Intended for healthcare professionals

Education And Debate The NHS revolution: health care in the market place

Medical generalists: connecting the map and the territory

BMJ 2005; 331 doi: (Published 15 December 2005) Cite this as: BMJ 2005;331:1462
  1. Iona Heath, general practitioner (,
  2. Kieran Sweeney, honorary clinical senior lecturer in general practice2
  1. 1 Caversham Group Practice, London NW5 2UP
  2. 2 Peninsula Medical School, Royal Devon and Exeter Hospital, Exeter EX2 5DW
  1. Correspondence to: I Heath

    The debate on market reforms must not overlook general practitioners' over-riding responsibility—to recognise and relieve patients' suffering


    Despite enormous advances within medical science over the past 100 years, an under-recognised but inevitable gap remains between the map of medical science and the territory of individual human suffering.1 The task of the medical generalist is to make useful connections across this constantly recurring gap. All doctors carry the medical map, albeit with patchy and varying levels of detail, but only the medical generalist uses it to try and make sense of the whole human person, transcending all the arbitrary divisions of specialist practice. Here we explore the role of the medical generalist and consider how this might be affected by current NHS reforms.

    Generalist's role

    In the initial consultation with a general practitioner, doctor and patient work together to explore the usefulness and the limitations of the medical map in relation to the territory (or subjective experience) of the patient's particular illness. When the patient has an acute and remediable illness or accident, attention will be mostly on the map, but when the patient is dying the attention will revert almost entirely on to the territory.2 In chronic illness, a careful balance must be achieved and maintained so that neither aspect is neglected.

    To work effectively in this context, the medical generalist must maintain a clear understanding of both borders of the gap. This requires a thorough, robust, and continuously updated knowledge of medical science; an empathic willingness to recognise, acknowledge, and witness the true extent of suffering; and an appreciation of the details of individual lives, combined with a respect for the history, aspirations, and values which have made those lives what they have become.

    Centrality of medical diagnosis

    General practitioners operate in a low tech environment, where, until recently, the most sophisticated instruments …

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