Generalism in Medicine has it a future? George Freeman Emeritus professor of general practice Department of Primary Care and Public Health seminar 12 th October 2011

2 medical generalism 1.has a past - but specialists are rampant today! 2.an expert generalist or just Jack of all trades? - special attributes but not a specialism 3.not confined to primary care 4.gatekeeping 5.evidence for – largely from Starfield 6.generalism and the marketplace 7.non-medical generalists 8.Generalism Commission recommendations for the future

3 1 history - of specialism the archetypal medical practitioner is a generalist – but specialism goes back at least to the 5 th century BCE (Herodotus) specialism took off from mid 18 th century starting with paediatrics in France now form majority in all developed medical economies – less so in UK than most generalists have long struggled for ‘parity’

4 2aexpert - or lowest common denominator? widely distributed - generals, general managers senior, wise, experienced with overview but low status in medicine in recent past public perceptions vary a lot (Nickols 1981)

5 2b expert – special attributes broad diagnostic framework patent centred values practise in context output is technical and emotional not specific to but most expressed in general practice

6 3not confined to primary care think of A&E care of the elderly acute medical intake medical managers secondary care tendency to put generalist at the front end contrast primary care with nurse triage

7 4gatekeeping gatekeeper role means strong general practice – both money and prestige –contrast GP in Belgium and Netherlands integral part of most comprehensive or managed care systems GP commissioning is highest form yet not always popular with patients recent questions about diagnosis the Gatekeeper and the Wizard (Mathers & Hodgkin 1989)

8 5evidence for Starfield better care outcomes with more primary care physicians international comparisons of comprehensiveness, family orientation 1.better access 2.better quality of generalist care 3.prevention in primary care 4.better early management 5.primary care is more appropriate care 6.reduction of inappropriate specialist care

9 6 generalism and the marketplace public faith in ‘expertise’ & ‘science’ specialists cannot survive unless patients believe they are better AMA has opposed –public health centres –public programmes for care of the poor –Health Maintenance Organisations the market place favours specialisation (Gordon Moore 1992)

10 7 non-medical generalists Nurse Practitioners increasing in first contact role different training run some PCOs no evidence of inferiority to GPs cheaper? better? better evidence needed!

11 8 Generalism Commission recommendations include importance of early accurate diagnosis generalism needs continuity of care more imaginative use of IT revise perverse reward systems training – more general for all; longer for GPs boost for academic GP & research –multi-morbidity; non-medical generalists

12 references Herodotus - see p 49 in Porter R. The greatest benefit to mankind: a medical history of humanity from antiquity to the present. Harper Collins, London, Nickols FW (1981). Generalist vs Specialist: Whom do I consult?” Performance & Instruction. Washington, D.C.: National Society for Performance & Instruction. (Updated version 2003 accessed on line via ) Mathers N, Hodgkin. The Gatekeeper and the Wizard: a fairy tale. BMJ 1989;298:172-4 StarfieldB, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Millbank Quarterly 2005;83: Moore GT The case of the disappearing generalist: does it need to be solved? The Millbank Quarterly 1982;70: Guiding patients through complexity: modern medical generalism. Report of an independent commission for the RCGP and the Health Foundation. RT%20ON%20MEDICAL%20GENERALISM%20OCTOBER% pdf?real Name=xbuUe5.pdf Health Foundation October RT%20ON%20MEDICAL%20GENERALISM%20OCTOBER% pdf?real Name=xbuUe5.pdf