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- Page navigation anchor for Scholarship-based medicine: teaching tomorrow’s generalists why it’s time to retire EBMScholarship-based medicine: teaching tomorrow’s generalists why it’s time to retire EBMReeve’s article does not address several issues, which simultaneously make the approach under-ambitious and have divisive (probably) unintended consequences.Firstly are there specialists and generalists? Many ‘specialists’ practice in a general nature within their discipline. GPs with a special interest contribute to secondary care.1 The division suggested would not incorporate these colleagues who would presumably utilise different philosophical models in different roles. It seems unlikely that these are the only models to answer clinical questions and there is no spectrum between these approaches. Psychiatrists take a bio-psycho-social approach to formulating a patient’s diagnosis and management rather than as described.2Scholarship-based medicine does not consider different approaches being needed at different times. The generalist will likely follow protocol in an emergency resuscitation situation: specialists may need to make a diagnostic decision (as described) then consider the appropriateness of major life changing treatment incorporating a wide range of factors. The advent of the new contract for GPs in Scotland refers to expert medical generalists.3 Are the real generalists non-medical members of the primary care team?Our major concern is the implicit criticism that specialists do not consider the whole patient...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Scholarship-based medicineScholarship-based medicineFew BJGP readers will disagree with Professor Reeve that “we need whole-person, generalist medicine”. But I feel that Reeve uses an overly narrow conception of EBM to justify throwing the baby out with the bathwater. By omitting to reference the growing literature that critiques EBM, this article sets up a straw man, ignoring the well-established move to focus on evidence-based practice. This move challenges the old ‘knowledge pipeline’ model, in which clinicians simply received ‘proven facts’ and used them, and patients relied on clinicians to hand over these facts. Instead we need to understand the way both clinicians and patients construct knowledge and use it in making decisions together.I agree with Reeve that this understanding requires a more nuanced model than the version of EBM she portrays. But rather than replacing this old (and increasingly discredited) model with a new one that emphasises the distinction between ‘specialist’ and ‘generalist’ practice, I suggest it will be more helpful to build on Greenhalgh et al’s call1 for a new ‘real EBM’, highlighting the central challenge that all clinicians face: how to use probabilistic information about a population to shape decisions about one individual. Like generalists, specialists should use this information within a holistic, person-centred approach that requires wisdom as well as...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Scholarship-based medicine: teaching tomorrow’s generalists why it’s time to retire EBMScholarship-based medicine: teaching tomorrow’s generalists why it’s time to retire EBMI thoroughly enjoyed and agreed with Joanne Reeve's interesting article. While I am rapidly becoming a relic of a bygone era, I don't find it difficult to help patients to navigate EBM to find the best treatment and management for them. What is difficult, however, is when this discussion and planning is completely disregarded when the patient encounters secondary care. The uninterested, obese and weight gaining diabetic, who, as a result of a serendipitous 2 day visit to hospital is started on insulin without education or follow up. This fait accompli along with the implicit and often explicit criticism of my previous management make reversing this ill thought through and undiscussed "application of guidelines" confrontational and difficult. This lack of respect for primary care and a lack of understanding of the limits of their relevance to long term condition (LTC) management requires to be addressed with secondary care clinicians.What is needed, therefore, is a conversation between RCGP and the other Royal Colleges as to what interventions in is appropriate as a result of short term contact with secondary care and to develop a position where specialists can be involved where they are beneficial and leave the general to the generalists.Competing Interests: None declared.