‘There is no groove of abstractions which is adequate for the comprehension of human life.’1
Perhaps without exception, the insightful and broad array of issues concerning general medical practice surfaced by the report Guiding Patients Through Complexity: Modern Medical Generalism2 are active in the US health policy arena and in other countries. The issues seem to be big and agnostic to forms of government and models of healthcare organisation and finance.
The assessments, conclusions, and recommendations of this report and the methods used to make them are similar and aligned with other serious studies.3,4 A particular strength of the report is the way it incorporates the voices and perspectives of patients, families, and communities: the people in charge of defining the work of generalist physicians. The report loudly echoes the life work of the late Barbara Starfield5 and her pointed claim that primary care is medicine’s way of improving population health and relieving disparities, while containing costs — and no study shows otherwise.
THE POSITION OF GENERAL PRACTICE
As this report states, general medical practice is more than primary care, cutting across all care levels, powered by the knowledge, skills, and attitudes necessary to integrate care for people across often arbitrary boundaries. This ability to integrate care can overcome the troubling fragmentation of specialised and dislocated services, and integration is the work of generalists. While the report illuminates what is needed by people and governments from medical generalists, it also confesses that current general practice is not delivering what is necessary. Between the lines, a triumph of business and management over medical professionalism is exposed. This is also true in the US.
With refreshing directness, solid logic, and inspiring qualitative analysis, a sobering message comes through: it is time for general medicine to make its next major adaptation to be all that it can and should be. Said more bluntly, this report rests on the recognition that specialism by itself is insufficient, current general practice is insufficient, and it calls on the medical profession to strike a proper balance across the generalist–specialist continuum. The report fundamentally claims that it is time, or past time, to figure out how to provide in an affordable manner the correct care people want and deserve.
THE REPORT IN PRACTICE
Acting on the message found in the report is obviously complicated. Powerful new knowledge that actually matters to people’s lives and additional technologies have disrupted old ways, requiring not an adjustment, but a remake of health care. The report calls out critical challenges for health care overall and medical generalism in particular; for example, a larger, older, multi-morbid, sicker population, and unmet needs of children. We would emphasise three advances that appear to us to be pleading for a remake of general practice and that represent opportunities for medical generalists to excel and work across present boundaries:
The Cartesian division of the world into two parts, the physical and the mental, is erroneous.6 The artificial separation of mental health services from physical health services fragments care at almost all levels. We are overdue for uniting substance use, behaviour change, support for families, and mental health care into the core business of general medical practice.
The mistaken separation of public health and personal health that crystalised about a century ago interferes with proper implementation of prevention and medical care necessary to promote health and cope with chronic disease. Health is won or lost in the community, and proper generalist physicians are an important part of communities. Their decisions and care inevitably play out in their communities. Population health is a community affair,7 and properly integrating primary care and public health in general practice is urgently needed.
Digitalisation of data of all sorts, if harnessed to aid patients and practices, makes continuous, coordinated, comprehensive medical services in partnership with patients and families actually achievable, not just an aspiration. Practice can be steadily improved by using, linking, and re-using digital data to develop information and new knowledge. Some of this knowledge is particular to location, and some of it is broadly relevant and cannot come from any place other than general practice.
NO TURNING BACK
To hope for a return to an old style of practice is futile in the face of such substantive progress plus the unsustainability of the current dysfunctions. As the report noticed, this does not mean that all prior ideas are flawed, ready to be jettisoned. Professor John Howie stated in the report:
‘Unless generalists have a serious think about going back to a model of comprehensive and continuous care that was the hallmark of the early definition, they are at serious risk of losing their standing and their ability to provide their patients with what they want.’
Also, we were particularly struck by the alignment of the vision of comprehensive generalists able to work in continuing relationships and across boundaries with the report’s ‘full support’ for extending training in the UK for generalist physicians to 5 years. While consensus has not been reached, there is also reconsideration of length of training for family physicians in the US, with active experimentation with training beyond 3 years.8,9 Lengthened training is probably part of the future of the best general physicians, and being the best is unlikely to ever go out of style.
BROADENING THE PERSPECTIVE ON GENERALISM
This report reminded us of another British author, TF Fox, and his claims:
‘The more complex medicine becomes, the stronger are the reasons why everyone should have a personal doctor who will take continuous responsibility for him, and, knowing how he lives, will keep things in proportion — protecting him, if need be, from the zealous specialist. The personal doctor is of no use unless he is good enough to justify his independent status. An irreplaceable attribute of personal physicians is the feeling of warm personal regard and concern of doctor for patient, the feeling that the doctor treats people, not illnesses, and wants to help his patients not because of the interesting medical problems they may present but because they are human beings in need of help.’8,10
Some 50 years later in this report, Julian Tudor Hart called out again for generalist physicians to look after their patients with imagination, judgment, humility, and emotional engagement. Perhaps the report would have been better titled: ‘Attending Patients Through Complexity’?
To respond to the needs of people, medicine requires both generalism and specialism in balance. The intellectual tensions between generalism and specialism have been documented since Plato and Aristotle11,12 and extend through Bacon13 and into poetry and legend.14 While it recalls this longstanding intellectual and practical tension, this new report cannot be expected to resolve it. To its great credit, however, the report lays out work for current leaders, and even with its uncertainties should add to worldwide momentum to modernise medical generalism.
We hope this report is sufficient to fuel further action from within general practice and the profession of medicine, not for aggrandisement, but to deliver what is needed.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2011
