Why ‘generalist’ is not a dirty word

A friend of mine suffers from bouts of anterior uveitis, a painful condition of the eye. She was on holiday in America recently when it flared up, and she saw a local ophthalmologist. On finding out my friend was from the UK the ophthalmologist exclaimed, “Well, you know that the world’s foremost expert on uveitis works in the UK? He is a professor of the anterior chamber of the eye. I was never ambitious enough to do all that. Me, I’m happy running my own clinic!”

The recent report from the RCGP/Health Foundation Commission on Generalism laments the decline of the ‘medical generalist’ at the hands of ever more narrow sub-specialisation, and suggests that the balance needs to be redressed - a sentiment I fully support.

Anyone who has had to be referred to a specialist for a specific condition will testify to the value of seeing someone who has up to date knowledge of developments in their field. But the narrowness of their clinical lens can lead to a disease-centred approach. The problem is magnified for patients with multiple co-morbidities. A generalist approach allows better coordination of the different strands, better continuity and ultimately a focus on person-centred care.

The question is, how can the Commission’s recommendations become reality? I am aware that an ophthalmologist cannot exactly be classed as a ‘generalist’ in the wider sense (someone who ‘looks after the whole eye, not just the anterior chamber?’), but his statement encapsulates many of the cultural barriers to high-quality generalism in medicine - namely those of status and reward. A 2002 study asked a medical school admissions committee to predict which candidates would go on to pursue a generalist career. Those they thought would become generalists were more likely to have lower school grades, no research background, and lower levels of parental education.[1]

Throughout medical training, the message is that sub-specialism is the natural path for the brightest and best. Super-specialisation and the associated kudos lead to greater financial reward and might grant greater job security. Generalism attracts few academic researchers and little funding, which erodes its status within the profession. GPs have the shortest training period of any of the clinical specialties, lending weight to the misperception that these ‘jacks of all trades’ are actually ‘masters of none’. All in all, the culture amongst both healthcare professionals and the wider public is that generalism is a second-class pursuit.

The Commission makes a good case for addressing the incentives and behaviours which perpetuate that mindset. Recognising the problem is a vital first step, but actually changing it will be immensely challenging. Do clinical leaders truly believe that high-quality generalists can transform patient care? If so, are we prepared to meet the challenge of reversing such a pervasive culture, one that has been long in the making?

Reference

Owen J et al. Can medical school admissions committee members predict which applicants will choose primary care careers? Academic medicine 2002; 77(4): 344-9.