Defining Generalism in Family Medicine: A workshop for Young GPs AAFP Global Health Conference 2014 Victor Ng MSc MD CCFP(EM) Steve Hawrylyshyn MD/MSc

Conflict of Interest/Bias  Ng  Practice primarily emergency medicine  Employed by the College of Family Physicians of Canada  Faculty member at the University of Western Ontario  Hawrylyshyn  Chair of the CFPC Section of Residents  Employed by University of Toronto

Workshop Objectives  Discuss and define the concept of generalism in general practice/family medicine from various national perspectives.  Discuss the advantages and disadvantages of the generalism philosophy of medicine from various national perspectives.  Determine possible barriers to generalism that exists within our societies and health care systems.  Describe possible ways in which generalism can be further fostered within our medical education systems and national health care systems.

Introduction  Advance of Medicine worldwide has led to sub- specialization  Medical schools are taught by specialists and become role models to students  Patients often ask to be seen by a specialist and bypassing the assessment by a general or family practitioner  Emergence of Family Doctors or General Practitioners with special interest

Introduction (2) This is our challenge!  What do we know?  Most patients presenting to general practice have multiple co-morbid conditions and not a single pathology (Starfield et al., 2003)  Populations with strong primary care systems exhibit better health indicators. (Shi et al., 2003)  Need to reinforce generalism even in specialty training to better serve community need. (RCPSC, 2011)

Defining Generalism Royal College of General Practitioners. Medical Generalism. Why expertise in whole person medicine matters.  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 one’s clinical method and therapeutic approach to all clinical encounters  Being able to deal with undifferentiated illness and the widest range of patients and conditions.  In the context of general practice, taking continuity of responsibility for people’s care across many disease episodes and over time.  Also in general practice, coordinating his or her care as needed across organizations within and between health and social care.

Defining Generalism (2) Stange K. The generalist approach. Ann Fam Med. 2009;14:198–203.  Way of Being (open stance, humility)  Way of Knowing (broad knowledge)  Ways of Perceiving (Scanning and Prioritizing)  Ways of Thinking (Integrating/Iterative)

Generalist’s Unique Skill McWhinney, IR. Lancet 1966  Undifferentiated problems  Sharpest “bedside” clinical acumen:  Knowledge of the whole patient over time:  Comfort with uncertainty

Discussion Question #1 What is your definition of a generalist physician? What are some defining features based on your national context?

Value of Generalism  Green et al., 2001

Value of Generalism  Test sensitivity is lower early in disease as Family physicians see diseases in the earliest stages. (McWhinney, 1979)  Value of watchful waiting  Pre-test probability increases as time goes on  Ability to manage multimobidities (Upshur, 2008)  Most clinical trials involve one disease process unlike multiple conditions seen in family medicine

Discussion Question #2  What are some other benefits of generalism that may exist in your communities?

Barriers to Generalism  Grumbach, 2003  Medicine reflects society march towards reductionism and subspecialization  Why Specialize? (Lewis, 2014)  Science has discovered more about disease mechanism.  Understanding causation has led to more effective care  Huge growth in knowledge has outstripped medical practitioners ability to understand it

Barriers to Generalism  Barriers to practicing general practice/family medicine  Employment opportunities  Educational opportunities  Lack of Role modelling  Remuneration  Career satisfaction  Career Prestige

Discussion Question #3  What are some barriers to practicing general medicine/family medicine in your local communities/countries?

Fostering Generalism  Education  Regulatory  Financial Support  Personal/Professional Support

 Education  Teaching family medicine/general medicine in medical school  Family medicine teachers in medical school and post graduate training  Establishment of robust post graduate programs in family medicine  Regulatory  Establish family medicine/general practice as a recognize specialty

 Financial Support  Decrease the remuneration gap between family doctors and specialists  Scholarships for students to pursue family medicine  Personal/Professional Support  Mentorship program involving practicing family doctors and students/residents  Ensure career progression opportunities available for family doctors

Discussion Question #4 How can we further foster general practice/family medicine in your local communities and countries?

Thank you ! Dr. Victor Ng Dr. Steve Hawrylyshyn

References Green et al. NEJM 2001;344:2021 Grumbach K. Chronic illness, comorbidities, and the need for medical generalism. Ann Fam Med 2003; 1(1): 4–7. Lewis S. The two faces of generalism. J Health Serv Res Policy Jan;19(1):1-2.The two faces of generalism. McWhinney IR. CFP 1979;25: Royal College of General Practitioners. Medical Generalism. Why expertise in whole person medicine matters. London: College of General Practitioners; Royal College of Physicians and Surgeongs of Canada. Generalism: Achieving a Balance with Specialization 2011 Shi, Starfield et al. J Am Board Fam Prac 2003;16: Starfield B, Lemke KW, Bernhardt T, Forrest CB, Weiner JP. Comorbidity: implications for the importance of primary care in “case” management. Ann Fam Med 2003;1:8–14. Stange K. The generalist approach. Ann Fam Med. 2009;14:198–203. Upshur R, CFP 2008; 54:1655