Expert medical generalism - ecological insights

  • Jon M. Dickson, GP and Senior Clinical Lecturer, The University of Sheffield
  • Other Contributors:
    • Adam G. Hart, Professor of Science Communication, University of Gloucestershire, University of Gloucestershire
2 April 2019
The Five Year Forward View aims to recruit 3250 GP trainees annually in England.1 Ahluwalia et al's2 article led us to ask what is the ideal number of GPs in relation to secondary care doctors and could scientific insights from other disciplines be helpful in answering this question?
 
GPs are medical generalists3 with a broad knowledge base. Their expertise is not defined by focussing on a specific body system but by their ability to assess and manage conditions which affect any of the body’s systems. This skill-set means that they are able to deliver the majority of patient contacts in the National Health Service (NHS). General practice is a rapid turnover and high-capacity part of the health-system and contributes to its effectiveness, cost-effectiveness and resilience.4. In contrast, specialists’ knowledge and their focus on a single system allows effective management of conditions that are beyond the knowledge and skills of a GP. But specialists do not retain their generalist knowledge on their journey to specialism; as they learn new skills, they lose others. Generalists and specialists have distinct and complementary skill-sets and the health-system requires a balance of the two but the optimal ratio is unknown.
 
Social insects, for example ants, also have to manage the specialist-generalist problem. Ant colonies must organise complex work including nest building, foraging and defense. Evolution has produced effective and robust systems of work organisation including, in some species, the evolution of extreme physical specialisation producing morphologically distinct workers adapted for specific tasks but unable to perform other more generalist tasks e.g. soldier ants. Less extreme forms of specialisation also occur where workers specialise in specific tasks at specific times of their lives. These workers are specialised to a specific task but there remains considerable flexibility and they can revert to earlier tasks as conditions dictate. The resilience, dynamism and flexibility of ants organisational systems is a major contributor to their ecological success and the optimal balance between specialisation and generalisation are central to that success. Natural selection generates effective solutions to complex problems and ant-inspired solutions to delivery and scheduling problems are routinely used in industry e.g. Ant Colony Optimisation. We propose that ant organisation could yield valuable insights into optimisation of the specialist-generalist ratio in health care.
 
References
1.  NHS England.  General Practice Forward View, 2016. www.england.nhs.uk/gp/gpfv/ (accessed 26 Feb 2019).
2.  Ahluwalia S, Hughes E, Ashworth M. In celebration of GP education.  Br J Gen Pract 2019; 69(681): 174-175. 
3.  Hunter T. The expert medical generalist. Br J Gen Pract 2018; 68 (675): 495-496. 
4.  Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Millbank Q 2005; 83(3):457–502.
 
Competing Interests: None declared.