Are generalists still needed in a specialised world?

As specialism in medicine progresses to subspecialism and superspecialism, it might seem that the general physician or surgeon is a relic of a bygone era. Here a surgeon and a physician argue that generalists are needed as much today as ever, particularly in emergency medicine and away from large hospitals in major conurbations

The renaissance of general surgery

Although the merits of specialisation within surgery are said to be self evident and in the interests of the patients, neither assertion has been proved. That the breadth of the field means that no one can be competent in all areas and that competence presupposes experience may be obvious. According to Sarmeinto, “One could argue that a structured exposure to subspecialties is imperative because of the explosion of knowledge and technology… The body of knowledge… is not necessarily greater. Instead new knowledge has replaced old knowledge. Other professions and traders have clearly demonstrated that point.”1 Taylor states succinctly that “the predominant argument in favour of superspecialization relates to the perception that high volume in surgery equates with better outcome.”2 That outcome is related to experience, teaching, training, and practice is true for all professions and crafts, but there is no proof that repeating a procedure hundreds of times and limiting the repertoire to a few procedures benefits the client.3 One thorough overview of the topic concludes: “Data from the literature do not support the idea that centralization of treatment of patients with solid cancers per se leads to improved results.”4

The relation between volume and healthcare outcomes was examined in an effectiveness bulletin in the December 1996 issue of Effective Health Care. After analysing around 200 studies, the bulletin concludes: “The best research suggests that there is no general relationship between volume and quality. However, in some specialties there appear to be quality …