Editorials

The specialist of the discipline of general practice

Semantics and politics mustn't impede the progress of general practice

General practice p   354

Over the past 50 years general practice has established itself not only as an academic discipline with its own curriculum, research base, and peer reviewed journals but also as the cornerstone of most national healthcare systems in Europe. In so doing, general practitioners have shown that the intellectual framework within which they operate is different from, complementary to, but no less demanding than that of specialists. General practitioners must achieve a working diagnostic and therapeutic knowledge across the reach of biomedical science and must be able to forge effective and continuing relationships with an enormous range of individual patients. They need to understand the processes by which illness is socially constructed within the patient's life, and they must mediate between the patient's subjective experience of illness and the scientific explanation.

The breadth and comprehensiveness of its endeavour has made general practice notoriously difficult to define.¹ On p 354 Olesen et al attempt a new definition that emphasises the frontline nature of the care offered and the need to incorporate psychological and sociological perspectives alongside biomedical ones.² Immediately, in using the term "specialist," they have become ensnared at the boundary between semantics and politics.

The English language uses "generalist" and "specialist" as opposites. Other languages may be more obliging, but in the BMJ we are stuck with English and must find a way of using it that does not obstruct our purposes. In many European countries general practitioners have needed to claim specialist status to achieve recognition as a separate discipline. In the United Kingdom, however, this recognition has been accomplished through exploiting the notion of opposites and showing that the expertise of the generalist is complementary to that of the specialist and that the two are profoundly interdependent. Having achieved this, many British general practitioners will find it difficult to accept a definition that includes the word specialist. Yet much rides on the use of this word.

The notion of opposites, with its consequences for optimal (cost) effective health care,³ in fact implicitly underlines the specific virtues of general practice. General practice is speciala specialtynot so much in terms of in depth expertise in the complexity of a defined biomedical area but in the complexity of medical care in the patients' context.⁴ Its focus is on integration and the ability to switch between different perspectives (biomedical, humanities) around patients' health problems.⁵ This relates to a specific set of concepts, rules, and criteria⁶ that appear in the definition of Olesen et al.² Yet the main database for biomedical research, Index Medicus, does not accept general practice as a specialty heading and provides an incomplete listing of general practice research journals. This severely impedes academic progress in general practice and is just one, but probably the most important, example of how recognition as a specialty might greatly strengthen the position of general practice.

The situation is further complicated by the complexities of European legislation, which seem to imply that general practitioners must claim specialist status if they are not to be disadvantaged in relation to specialist colleagues. The division between specialist and generalist is enshrined in the European Union Medical Directives, which have separate sections dealing with postgraduate education and training for specialists (title 3) and for general practice/family medicine (title 4). The requirements under title 4 are minimal and are exceeded in several countries throughout the union. Over the past five years general practice bodies in Europe and the Advisory Committee on Medical Training have made considerable efforts to improve the standards for postgraduate training for general practice. So far, these have been to no avail because of an apparent lack of will on the part of national governments and the European Commissiondespite the importance of improving the quality of frontline care provided to patients. Frustrated by this lack of political will, the profession in some countries is suggesting that general practice should abandon title 4 and claim specialty status to argue its case more effectively for high standards for postgraduate training.

Given this semantic and political muddle it might be important to refer to general practice in terms that reflect its intellectual potential. In Dutch "huisarts" (home doctor) refers to medical care in the patients' context. "Family physician" also pays tribute to care in the patients' context, though family should refer to "a group of intimates with a common history and future," not just to the conventional nuclear family.⁶

Semantics and politics must not continue to impede the progress of general practice. Ways must be found to ensure that the interdependence of specialist and generalist roles is reflected in mutual respect and equivalent statusprofessionally, in remuneration, and academically. On this basis, the terms specialist and generalist might still be used but with a different emphasis, having lost their divisive and politically harmful connotations.

Iona Heath, general practitioner. 

London N1 2JL

Philip Evans, general practitioner. 

The Guildhall Surgery, Bury St Edmunds, Suffolk IP33 1ET

Chris van Weel, professor of general practice. 

Department of General Practice and Social Medicine, University of Nijmegen, PO Box 9101, 6500 HB Nijmegen, Netherlands (C.vanWeel{at}hsv.kun.nl)

1.	Rudebeck CE. General practice and the dialogue of clinical practice: on symptoms, symptom presentations, and bodily empathy. Scand J Prim Health Care 1992; 10 (suppl 1): 3-87[Medline].
2.	Olesen F, Dickinson J, Hjortdahl P. General practicetime for a new definition. BMJ 2000; 320: 354-357[Free Full Text].
3.	Starfield B. Is primary care essential? Lancet 1994; 344: 1129-1132[CrossRef][Medline].
4.	Van Weel C. International research and the discipline of family medicine. Eur J Gen Pract 1999; 5: 110-115.
5.	Heath I. "Uncertain clarity": contradiction, meaning and hope. Br J Gen Pract 1999; 49: 651-657.
6.	McWhinney IR. Family medicine. 2nd ed. Oxford: Oxford University Press, 1997.