COMMISSION%20REPO
RT%20ON%20MEDICAL%20GENERALISM%20OCTOBER%202011.pdf?real
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Name=xbuUe5.pdf Health Foundation October 2011