Reclaiming generalism An international perspective

Definitions of generalists ‘a person whose knowledge, aptitudes, and skills are applied to a field as a whole’ (as opp. specialist). ‘person who is knowledgeable in many fields of study’ ‘an organism able to utilize many food sources and therefore able to flourish in many habitats’ ‘Practice which is person, not disease- centred, continuous, not episodic, integrates biotechnical and biographical perspectives, views health as a resource for living, not as an end in itself.’

Seeing the person as a whole and in the context of his or her family and wider social environment Using this perspective as part of your approach to all clinical encounters Being able to deal with undifferentiated illness and the widest range of patients and conditions Taking responsibility for people’s care across many disease episodes and over time Co-ordinating care of your individual patients as needed within and across organisations. MEDICAL GENERALISM

The situation in South Africa A limited infrastructure, supply chain difficulties and staffing levels. High clinical workloads, leading to problems with motivation, burnout and poor performance. Biomedical task orientation in clinical workers. Patients bypassing GPs and going directly to secondary care (in cities).

Outline The essence of family medicine Developing generalism Why How Who with Ideas for UK and SA

Reclamation The restoring of something productive, moral or useful

Recommendations for effective use of medical generalism in primary care Effective use of patient feedback Attention to unscheduled and out of hours care Development of generalist models of care for complex and chronic conditions in the community Improved communication between GPs and specialists Extended training for GPs Primary care leading service development Further research into multiple morbidities and early, accurate diagnosis in primary care

Why do we need generalists? We’ re smart! Increasing need - ageing, co-morbidity Increasing costs Patient satisfaction – ‘one stop’ personalised care

People like generalists and generalist services a comprehensive service in one setting or from one team avoiding condition specific care continuity over time Preventive opportunities Integration of need, treatment and care Pragmatic balancing of risk Patient and community oriented – taking priority needs into account

Generalists like people! Person oriented Consultation a large part of clinical method (more than procedural / technical skills) Use their knowledge and interpretation of people to maximise diagnosis and management Therapeutic relationships Patient empowerment for self care

Selecting and training generalists Select people for people skills as well as academic Train them in community settings Encourage them to be curious about people Community oriented project work Team based learning Taking responsibility for aspects of patient care

Key learning for generalists Commission on Generalism - “Medical training needs to become much more generalist in content, with more of it taking place in primary care settings. A placement in general practice should be compulsory during training for all medical graduates. There should be an immediate extension of the length of specialist training for GPs from three years to five. All medical undergraduates should have greater experience of these core disciplines, and opportunities for shared training modules across health and social care should be pursued. medical royal colleges should review career paths and reward systems to ensure that there are sufficient sources of advice and incentives in place to encourage talented doctors to pursue careers as generalists”.

Valuing generalism Give support to those working in new ways and making changes Invest time and resources Show respect and recognition for generalists

Working with others The community Other professionals Government and ministries Charities and NGOs Each other Medical generalism - why expertise in whole person medicine matters

Risks and remedies Risks Excessive demand Burnout Weak models (*not expert generalists) Low status Underused across the health care system Market forces disrupt Lack of evaluation and research Remedies Invest in capacity Ensure time out for professional development Be systematic about minimum requirements and keep scrutinising Avoid bypasses and gaps Ensure quality assurance and networks for learning

In summary Ensure you establish generalist models of care for complex and chronic conditions in the community Emphasise improved access and integration of care in community settings and within the primary care workforce Change education and training to improve understanding of generalism and make it more attractive to medical and nursing students Put family physicians in leadership roles for developing and running services Invest in more research on multi-morbidities and generalism – also better use of research in primary care.

The RCGP is looking up to the SAAFP with hope!