Generalism for specialists: a medical reformation
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m157 (Published 16 January 2020) Cite this as: BMJ 2020;368:m157
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The 1948 World Health Organization (WHO) definition of ‘Health’ is instructive: It is not the ‘Mere absence of diseases and infirmities but the presence of complete physical, mental and social well-being’ [1]. This can be expanded to include the ‘Presence of Emotional, Spiritual, Religious, Economic and Financial Well-being’! ‘Health’ is viewed beyond ‘Biomedical Concept’ to encompass ‘Socioeconomic Concept’!! Some raised ‘Issues’ of ‘Measurability’, ‘Broadness’ and ‘Vagueness’ concerning this ‘WHO Definition’!! The 1984 WHO revised definition of ‘Health’, cognizant of these ‘Issues’, disposed thus: ‘Extent to which an individual is able to realize aspirations and satisfy needs and to change or cope with the environment. Health is a resource for living and not the objective of living and is a positive concept emphasizing social and personal resources and physical capacities’ [2]. To cope with ‘Health Challenges’, there is an imperative to review and readdress the ‘Capacities’ and ‘Preparedness’ of the ‘Medical Workforce’ and this will be discussed later in this ‘Conversation’!
Recent trends in ‘Health Realities’ in several parts of the world suggest the need for ‘New Interventions’ to cope with the evolving and emerging dispositions! Patients are increasingly presenting with ‘Multimorbidities’ or ‘Multiple Health Conditions’ requiring Medical Doctors to demonstrate the capacity to deal with a cluster of diseases in a given patient: ‘Cluster Medicine’ [3-6]. This ‘Cluster Medicine’ is becoming the pattern among patients in older populations in the developed countries with improved Life Expectancy while the same ‘Multimorbidities’ increasingly colour the ‘Patient Presentations’ in the younger populations in the less developed countries [3]. To cope with this disposition, the ‘Medical Workforce’ needs to be addressed with the ‘Medical Reformation’ with focus on Medical Training, Medical Practice and Medical Research!
Concerning ‘Medical Training’, the important determinant role of ‘Medical Socioeconosophy (MSE)’ has been proposed previously [7,8]. This proposed ‘Intervention’ emphasizes ‘Interdisciplinarity’ as a strategy for ‘Basic Medical Education Improvement (BMEI)’ with the introduction of the relevant aspects of certain selected ‘Non-Medical Academic Disciplines (NMADs)’ into the ‘Basic Medical Education Curriculum (BMEC)’ for Undergraduate Medical Education. The relevant NMADs can be explored and exposed with the use of the Bacronym ‘PRICE’ as elucidated in previous ‘Communications’ [7,8]! This ‘Intervention’ assures the formation and production of Medical Doctors who can ‘Think Outside The Box’, be ‘Teamwork-compliant’ and can cope with the demands of ‘Multimorbidities-compliant Patient Care’!!
Concerning ‘Multimorbidities-compliant Patient Care’, the emerging imperative is for ‘Generalism’ to be intertwined with ‘Specialism’ in evolving promising ‘Medical Practice’ for the ‘Contemporary Multimorbidities Challenges’ 3-6]. Every patient needs to be evaluated with the ‘Potentiality’ of ‘Multiple Health Conditions’ disposing the ‘Cluster Medicine’ in one person! The Medical Doctors who have built their capacities in defined ‘Specialties’ must be encouraged to develop their capacities further in ‘Generalism’. This will assure a new ‘Pool’ of Medical Doctors who are ‘Specialists’ with ‘Generalist Skills’; Another strategy for ‘Thinking Outside The Box’ [4-6]!! This strategy is permissively facilitated by the MSE in the BMEC!! Both ‘Generalism’ and MSE are to be highlighted as ‘New Infusions’ or ‘Revisions/ Reminders’ in ‘Continuous Professional Development (CPD)’.
For the imperative of ‘Medical Reformation’, this ‘Conversation’ proposes that ‘Generalism’ in ‘Medical Practice’ and MSE in ‘Medical Training’ constitute ‘Twin Interventions’ capable of enhancing the ‘Formation’ and ‘Preparedness’ of Medical Doctors to cope with the emerging ‘Contemporary Multimorbidities Challenges’ for improved patient care! The ‘Twin Interventions’ with beneficial ‘Complementarity’ is also manifestly relevant to ‘Medical Research’. With the complementary ‘Twin Interventions’ of ‘Generalism’ and MSE, there is a promising outlook for the Triad of improved ‘Medical Training’, ‘Medical Practice’ and ‘Medical Research’! The ‘Challenges’ ahead are enormous and this is a promising trajectory: A Panacea worth exploring!!
REFERENCES
1. World Health Organization. The first ten years of the World Health Organization. Geneva. WHO 1958
2. World Health Organization. Regional Office for Europe. Health Promotion: A discussion document on the concept and principles: Summary Report of the Working Group on Concept and Principles of Health Promotion. Copenhagen, 9-13 July 1984.
3. Schiotz ML, Stockmarr A, Host D, Glumer C, Frolich A. Social disparities in the prevalence of multimorbidity: A register-based population study. BMC Public Health 2017; 17:422
4. Academy of Medical Sciences. Multimorbidity: a priority for global health research. AMS. 2018
5. Whitty CJM, MacEwen C, Goddard A et al. Rising to the challenge of multimorbidity. BMJ 2020; 368:l6964 of 6th January 2020
6. Abbasi K. Generalism for specialists: a medical reformation. BMJ 2020; 368:m157 of 16th January 2020
7. Eregie C.O. The NHS Health Workforce Crisis and the Modern Firm: Considering an Additional Role for ‘Medical Socioeconosophy’ in Basic Medical Education Curriculum Improvement. https://www.bmj.com/content/365/bmj.l4173/rr-3 of 26th June 2019
8. Eregie C.O. ’Fit-for-Purpose’ Medical Doctors in Today’s Globalized World: Further Imperative for ‘Medical Socioeconosophy’ in Basic Medical Education Improvement. https://www.bmj.com/content/366/bmj.l4997/rr-1 of 30th August 2019
Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria,
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria,
UNICEF-Trained BFHI Master Trainer,
ICDC-Trained in Code Implementation,
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria,
*No Competing Interests.
Competing interests: No competing interests
Dear Editor
Absolutely! It's like the blind men each feeling different parts of the elephant and coming up with different suggestions for what sort of animal it is
Most people die in the west of diseases of dietary excess, from cancer to heart disease, autoimmune conditions to diabetes, being treated by different specialists in their own ways without ever addressing the root cause - life style, principally diet. Until we do this we will lose the battle against chronic diseases which are bankrupting our health systems and killing our populations.
Facilitate diet and lifestyle change and support this and we are treating the causes rather than symptoms of our health crisis. Huge financial savings can be made this way so it is win-win. It has to be matched by government support with public health and legislative back up however to be successful, joining the dots.
Competing interests: No competing interests
Dear Editor,
The reductionist approach has ensured that organ systems have been studied and understood in enormous depth. Diagnostics and imaging have reached heights; genetics applications have commenced. In this scenario of apparent progress, the delivery of care has not kept up. 'Fragmentation' of Medicine has added to the complexity of care; duplication and even confusion may prevail when a patient receives advice from two or more subspecialities simultaneously. Joint consultations are a must, though not easy to conduct logistically. Yet they are necessary and very much required; no speciality can function effectively in splendid isolation.
Dr Murar E Yeolekar, Mumbai.
Competing interests: No competing interests
Clinical efficacy of continuity of GP care versus care plans and MDT meetings (From the Journals, p 72, 18th January 2020)
Dear Editor,
Dear Editor,
Alex Nowbar in his research review "Healthcare hotspotting for superutilisers" (From the Journals, p 72, 18th January 2020) seems surprised that intensive clinical and social input did not reduce readmissions of patients with complex conditions. This is not unexpected.
The Avoiding Unplanned Admissions DES, which operated along similar lines, was eventually scrapped after evidence showed that GP practices with more patients on care plans had higher rates of unplanned admissions than those with fewer care plans. In spite of this, the new draft Network Contract DES is suggesting the same interventions - personalised care and support plans for all patients with frailty or complex needs and regular MDT meetings to discuss these patients. It is a pity that NHSE and NHSI have not considered the wealth of evidence which already exists to show that these measures are not helpful in reducing morbidity, mortality or hospital admissions.
There is good evidence that continuity of care with one clinician does improve health outcomes and reduce unplanned admissions. This is becoming increasingly difficult to deliver due to the demands for time to be spent attending PCN and multiple other planning and review meetings which prevent GPs from providing the consistent good clinical care they aspire to.
Sheila Jackson
GP
sheila.jackson@nhs.net
Competing interests: No competing interests