Intended for healthcare professionals

Opinion Talking Point

John Launer: Seeing the big picture—the distinctive value of generalism

BMJ 2024; 385 doi: https://doi.org/10.1136/bmj.q1054 (Published 15 May 2024) Cite this as: BMJ 2024;385:q1054
  1. John Launer, GP educator and writer
  1. London
  1. johnlauner{at}aol.com
    Follow John on X @johnlauner

Patients are often the beneficiaries of medicine, but they can be its victims too. Most people in the western world are likely to know by their 60s that they have at least one chronic condition or risk factor, if not several. As they age further the number of these will almost certainly increase, along with regular check-ups, investigations, and an escalating amount of treatment.

Some of the effects of this may be positive in terms of a person’s longevity and quality of life, although good nutrition, housing, education, and a decent income are likely to have been more important. Over time, however, their risks of harm will also become greater. These may include an altered self-image, the iatrogenic effects of overdiagnosis and polypharmacy, and a paradoxical lessening of their overall enjoyment of everyday living.

Many interconnected cultural influences have led us to this. One important strand has been the growth of medical specialties, each vying to place emphasis on their organ of interest—whether cardiac, renal, or whatever—and on the importance of finding treatable or preventable pathology there. There’s little prestige in promoting the idea that most people want to seek a balance between their wellbeing and their dependence on doctors, or that a doctor’s principal role might be to facilitate intelligent conversations about achieving that balance—even if some biochemical number, fuzzy x ray image, or guideline suggests otherwise.

In recent years an important concept has gained traction in promoting such an approach: generalism. Generalism isn’t synonymous with general practice, nor is it in opposition to being a specialist. It’s been defined as the expertise needed to practise whole person medicine. Specialists can be outstanding generalists while also remaining experts in their own field. GPs may apply specialist knowledge, such as when making an exact diagnosis of a dangerous neurological condition. I like to think of generalism as “big picture” medicine: our understanding of another person is always going to be partial and provisional rather than “whole”—but it may require a gaze that goes beyond the problem and even the patient, to encompass the family and care system or the wider social and political context.

Two new books have set out a convincing manifesto for generalism. Generalism in Clinical Practice and Education, edited by Sophie Park and Kay Leedham-Green, looks at the subject across the profession.1 It covers a wide range of generalist values, including personalised care, wellbeing, and social accountability, as well as how medical education needs to change. By contrast, Medical Generalism, Now! by Joanne Reeve has a focus on primary care. Reeve advocates for GPs to be seen as experts in advanced generalism and to be supported in the knowledge required for this.2

I need to declare a vested interest in both books: I wrote the foreword to the first, and I run courses on generalist skills with the author of the second. But I hope that these two books, and other projects focusing on the subject, will help to reset the dial for medical education and practice, so that generalism is seen as essential in the work of every doctor.

Footnotes

  • Competing interests: I have received payment for teaching on the Catalyst programme at Hull York Medical School for GPs, led by Joanne Reeve. I have written the foreword to the book edited by Sophie Park and Kay Leedham-Green, without remuneration.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References