It will run over a period of approximately 12-15 months and preliminary
findings will be presented to RCGP Council in September this year.
The process will culminate in the publication of an independent report
in early 2012. The Commission sought views on medical generalism and
the role of the generalist in today’s healthcare system.
The Royal College of Physicians of Edinburgh (the College) is pleased
to respond to the Royal College of General Practitioners on its Commission
on Generalism consultation.
The College recognises the importance of generalist practice in secondary
care as patient demand and technological advances drive ever increasing
specialisms. Medical generalism will remain a vital part of secondary
care, both for those presenting with multiple problems and those presenting
as emergencies that require urgent intervention beyond the capacity
or resources of primary care. This is particularly pertinent
in remote and rural parts of Scotland.
The College has the following answers and comments on specific consultation
questions:
- What do you understand by
the term medical generalism? Where you can, please give examples
of where you see it:
- In general practice
- In other settings
In the College’s understanding, the term medical generalism
usually refers to a holistic approach to the assessment and treatment
of patients who may have a wide range of symptoms.
-
Within general practice, it is seen in those colleagues who will
manage the overwhelming majority of patients without need for secondary
referral but who will refer to specialist services selectively and
appropriately, often after initial investigation.
-
In secondary care,
paediatricians and geriatricians are often the most likely to take
a generalist approach within some constraints of age, whereas emergency
physicians and acute physicians must take a generalist approach albeit
over a short period of time.
What are the
core values of medical generalism?
The core values of medical generalism embrace a holistic approach,
which is multidisciplinary and involves whole-system integrated care.
In addition, the following values are important to the understanding
of medical generalism:
- Providing a consistent approach to the delivery of care on an ongoing
basis;
- Ensuring good communication and smooth transfers of care;
- Timely escalation prioritised on the basis of clinical need;
- Care closest to home as is realistic and feasible; and
- Taking a considered approach to risk.
- How do the values you describe
fit with what you recognise as generalism in practice (as you outlined
in your response to question one)?
The values described in the previous questions are frequently shown
in general practice, and also in specialties such as geriatrics
and in much of paediatrics. They are also of particular
relevance in the treatment of people with chronic conditions and in
palliative care.
There may be challenges to implementing these values because of limitations
of availability and work patterns etc.
Where do the boundaries
of medical generalism lie? What are the challenges at the interface
of medical generalism with other areas of practice?
All subspecialties need good core generic medical practice: looking
at the whole person, respecting patients, communicating well and understanding
relevant evidence, but as frontiers of medicine expand, there is a
need to strive to achieve the correct balance between generic good
practice and specialist expertise, and to recognise the limitations
of both.
A major issue for medical generalism in the twenty-first century is
to make it clear that developing and maintaining general skills
is as challenging as specialist expertise in a more focused area, and
requires at least equivalent levels of training.
Are there elements considered
to be part of medical generalism that ought to be modified or abandoned? Does
medical generalism need to adapt, and if so, how?
Risks associated with medical generalism can be mitigated by
ensuring that generalists work in teams (actual or virtual) both to
reduce professional isolation and to allow some specialisation
among team members; and by facilitating speedy access to specialist
advice when needed.
It is important that referral pathways must be flexible enough to
fit patients who may not fit into any neat box, and the role of a GP
in directing patient referral appropriately is crucial.
Medical generalists, and indeed perhaps general physicians and surgeons
more than others, are sometimes labelled as being 'jack of all trades
but master of none'. However, particularly in remote and rural
areas, this general expertise offers local and emergency access to
essential services. A typical example of this is given from a
Fellow of the College who practices as a General Physician in a rural
general hospital, and states that he has a very wide remit within hospital
general medicine which can include psychiatry, paediatrics and community
care.
The essential competence of the generalist in all areas is knowledge
of one’s own level of competence and when to seek help, and from
whom, in any given situation. In this context, the development
of managed clinical networks, and links with specialist colleagues
in central hospitals, is vital.
The Commission could help to define the limits in contemporary
healthcare of what is safe and clinically effective generalist
practice.
- What threats and challenges
do you think medical generalism faces today? What threats and
challenges do you foresee in the next 10 to 15 years?
Threats and challenges to medical generalism include:
- An ageing population;
- Pressure on limited financial resources;
- A societal review of real risk;
- A more demanding public not necessarily focused on medical need;
and
- Prematurely early specialisation and divergence of CPD and professional
experience, leading to a loss of confidence in managing general problems
amongst those with narrower fields of interest.
The College recognises the importance of generalist practice in secondary
care as patient demand and technological advances drive ever increasing
specialisms. Medical generalism will remain a vital part of secondary
care, both for those presenting with multiple problems and those presenting
as emergencies that require urgent intervention beyond the capacity
or resources of primary care.
It is vital not to downplay the importance of specialist expertise
but also to endorse the benefits - for patients and for the NHS
- of generalist expertise. Professionally, this is already
happening as general practice becomes a more popular career
choice for medical graduates, but more could be done in medical education
to emphasise the importance of holistic medicine.
As far as patient expectations are concerned, the merits of the
generalist contribution - in terms for example of early diagnosis, caring
for and treating the whole person and coordinating care within the
NHS and with other agencies - need to be publicised, something
to which the Commission could make a very valuable contribution.
-
What can be done to strengthen
medical generalism – particularly those aspects that you care
about? How would you propose to go about doing this?
At present incentives and rewards eg discretionary points have tended
to follow those who become very specialised and who may opt out of
generalist care.
It is important to encourage and reward colleagues who assist in the
management of complex and challenging cases. However, there is
also a need to support and incentivise excellent generalist activity. A
solution may be for all specialists to be expected to participate in
some generalist activities in the formative years of their career.
Trainees should be exposed to the general medical challenges of colleagues
in district and rural general hospitals, and general care (especially
of emergencies) must be part of all training. Greater awareness might
encourage cross fertilisation between general practice and hospital
specialties.
Due to focus on very particular specialisms, there is actually an
increasing role for the generalist who can translate all the specialist
help into practical, realistic and effective therapy and care and have
an overview of the impact and interplay of multiple illnesses, and
the influences and limitations of the real world in which the patient
lives.
What recommendations would
you make about the future development of medical generalism; are
there particular aspects of this that relate solely to general practice?
-
Generalism has been one of key strengths of UK Medicine over the
last sixty to seventy years. The concept requires revision,
refocus and reprioritisation to reflect the demands of scientific
and technological advances and greater patient focus.
-
The balance between generalist and specialist care must be redressed
to benefit overall patient care, ensuring NHS resources allow generalist
practice to flourish in the community taking care not to erode the
provision of specialist care for patients requiring it.
-
It is important to raise the profile of generalist work both in
primary and secondary care.
There is a need for practical debate and collaboration, where specialism
and generalism are seen as two ends of a continuum of care, and for
each facet of a patient’s problem there will be an appropriate
balance between these in order ultimately to provide the optimum quality
of care.
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[14 June 2011]
