With role models like former RCGP president Iona Heath, trainee GPs have no excuse not to appreciate that generalism is the essence of what we do and something that we should take much pride in.1 While this, of course, means recognising hidden context in presentations and appreciating the nuances of patient–doctor interactions, it also refers to clinical generalism and the ability to capably manage diseases and presentations across various systems. With an ageing and a growing population and the health burden of issues such as multimorbidity and obesity, these generalist skills are more relevant than ever. A classic line from the Greek poet Archilochus declares:
‘The fox knows many things, but the hedgehog knows one big thing.’2
This seems to fit nicely. The generalist ‘foxes’ are cunning and able to tackle many problems, whereas the specialist ‘hedgehogs’ are protective of their one fragment of detailed knowledge. Clearly, this interpretation will not be shared by all!
Yet GPs are not alone in treading the intriguing path of generalism. There are another group of clinicians who are brave enough to assess and manage patients with presentations as diverse as psychosis, epistaxis, and breathlessness. Like us, they often face difficult interactions with obstructive specialist colleagues, the frustrations of the worried well, and the constant struggle of keeping up-to-date with seemingly endless new prescribing and referral guidelines. I’m talking, of course, about emergency physicians, or ‘casualty officers’ as they were once known.
As with general practice, emergency medicine (EM) has evolved immensely in recent years. Both specialties have had their training programmes radicalised and now have a more formal curriculum and career pathway for trainees. They also both face a struggle to shake off their old reputations. GPs are no longer physicians that couldn’t pass the MRCP exam and emergency physicians are no longer failed orthopaedic surgeons. They are now specialties in their own right. No other group of clinicians, for instance, can boast as much expertise as GPs in areas such as vaccinations, contraception, and minor illness. Similarly, emergency physicians are the masters of pre-hospital care, managing major trauma and acute poisoning. Both specialties also have a unique insight into patient’s social lives and the responsibility to suspect problems such as domestic violence and child abuse.
Why, therefore, is there not more of an understanding between the two?
Ethnography is a means by which a researcher immerses themselves in a community in order to understand it.3 I recently spent 6 months working in the local emergency department as part of my training and this gave me an opportunity to do just that. My ears would prick up at the mention of ‘GP’, which, sadly, was almost always in a negative context. Few days would pass where I wouldn’t hear a nurse or doctor ridicule a referral letter by a GP or worse still, join in with a patient in undermining the management approach that their GP had taken. Sadly, this is not unique to any one hospital. Having worked in other emergency departments and spoken to trainees in other deaneries, it seems this specialty trend exists up and down the country.
Of course, it is not a universal phenomenon and many EM doctors endeavour to work together with GPs to buck this trend. Indeed, it is often the senior emergency physicians who prove to be most sympathetic to the GP plight, which may reflect the fact that trainees in EM are relatively poorly exposed to management issues than GP registrars.
So what does the future hold for the relationship between the last of the two generalist specialties? Well, perhaps we should roll the clock back and create secondments for EM trainees into general practice. The benefits of such secondments were discussed some years ago,4,5 in the days when training was more flexible. It could provide EM trainees with valuable insights into the organisation of the modern health service, where around 90% of interactions occur in primary care. There would also be useful exposure to communication and management skills and an appreciation of the challenges of resource allocation, particularly with the advent of practice-based commissioning.
It seems clear that these two great generalist specialties need to engage more dynamically and benefit from one another mutually. Trainees from these important specialties should better understand one another. Most GP trainees spend time in EM and perhaps it’s time to invite EM doctors into our world and see what GPs do. This may prove a valuable reminder of what we do and that while our environments differ, we also have a great deal in common. After all, in a world of super-specialisation, we are the last of the foxes.
- © British Journal of General Practice 2013