Generalism as a cross-disciplinary practice in medicine

Abstract

Objective

To clarify who generalist physicians are and what characterizes their practice.

Data sources

MEDLINE, PsycInfo, SocINDEX, Embase, Ovid HealthSTAR, Scopus, and Web of Science.

Study selection

Empirical studies (quantitative, qualitative, mixed methods) that described the attributes of generalist physicians across various disciplines in the clinical literature.

Synthesis

A total of 262 studies from 25 countries met inclusion criteria. Forty-seven percent of studies lacked essential participant information. The remaining studies primarily framed generalism in terms of an absence of specialist training, reflecting a “deficit model” of care. We identified 4 archetypes of generalist practice: broad-based knowledge, generalism as adaptive expertise, generalism as integrative expertise, and generalism as interpretive expertise.

Conclusion

Generalism lacks a consistent meaning across clinical disciplines in medicine. Four archetypes of practice are proposed to promote cross-disciplinary dialogue and guide the design of future health care systems and professional roles.

A robust workforce of medical generalists is frequently described as “the backbone” or “cornerstone” of any public health system.¹ Traditionally, family physicians (general practitioners) were the quintessential generalists.^2,3 Globally, however, generalism is increasingly endorsed across a range of specialties and health care settings, reflecting a growing recognition of its crucial role in addressing the complexity, uncertainty, and fragmentation characteristic of contemporary health care delivery.^4-6 Medical education systems are increasingly tasked with producing more graduates oriented toward generalist careers.^7-9 In Canada and the United Kingdom (UK), new medical schools have been established explicitly to train generalist practitioners. In the UK, the National Health Service (NHS) Long Term Workforce Plan⁶ explicitly emphasizes generalist training, anticipating the growing burden of multimorbidity and chronic disease in an aging population. Parallel to this, evolving models of care are extending generalist roles beyond traditional primary care settings: for example, the growing role of hospitalists or family physicians with focused areas of practice. These developments position generalism as a cross-disciplinary, boundary-spanning practice that transcends established specialty silos and enables clinicians to deliver more integrated, person-centred care across diverse clinical contexts.

Despite its increasing prominence, the practice of generalism remains elusive. It has been variously described as a philosophy of care⁴ encompassing the therapeutic doctor-patient relationship; contextual understanding of the patient within their familial and environmental milieu; continuity and coordination of care; and care with an emphasis on prevention and health promotion.¹⁰ Others characterize it more succinctly as whole-person care.¹¹ However, such definitions, while conceptually rich, often fail to adequately articulate the core practices that define generalism as a clinical approach.¹² Both medical students^8,13 and experienced generalist clinicians¹¹ report difficulty in conveying the fundamental nature of generalist practice.

A recent narrative review of international policy and mission statements—spanning both generalist and specialist domains—revealed substantial heterogeneity in how generalism is conceptualized.¹² Some institutions frame it as a distinct form of clinical expertise grounded in breadth, while others view it as foundational knowledge applicable across various disciplines. This suggests a need to advance beyond the rhetorical commitment reflected in mission and policy statements to identify tangible strategies for embedding generalist principles into the fabric of clinical practice. As health care systems worldwide seek to address the consequences of fragmented and overly specialized care, a clearer understanding of how generalism is enacted in real-world settings becomes essential. Clarifying the characteristics of generalist clinicians and the nature of generalist practice is vital for informing the design of integrated, equitable, and responsive health care systems.

This review, therefore, aimed to develop a comprehensive understanding of how generalism is described and operationalized within the clinical literature. Specifically, we asked: How do empirical texts characterize generalists (the individuals engaged in generalist clinical work) and generalist practice (the nature of their work in practice)?

METHODS

We performed a mixed-studies systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline.¹⁴ The study protocol was published¹⁵ and registered with the International Prospective Register of Systematic Reviews.

Theoretical orientation

We used hermeneutics, the theory and practice of interpretation, to analyze the meanings attributed to words and descriptions of practice. Hermeneutics allowed us to explore how generalism is characterized within texts (eg, hidden curriculum, stigma). This approach assumes that no definition could be an objective, knowable structure and that we should “peer behind language”¹⁶ used to discuss generalism.

Search strategy

The search strategy was built with medical librarians. We searched MEDLINE, PsycInfo, SocINDEX, Embase, Ovid HealthSTAR, Scopus, and Web of Science databases. Search terms included generalism and generalist, and other terms representing general practice. To ensure that generalism within specialties was represented, we combined search terms for generalism with internal medicine, surgery, pediatrics, and psychiatry. The search strategy is available in Appendix 1 from CFPlus.^*

Eligibility criteria

Table 1 reports inclusion and exclusion criteria. We focused on empirical studies to understand generalism as clinically enacted, instead of conceptual papers that describe how it should be done.

Table 1.

Inclusion and exclusion criteria

CRITERION	INCLUSION	EXCLUSION
Time period	Published from 1999 to 2022	Published in 1998 or earlier
Language	English	Languages other than English
Type of article	Empirical studies: quantitative, qualitative, and mixed-methods studies, and systematic reviews	Conceptual papers, policy papers, conference abstracts, theses, books, general discussions, and letters
Study focus	Clinical practice	Education (eg, reports of placements, educational programs)
Population	Physicians in primary and secondary care practice	Other health care professionals such as nurses, social workers, midwives, pharmacists

Study selection

Two reviewers independently reviewed abstracts. Items were included if they made explicit reference to generalism or generalists. The full text was retrieved if both reviewers could not reject a title or abstract with certainty. Next, 2 reviewers independently reviewed the full texts and discussed discrepancies with the team to reach a consensus on inclusion or exclusion.

Quality appraisal

Since our main aim was to review conceptualizations of generalism rather than empirical findings, we followed a precedent set by earlier researchers¹⁷ to include all relevant articles, irrespective of the strength of their methods.

Data extraction

We used a template in Microsoft Excel to organize and manage extracted data, and compiled tables describing study characteristics. To identify and describe generalists, we included studies where the terms generalism and generalist were used by paying attention to the stated and implicit meaning. We adopted a heuristic approach that regards linguistic expressions as having 2 aspects: intensions and extensions.¹⁸ Intensions are attributes, characteristics, ideas, or properties that a concept implies or suggests; extensions are objects (or classes of objects) to which a word or concept applies.^18,19 To include a study, we required it to have either stated a substantive feature of generalism and specifically connected it to generalism (eg, “generalism involves patient-centred care”), or provided a clear example of generalists (eg “generalists are general practitioners [GPs] and other primary care physicians”).

Data synthesis

We used a convergent design to synthesize quantitative and qualitative study findings²⁰ by analyzing qualitative and quantitative data separately before integrating them,¹⁷ and then bringing the 2 into conversation by representing quantitative data qualitatively. We achieved this by interrogating the data with questions such as the following: Who does this study involve? Who is described as a generalist? What characteristics of generalism are described?

Codes were generated inductively and then grouped into themes, refined through team meetings. We also searched the data for discordant findings to challenge and refine our interpretations. We drew on strategies suggested by Crabtree and Miller²¹ to promote team reflexivity and avoid premature anchoring. The study team consisted of family physicians (M.A.K., S.P., A.R., S.S.), a medical student (A.S.), and research assistants from Canada and the UK (S.C. and others). We also collaborated with patient partners during the project’s preparatory and analysis stages. To integrate the findings, we developed descriptive themes, which took account of similarities and differences across datasets; and analytic themes, resulting from an interpretive synthesis of perspectives on generalism present in the data.²²

Ethics

This review did not require formal ethical approval as it draws on secondary data from published articles.

RESULTS

Of 6541 papers identified, 262 studies from 25 countries entered the final analysis (Figure 1). Table 2 summarizes their geographic locations and study designs.^23-25 Most studies were quantitative: surveys (n=86 studies), retrospective reviews of administrative data (n=78), prospective cohort studies (n=11), statistical or economic modelling (n=9), and others (n=22). The rest of the studies were qualitative (n=33), reviews (n=13), mixed methods (n=6), and other types (n=4). Appendix 2, available from CFPlus,^* details the aims, contexts, and participants (if known) of included studies.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram

Table 2.

Studies included by geographic location and design: Three studies were conducted in 3 or more countries.^23-25

COUNTRY	TOTAL STUDIES (N=262), n (%)	QUANTITATIVE STUDIES (N=206), n (%)	QUALITATIVE STUDIES (N=33), n (%)	REVIEWS (N=13), n (%)	MIXED-METHODS STUDIES (N=6), n (%)	OTHER STUDY TYPES (N=4), n (%)
Asia	9 (3)	7 (3)	2 (6)	0 (0)	0 (0)	0 (0)
Australia and New Zealand	16 (6)	8 (4)	3 (9)	4 (31)	0 (0)	1 (25)
Canada	24 (9)	17 (8)	5 (15)	1 (8)	0 (0)	1 (25)
Europe	20 (8)	12 (6)	5 (15)	2 (15)	1 (17)	0 (0)
Other countries	9 (3)	6 (3)	2 (6)	0 (0)	1 (17)	0 (0)
United States	162 (62)	150 (73)	3 (9)	5 (38)	3 (50)	1 (25)
United Kingdom	22 (8)	6 (3)	13 (39)	1 (8)	1 (17)	1 (25)

Clinical disciplinary focus

Overall, 110 studies investigated generalism and generalist practice in medical specialties. Several additional studies crossed generalist and specialist boundaries by addressing career characteristics or medication use. Nearly half the studies included disciplines other than family medicine such as cardiology (n=24), women’s health including obstetrics and gynecology (n=19), pulmonology (n=14), pediatrics (n=14), and infectious disease (n=13). Surgical disciplines discussed included general surgery (n=2), otorhinolaryngology (n=7), and orthopedic surgery (n=5) (Appendix 3, available from CFPlus^*).

Descriptive themes

Two broad descriptive themes—comparison and collaboration (Table 3)—were strongly represented. The comparison theme justified 1 approach against the other, often by referring to recruitment, working conditions, remuneration, or other structural workforce issues between generalists and specialists. The collaboration theme referred to the need for better communication, teamwork, and cooperation in both generalist and specialist practice. These themes were often in tension with each other within a single paper; for example, comparing outcomes as inferior or superior but ending with a call for greater collaboration, with less attention to how health care organizations and context shaped conclusions (eg, access to care, multimorbidity).

Table 3.

Descriptive themes by study type

STUDY TYPE	THEMES
Quantitative (n=206)	Compared generalists and specialists on metrics such as the adherence to protocols of management plans, medication use, and single disease–based outcomes Most data came from surveys, cost comparisons (using medical claims data), or retrospective chart reviews Studies comparing disciplines by describing workforce issues such as recruitment, remuneration, retention, and academic output
Qualitative (n=33)	Viewed generalists as negotiating decisions with patients and their families Emphasized continuity of care, patient advocacy, and the broad knowledge of generalists Focused on boundaries, including who bears responsibility for a patient’s care Discussed ethical issues such as availability of and access to services in relation to evolving clinical domains (eg, genetics)
Review (n=13)	Compared generalists and specialists Advocated for better understanding of how specialists and generalists could work together (eg, by clarifying areas of competence or examining models of care)
Mixed methods (n=6)	Compared knowledge between generalists and specialists Suggested need for generalist and specialist services to be integrated Generalists key to providing service in areas with limited access to specialists Generalists providing continuity of care and sustaining personal relationships with patients
Other (n=4)	Emphasized context (eg, the needs of specific communities and cultures, the historical structuring of health system) to explore how to develop appropriate models of care (eg, providing effective, high-quality health care in rural or remote areas) Supported better alignment between specialist and generalist care to integrate care

Analytic themes

Characterising a generalist. Of the included studies, 122 (47%) did not define generalism or describe the nature of generalist participants. The remaining 140 studies (53%) provided greater detail: 72 identified participants by broad disciplinary affiliation (eg, family medicine, general internal medicine) and 68 of these further specified subdisciplines as generalist (eg, general cardiology, general pediatrics). Ninety studies defined generalists in deficit terms—as physicians lacking specialist training. Only 23 described positive attributes of generalism, including holistic care, patient-centred understanding, and sustained relationships.

Archetypes of generalism in practice. We identified 4 archetypes of generalist practice: generalism as breadth of knowledge, generalism as adaptive expertise, generalism as integrative expertise, and generalism as interpretive expertise. These categories represent distinct but sometimes overlapping conceptualizations of generalism (Appendix 4, available from CFPlus,^* details illustrative quotes, references, and practice implications).

Generalism as breadth of knowledge: The most prevalent archetype, especially in United States (US)–based studies, defined generalism as broad-based knowledge; practitioners were those in general internal medicine, pediatrics, surgery, and generalists in subspecialties (eg, general neurology, radiology). These clinicians applied deductive reasoning and followed established diagnostic or treatment algorithms. Articles reported comparative outcomes, for example, in relation to adherence to guidelines, length of hospital stay, or prescribing practices. Articles written from this viewpoint often concluded that knowledge deficits led to suboptimal practice. Generalism was characterized by the presence or absence of knowledge. Perceived deficits could be addressed by filling knowledge gaps.

Generalism as adaptive expertise: Here, generalists were often family physicians or physicians working in primary care with additional procedural or clinical expertise (eg, in obstetrics, surgery, diabetes, or human immunodeficiency virus infection), often acquired to meet population needs—especially in underserved or rural settings. It also included physicians working in areas such as pediatrics or infectious disease who adapted their clinical practices in response to community needs, in particular the absence of subspecialty care. Generalism was characterized as flexible and responsive, adapting to local service gaps and often bridging primary and secondary care. In this type of generalist practice, the focus of the research studies was typically on service extension and its evaluation or comparison, with less emphasis on relational models of care.

Generalism as integrative expertise: This model was primarily associated with family medicine (North America), general practice (UK, Australia), hospitalists, geriatrics, and palliative care. In the US it also included community-based doctors working in primary care, such as internal medicine or pediatrics and other services where patients had repeated, and sometimes long-term contact with a physician or service. Emphasis was placed on care coordination, interprofessional communication, and the synthesis of specialist input within a broader biopsychosocial framework. Studies examined, for example, the role of teamwork, communication practices between primary and secondary care interfaces, and how to coordinate care. This archetype was oriented toward wellness, prevention, and continuity, drawing on but not confined to biomedical paradigms.

Generalism as interpretive expertise: This archetype emphasized relational, longitudinal care and inductive, person-centred problem solving. It treated generalist care as inherently interpretive and context-sensitive—a hermeneutic practice adapting, integrating, and implementing biomedical knowledge with a focus on understanding patients’ lived experiences as a holistic endeavour. This type of generalism was predominantly (but not exclusively) identified in qualitative studies based in family medicine from the UK.

“Ways of knowing” informs “ways of doing” generalism. These archetypes reflect divergent epistemologies—“ways of knowing” that shape “ways of doing” generalist care (Table 4). Most studies—especially US-based, quantitative research—positioned specialism as the norm, often treating generalism as the absence of further training (a deficit model). In contrast, a smaller body of qualitative, European, and UK literature portrayed generalism as a coherent, socially embedded model, emphasizing prevention, community engagement, and holistic care.

Table 4.

Different approaches to generalism and generalists

APPROACH	GENERALISM AS BASIC KNOWLEDGE (DEFICIT MODEL)	GENERALISM AS INTEGRATIVE (ATTRIBUTE MODEL)
Axiology	Knowledge as accumulation; extension through acquisition	Knowledge as virtue; holistic understanding as intrinsic value
Ontology	Reality is objective and external; specialists know more (ie, in depth or in detail)	Reality is co-constructed; expertise emerges through socially situated interactions
Knowledge	Discipline-specific fundamentals; deductive reasoning	Knowledge is relational, contextual, and adaptable across settings; problem solving is inductive and integrates biopsychosocial domains
Types of studies	Predominantly comparative: outcomes-focused; generalists positioned in relation to specialists (dichotomy)	Exploratory and explanatory focus: inductive, qualitative, or mixed methods. Emphasis on care processes, patient perspectives, and generalists’ strengths
Characterization	Deductive, compartmentalized. Deficit model of education. Measurement and attainment of additional specialist knowledge. Generalist relinquishes responsibility with specialist expert referral	Contextualized and integrative. Oriented toward wellness and prevention, holism, longitudinal relationships, and growth
Recommendations	Address “knowledge deficits.” Emphasis on specialist benchmarks	Shared experiential knowledge. Interprofessional collaboration and cross-disciplinary education as knowledge exchange

The concept of “complexity” illustrated this divergence. In broad knowledge-based generalism, complexity referred to biomedical severity requiring highly skilled specialists. In integrative and interpretive models, complexity was social and relational—managing multimorbidity within patients’ broader life contexts, requiring ecological awareness of individuals and communities.

Similarly, views on education diverged. Generalism emphasizing broad-based knowledge as the primary feature of generalism proposed discrete interventions to address gaps, such as formal training modules. Interpretive and integrative models emphasized ongoing, situated learning embedded in clinical practice—an iterative process linked to experience, context, and evolving care needs.

DISCUSSION

In an era when international health care systems struggle to recruit generalists, it is crucial that we value and recognize the range of expertise they bring. Our review highlights a persistent and counterproductive tension in the clinical literature.

The terms generalist and generalism are enacted across disciplines with differing epistemologies, shaping how generalist practice is applied, studied, and valued. While generalists and specialists are frequently framed as collaborators, generalism is more often constructed as a deficit rather than a distinct, skilled practice. This discourse positions generalism as “a lack of” rather than a specific way of practice. To reframe generalism and develop a cross-disciplinary dialogue around generalism, we identified 4 archetypes: knowing, adapting, integrating, and interpreting. Rather than reduce generalism into components, this spectrum of generalisms could be used to clarify assumptions and articulate understanding of generalism to support collaborative, patient-centred care—a practice of generalism that spans disciplinary boundaries.

Comparison with existing literature

The tendency to portray generalism as lacking scientific expertise has been documented in prior research.^26,27 This contrasts with family medicine scholarship, which frames generalism as a mode of expertise grounded in inductive reasoning, contextual understanding, relational continuity, and holistic care.^28-32 While broad knowledge is widely acknowledged as foundational to generalist practice, discussions of ways of knowing^33,34 recognize knowledge as both objective and interpretive, embodied, and situated. The adaptive capacity of generalist clinical practice is central to several formal definitions; for example, both the Royal College of Physicians and Surgeons of Canada⁴ and the King’s Fund³⁵ in the UK advocate for generalism as a means to meet community needs.

The COVID-19 pandemic further highlighted generalists’ flexibility as crucial to physician redeployment, as recognized in the NHS workforce plan.⁶ Adaptive expertise is also essential for addressing multimorbidity and service fragmentation.^10,36 Cross-disciplinary generalism is increasingly evident in fields such as pediatrics, geriatric care, respiratory medicine, and cardiology. As the 2011 independent commission report of the Royal College of General Practitioners and the Health Foundation noted, most physicians lie along a continuum from generalism to specialism.⁵ Greater clarity is needed to articulate this continuum to inform role definition and collaborative practice, recruitment, and retention.

Strengths and limitations

This systematic review draws on a broad literature base spanning multiple disciplines and care settings. The inclusion of diverse methodologies allowed for the triangulation of quantitative and qualitative findings, enhancing the validity of our synthesis.

Initially, we considered using a priori definitions of generalism—primarily rooted in family medicine—as inclusion criteria. However, given the limited presence of such definitions in the wider literature, and endorsed by our patient advisors, we adopted a bottom-up approach. This decision allowed us to map the diversity of how generalism is understood and enacted beyond family medicine. Had we used fixed criteria, our final dataset would have been considerably restricted. Our approach thus “listened to the noise” of generalism in the literature, making visible its heterogeneity.

We limited our scope to studies from medical disciplines, excluding allied health professions. Given their growing role in health care, a review of how generalism is conceptualized across these groups would be a valuable complement.

Implications for research and practice

By framing generalism as a form of practice, we revalue a core mode of medical work. However, we also identified that “not all generalisms are equal.” Thus, when planning health care organization and workflows, articulating understanding of the nature of generalist practice could be an important starting point to avoid conflation about generalism across disciplines. Our archetypes offer “a world not of propositions but of practices”³⁷—a constellation of ways in which generalism can be enacted and examined.³⁷

Future research should be attentive to methodologic strengths and limitations in how generalism is studied. Building on consensus and the imperative for more generalists in the workforce to meet patient needs, researchers should in addition describe what they mean by generalism and include details of study participants. Comparative and qualitative approaches each illuminate different dimensions of generalist practice and should be used thoughtfully to advance both theoretical and empirical understandings.

Conclusion

“We learn who we are in practice, not in theory.”³⁸ To support generalism as a care philosophy, we must move beyond simplistic binaries that oppose it to specialism.^39,40 Focusing on what generalists do—knowing, adapting, integrating, and interpreting—and drawing on pragmatic examples from across the clinical literature offer a path toward clarifying and elevating generalist expertise in contemporary health care.