So you want to be...an expert medical generalist

Tell someone you are training to be a doctor, and the response is often, “what will you specialise in?” Many doctors specialise in the management of specific conditions (e.g. diabetes or cancer) or of organ systems (e.g. cardiology, urology). But growing proportions of patients have problems that don’t fit neatly into these biomedically defined categories.

Which is why we also need doctors who specialise in whole person medicine. These are doctors with the distinct skills and expertise of medical generalism [1]. Skills that enable them to safely construct robust, individually-tailored, whole-person explanations of illness experience; and so implement person-centred healthcare designed to enhance health-related capacity for daily living [2].

The NHS Long Term Plan [3] recognises that changes in our population – including growing numbers of older people living with (often multiple) chronic illness - mean we need to expand our capacity for medical generalist practice within modern healthcare – both in hospital and primary care settings.

So what is medical generalism? What does the medical generalist do? What skills do they use to practice? And what do you need to know if you are interested in working as a medical generalist?

This essay offers an introduction to how you can use your medical training to find out more about this most intellectually stimulating area of medical practice.

Medical generalism: a priority for patients, professionals and policy makers

“The good physician treats the disease, the great physician treats the person with the disease” (Osler, 1849-1919)

The importance of person-centred medical care has long been recognised by the medical profession [4]. Recent years have seen an international call for a revitalisation of medical generalist practice. One of the key drivers for this comes from the expressed need of patients. You will no doubt have met a patient like Elsie.

Elsie is in her 70s and has multiple health problems - diabetes, arthritis, hypertensin, anxiety. She finds it hard to manage her daily routine - to keep active so she doesn't stiffen up, eat he meals at the right time, take her 15 tablets a day at the right times, and stay calm about it all. Especially when she is also caring for her husband with dementia, looking after her grandchildren, managing the daily household tasks, gettng the shopping in, paying the bills. Some days, Elsie feels overhwlemed by the number and range of daily tasks she must do just to keep life ticking over. When things get too much, she sometimes misses some of her tablets or hospital appointments. But then worries that she may make herself unwell. 

 There are a growing number of people like Elsie [5] who live with the daily challenge of looking after their home and family [6], whilst also managing multiple long-term conditions, including  dealing with the healthcare (medicines etc) that is  intended to help [6-8]. Some of them tell us that the healthcare we offer has become more of a problem (a burden) than a help [6-8]. People like Elsie want us to tailor their care to their individual circumstances [9]. They want generalist medical care.

Aging populations living longer with multiple long-term conditions mean governments and policy makers have also realised that we need more capacity for medical generalist expertise [1,2, 10-12]. Expanding generalist capacity is an international healthcare priority.

Medical generalism: scientific method for a distinct form of clinical practice

Practising medicine requires us to have both knowledge about health and illness, and the wisdom to use that knowledge in order to help our patients. Anyone with a smart phone and access to the internet can know medical facts. The wisdom of medical practice comes not from what you know, but how you use what you know to help your patient [13]. Specialist and generalist medical practice use knowledge differently to answer different questions.

The scientific reasoning of specialist practice addresses questions such as: what is the likelihood that this person has a given condition; what is the probability that a given treatment will benefit/harm this person? It is grounded in the scientific practice of hypothetico-deductive reasoning: the systematic collection of data through the clinical consultation supporting the objective assessment of (statistical) likelihood of a given outcome [14,15]. The clinician considers the individual patient against the standard of externally-derived biomedical scientific evidence to decide if this patient has a defined condition and is likely to benefit from an evidence-based intervention.

There is no such external evidence-base for a given individual – someone like Elsie, a ‘whole person’ living in their individual context. The scientific reasoning for whole-person, generalist practice must therefore differ. To understand an individual – a whole person – we must draw on evidence and data from a range of sources to help us gain a whole picture view of what is happening. This form of clinical practice is grounded in the scientific principles of inductive reasoning, with the aim being to construct a trustworthy interpretation or explanation of an illness phenomenon. This form of practice places an emphasis not on estimating statistical certainty, but on the robustness of the interpretive process, and the utility of the explanation in addressing the healthcare needs of the individual [2].

Let us return to Elsie to illustrate the difference between the two approaches. In Elsie’s case, hypothetico-deductive reasoning can help us work out the reduced risk of a stroke if she were to improve the control of her diabetic sugars. But it cannot tell us if the burden of taking extra diabetic medication (eg adding insulin) will be adequately balanced by the (potential) improvement in her overall health as a resource Elsie needs, and uses, to live her daily life [6]. To understand this broader picture, we must draw on our consultation skills to hear Elsie’s full story; our biomedical knowledge of the science of diabetes; our wider scientific knowledge of the personal experiences of living with chronic illness; our understanding of the ethics and principles of good health care, amongst others. Ultimately the decision about whether to treat or not is an interpretation of this complex data set. This is inductive reasoning -  a data driven form of practice in which multiple elements (all believed to be robust) are combined to infer an explanation or conclusion. Inductive reasoning produces explanations that are plausible, reasonable, justified – but never certain. The use of inductive reasoning highlights the need for follow up (continuity of care) in generalist medical practice in order to appraise and (re)assess the conclusions reached.

Both specialist and generalist reasoning produce new knowledge about a patient. But the insights from these two approaches may differ. Judging between competing knowledge is a branch of scientific practice in its own right – being the area of practice known as epistemology. Epistemology asks questions about how do we know what we know, and how can we trust what we know? These are questions that scientists openly grapple with every day. For clinicians, this work is often less visible. Nonetheless clinical epistemology is a key principle of generalist practice.

It is important to start by noting that the skills of medical generalism are used by many different types of doctors working in a range of settings [1, 16, 17]. Generalist medicine is a set of skills that GPs commonly use in their daily work, but it is not synonymous with General Practice [16-18]. (Indeed GPs use both specialist and generalist skills in their daily work). However, much of the scholarship to describe this form of practice has been done in General Practice.

Gabby and le May observed GPs in practice over a long period and described how they are able to flexibly use and apply data and evidence in context (what they described as ‘contextual adroitness’) to generate new ‘knowledge-in-practice-in-context’ [19]. They recognise generalist practitioners robustly analysing data (including ‘traditional’ scientific evidence), in the context of a consultation, in order to generate new, individualised understanding of a personal illness experience [2,20].

Donner-Banzhoff et al also observed GPs at work and found that hypothetico-deductive reasoning was not the most common model of practice.  Instead they saw doctors collecting data, through a patient-led exploration of the illness to infer (deduce) an explanation of illness. They described this as ‘inductive foraging’ [21].

In 2015, I described the SAGE consultation model [22]. By adapting established scientific method for generating robust, trustworthy interpretations through inductive reasoning, I described five key necessary elements for a ‘whole person’ (generalist) consultation [2,20,22]:

• The clinician’s ‘lens’: the clinician must seek to understand the presented illness from the patient perspective. [6]
• Multi-source data: the clinician must collect and consider the full range of data needed to understand this illness experience. [2]
• Exploration and Explanation: where the clinician explores the data set with the patient [2,18,22]; combining the data with an understanding of context [19] to analyse the illness problem; employing explanatory reasoning [14], to make sense of the patient’s problem [2]; and so deliver robust, judicious, context-specific decisions [16].
• Safety netting: where the clinician checks with the patient, themselves, and potentially a wider team whether they have ‘missed something’ [2,22].
• Impact review: where the clinician follows up the patient to evaluate the impact of the explanation and decision [2,22]

Medical generalism has been described in the professional literature over many decades [17,18, 23-25].  Despite this rich history, generalist practice has arguably fallen from favour. In the late 1980s and 1990s, generalist medicine became described as ‘a jack of all trades’ role – knowing a little bit about a lot of things [26]. Although the implied ‘master of none’ was rarely spoken, it is arguably one element behind the beliefs of those who described generalist physicians as “doctors who have fallen off the specialist ladder” [27].  Yet this description of medical generalism fails to recognise the skill and complexity of the tasks of practice.

With recognition of an urgent and growing need for expert generalist capacity, we have seen new accounts of generalist practice from around the globe. Including Gunn and Palmer’s review in Australia [10], Stange’s work in the US [11], the Canadian College of Family Medicine [12], the UK RCGP report [1] and most recently an international consensus statement describing quality standards for generalist practice [20].

Our understanding of, and writing about, generalist medicine is rapidly being updated for emerging 21^st century healthcare systems characterised by evidence-based practice, guideline care, and the emerging technologies associated with artificial intelligence; along with complex patients and healthcare needs.

There is exciting new educational research and practice to support professionals in understanding and delivering care [28,29]; new research examining enablers and barriers to generalist practice to inform new models of care [7,8]; and new thinking on health systems design [30].

On a day to day basis, the profession – the doctors who you meet in your clinical attachments – are working to make sense of how to be a generalist in the new healthcare context. You are both witnessing, and becoming part of, an emerging new world. There has never been a more important time to be talking with your tutors, as well as the clinicians and patients you meet on a daily basis, about what generalist medicine means to them. So that you can contribute to shaping future medical practice.

The expertise of medical generalism is a distinct form of clinical practice that, alongside the expertise of specialist medicine, is integral to the sustained delivery of comprehensive healthcare for 21^st century needs.

Expert generalist practice is not a subset of specialist medicine. It is a distinct, demanding, but intellectually stimulating, form of practice underpinned by clinical scholarship. It requires both an understanding of health and illness in context, and the scientific expertise to use knowledge in practice to generate robust individualised interpretations of illness.

It is an area of medical practice that continues to evolve new approaches to teaching and delivering this important form of practice.

I hope this brief introduction has inspired you to explore how you can develop the expert generalist skills you will need for a career in medicine, whatever specialty you ultimately practice in.

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