The FHJ debate generalist skills: For the many or the few?

In 2012 Hospitals on the edge¹ set out the huge challenges facing healthcare delivery to avoid a ‘catastrophic’ impact.

In the same year the Future Hospital Commission examined the organisation of care, care processes and care standards. Future hospital: caring for medical patients² subsequently reported the commission's findings for care to be delivered across a range of settings and by a collaborating team of professionals. Implicitly and explicitly in the recommendations was a need to develop more delivery capability for generalist care. It envisaged some fundamental changes to the delivery of care with all patients ‘… to receive safe, high-quality, sustainable care cantered around their needs …’.

Demographic data^3,4 make sobering reading as we contemplate the future needs of the NHS. The social changes in the UK from the mid-1960s resulted in a boomer generation who are now approaching late middle age and old age, who have stayed relatively non-frail by good healthcare but many are developing a host of diagnoses that are not necessarily aetiologically related. They present a very different challenge from previous generations when ‘well’ life expectancy was shorter, and technology was not such that it was able to identify and treat the wide range of conditions that we can today and will be able to in the future.

The arguments for the direction and soul of physician practice remain vibrant.

Case for specialism

The saying, ‘Jack of all trades’ dates back to at least 1390 and was used as a compliment; ‘Master of none’ was added to make the statement less flattering in the late 18th century. General physicians were seen as the masters of the physician arts, but times move on …

Modern and future medical practice is and will be increasingly complex. To deliver such high-level care requires intense and focused training and experience. More of both is required to maintain and develop skills. Technology will change and with it the need for continuous upskilling and re-skilling of the physician workforce.

I believe contemplating a care system in which the expert is also the generalist is simply not realistic. Yes – patients may be collecting many comorbidities, but these will each require skilled management. The proposition that the specialist can also be, to any meaningful extent, a generalist is fanciful and potentially endangers the delivery of the high-quality care to which we should be aspiring. Within specialist departments will be even more highly skilled subspecialists, others will be more generalist within their specialty.

There are inefficiencies in the delivery of care. The interface to primary care could be better. We need provision of intermediate care. This does not preclude the ‘general’ specialist, who may act as the gateway directing patients to more in-specialty expertise. These are organisational challenges, not a charter for distracting specialists from that which they do best.

Fundamentally I feel that patients want to receive expert, specialist care for all of their health problems and they want to have confidence that the providers of this care have been trained and practise to the highest possible levels.

The UK training system is still much longer than that of comparable nations. Diverting training time to the development of significant general medicine skills will potentially lengthen training still further. Already many trainees complain that they do not have enough time to develop in their specialty. Indeed, the dilution of specialty training may reduce further the passion and morale of trainees. Post-CCT, the maintenance of robust general medicine skills will also detract from the maintenance of specialty skills. No matter how adept, a single doctor cannot be the ‘jack of all trades’ to the extent needed to ensure high-quality practice.

The resources needed to train and maintain sufficient general physicians will distract from their use elsewhere. Recruitment will be challenging and not sustainable once the pool of those not able to gain access to specialty training programmes is exhausted. Recruitment also risks attracting those who want a ‘quick CCT’ and who will later seek to evolve into specialist. There is no clear career pathway for general physicians and many will end up disillusioned or effectively filling gaps in front-door delivery.

Generalism remains an ill-defined and differently defined concept that is undeliverable at the same time as ensuring standards of specialty care.

In an era of restricted healthcare resources, it is important that we focus our medical expertise where it can be of optimal benefit and introduce other, suitably trained professionals to support the wider social needs of each patient.

Summary

The adaptation of physician-delivered healthcare to the changing needs and resources of the UK population should not be at the price of delivering high-quality specialty care. Technological change requires more, not less, focus on the expertise of specialists. As with all complex problems, one-bullet solutions will be inadequate. Meeting these needs will require a more multifaceted approach across both primary and secondary care, together with the long-awaited reforms of the care sector.

Case for generalism

My esteemed colleague has raised some interesting points. I cannot argue with the increase in specialist knowledge, the advent of technology unimaginable mere months previous, nor the length of training. However, rather than presenting what we cannot do, I would like to paint a picture of what we could do, and why the breadth in definition of ‘generalism’ is a blessing rather than a curse.

While many patients require the input of specialist services, the complexity in the way that their multiple morbidities interact is often more impactful on both their quality of life and their morbidity and mortality. As physicians specialise and subspecialise, the knowledge base becomes more and more narrow. For example, let's take the case of a patient with ischaemic heart disease and other typical comorbidities, type 2 diabetes, chronic kidney disease, hypertension and left ventricular failure. While I do not argue with the need for the cardiology interventionalist to have enough time delivering their craft, as any of their surgical colleagues would, in order to maintain their physical skill, I believe that the patient they stent does not, or rather should not, require three distinct outpatient appointments every 3–6 months with the cardiology, endocrinology and nephrology teams; often across different sites, with little or no information shared between the three. In addition, when an illness decompensates the heart failure, chronic kidney disease and diabetic control in equal measure, they will be admitted under one of the above medical teams, often waiting for days for each additional relevant ‘specialty’ to visit and advise. Each of these days can result in reduction in mobility, increase in frailty and loss of independence.

I ask you instead to imagine a service in which the care being provided is aligned with the population it serves: an increasingly multimorbid one whose physical health does not exist in isolation from their mental health and social care needs, nor from the realities of the service pressures and wider environmental impacts of healthcare. This service is staffed with generalists, of all definitions. There is a blanket understanding across the health and social care MDT of how the local system works, which third sector organisations can support the patient on discharge, how the integrated care system is connected, and how to initiate and manage change as it is required through adequate leadership skills, irrespective of place in historical hierarchy.

Our recently stented patient above then visits the hospital once, to a general medicine clinic, in which a registrar focusing on general internal medicine assesses their interconnected pathologies. They have a clear understanding of potential drug interactions, of interventions likely to decompensate associated diseases, and of how to balance these for optimum patient care. This registrar is a member of a wider team, and entire department, dedicated to generalist medical care. This department does not spend a post-take ward round filling in referrals to disparate specialty wards, but delivers person-centred care to all and seeks advice through well-established and rapid channels when distinct specialist input is required.

This is not a new concept, let me introduce to you the generalists of new and old (pun intended): the paediatrician and the geriatrician. There is a reason these roles exist – for the patients at the early and latter stages of life who are better cared for as a whole than as individual conditions. I would argue that those in the middle of life are now in the same situation, yet the service available to them does not align.

I now tentatively introduce the impact of identity in the resistance to this inevitable shift. For several years it has been the aim of many to arrive at a final destination, a box ticked, a summit reached: a consultant specialist. As my colleague has pointed out, this is also what patients have been led to believe is optimum care. However, as we have seen through history, what is believed to be optimum care is often quickly disproved in retrospect – let us not forget the smoking physician espousing the benefits of the cigarette.

As for the length of training, I ask what we are training for? Yes, the traditional training structure is comparably lengthy, as the unenviable task of producing generalists for patient need AND specialist as per traditional pathways has been melded into one scheme. With system-wide acknowledgement that generalism is in fact for the many, not the few, training offers can be altered appropriately. In fact, this is already happening with positive impact: standalone general internal medicine is now available across England, with the increasing establishment of general medicine departments alongside. In terms of those broader generalist skills – local system knowledge, leadership, environmental impact of healthcare and digital capability – the enhance programme is now established across England for all foundation doctors, as well as a variety of multiprofessional offerings for middle- and later-career health and social care specialists. Not only has this programme delivered positive patient outcomes through service improvement, but evaluation also has shown an increase in professional identity and reduction in burnout.

Summary

The needs of our present and future population should determine the service model of care, which in turn should both impact, and be impacted by, the education and training that we deliver. Those needs are increasingly related to complex multimorbidity alongside an ever-growing understanding of the wider determinants of health. Accepting that generalist skills are essential across all definitions, and therefore prioritising their development and delivery, is a necessity. Generalist skills are not for the many, they are for all.

We are therefore at a crossroads for the future direction of physician practice and the training and revalidation of physicians. There are many other considerations pertinent to this discussion, not least the significant resource constraints and likely technological developments, including support from AI.

An informed debate is needed. Cool and logical heads are needed. We need to put aside our ‘tribalism’ and seriously consider what is the best way to go and what is practical to deliver.

What do you think? Vote at https://forms.office.com/e/JHRFTCr3RG until 15 September 2024.

Do you like the debate feature? Send us your thoughts to fhj@rcp.ac.uk

Declaration of completing interest

Professor Phil Bright was the clinical adviser for internal Medicine (NHSE) and chair of the Pure GIM pilot steering group. Dr Ruth Silverton was NHSE fellow for the enhance programme – enhancing generalist skills. No conflicts of interest.