Views And Reviews Acute Perspective

David Oliver: Celebrating the expert generalist

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3701 (Published 05 July 2016) Cite this as: BMJ 2016;354:i3701
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com

In 2011 the Royal College of General Practitioners led a commission on medical generalists.1 Definitions vary, but I like the response from the Medical Schools Council: “doctors prepared to deal with any problem presenting to them, unrestricted by particular body systems and including problems with psychological or social causes as well as physical ones.”2 The Royal College of Physicians has emphasised the key role of generalist training.3 4

Increasingly, patients have several long term and acute conditions simultaneously. They value personalised continuity and coordination, not piecemeal care by multiple medics.5 6 Medical generalism in acute care—the engine room—is key to making general hospitals run and flow.

GPs are true expert generalists, dealing with a wide range of problems and presentations—nine in 10 consultations in the NHS.7 However, medical generalists also work in secondary care.

Emergency physicians see all-comers, including many patients with primary care sensitive, and multiple long term, conditions.8 9 Yet they also have specific skills in the first phase of acute care, overlapping with many other medical and surgical specialties and seeing patients of all ages. Acute internal medicine physicians are also true expert generalists, albeit with specific specialist knowledge defined by the acute phase of care and the systematic organisation of “front door” services, including ambulatory care.10 Geriatricians have a role defined by complexity, frailty, multidisciplinary and cross agency working, and the age and related multiple morbidities of patients.11

Generalists are no less expert simply because their skills and value aren’t defined by an organ system or procedure.

In the United Kingdom, specialists in big disciplines such as acute medicine, geriatrics, gastroenterology, respiratory and renal medicine, or endocrinology and rheumatology are mostly extensively trained and certified in general internal medicine,12 taking nine or 10 years after qualification.4 This is welcome because most acute inpatients, with a ward or clinical team defined by a primary presenting complaint, also have multiple comorbidities requiring generalist skills.

Generalists are no less expert simply because their skills and value aren’t defined by an organ system or procedure

The exponential growth of evidence and interventions makes it hard to manage specific single conditions as adequately as a specialist. And if you do have, say, an acute stroke, severe asthma, or acute coronary syndrome you need prompt access to specialist care. This creates tension between specialty work and general medicine in several specialties.13

It’s rare these days for people to call themselves “general physicians,” even in smaller district hospitals. But job advertisements for medical generalist specialties are common, and a big general medicine contribution is often expected in others.12 This reflects the real needs of modern hospitals.

We need to celebrate the expert generalists who hold such system critical roles, ensure parity of prestige, and do more to attract potential applicants.

Footnotes

References

View Abstract