Dismantling Lord Moran’s ladder: the primary care expert generalist

‘It’s not a choice for me to be a generalist. I would have liked to have done something more.’ (Early career doctor)¹

It is over 50 years since Lord Moran suggested that GPs were doctors who have fallen off the specialist ladder.² Then, two-thirds of early career GPs would have preferred to have been specialists.² Today Lord Moran’s ladder lives on. General practice is still not a first career choice for many graduates, certainly not enough to sustain the workforce we need.³ Our conversations with early career medics reveal that they value the opportunities for flexible working within general practice. But also that they want ‘something more’ than the GP role: notably, opportunities to develop ‘special interests’. We suggest this represents a failure to recognise, or value, the specific expertise of the GP role itself; and in particular a misunderstanding of the primary care expert generalist approach.

THE PRIMARY CARE EXPERT GENERALIST

We start by considering what we understand by the expert generalist. The role is defined by two elements. First, a principle of personalised decision making which recognises health as a resource for living and not an end in itself.⁴ Second, it is the practice of interpretive medicine: the critical use of a range of knowledge in a dynamic exploration and interpretation of individual illness experience.⁵ (Knowledge includes the biographical and biotechnical, as well as that derived from professional experience.) Crucially such expertise includes the capacity to judge the trustworthiness of the interpretation.⁵ Thus, we can distinguish between the specialist who offers solutions (and may indeed re-frame problems to fit their solution), and the generalist who helps to ‘define the problem’.⁶

However the wider literature highlights two differing views of the generalist, as a ‘jack of all trades’ and as practitioners with an ‘acquired expertise’.⁶ The former ‘all-rounder’ view of the generalist GP is widespread both within and outside the profession. In interviews with local GPs, many described generalist practice as ‘knowing a little about a lot, rather than a lot about a little’. This is reflected in health service managers’ view of generalists as having capacity to take on an ever broader range of care, including the flexibility to plug gaps in the system. Generalists become defined by their range of work, rather than by their expertise.

The failure to recognise, or value, generalist expertise in turn contributes to the creation of technical systems to support ‘non-specialists’ in delivering ‘expert’ care. As ever more (specialist) health care is moved into the (non-specialist) community setting, health systems replace the need for ‘specialist expertise’ with a protocol defining quality of care that can be delivered by a technician.⁶ The result is a system of care that overburdens patients and practitioners alike. It arises from a failure to differentiate expertise from specialism: to understand that while a specialist has to ‘be able to solve the problem’, the expert has to ‘know its solution’.⁷ However, it also means that generalist practice becomes seen as a technical rather than an expert role, thus maintaining Lord Moran’s ladder.

THE GP AND EXPERT GENERALIST PRACTICE

The ‘all-rounder’ GP is not without expertise. Current GP training develops expertise in consultation skills. This refers to a set of practices describing the way we communicate and relate with patients which helps deal with the diversity and risk faced by the all-rounder, especially when working with undifferentiated problems. The profession, along with a body of evidence, recognises the therapeutic benefit of the consultation and associated doctor–patient relationship. It is also an area of practice that has long appealed to some, albeit perhaps a minority, of early career doctors.²

However, general practice is not synonymous with expert generalist practice (EGP). Rather, EGP is an extended role undertaken by many, but not all, GPs. Consultation skills can enable (or constrain) interpretive practice; but do not define the expert generalist. Expertise is developed through formal training as well as experiential learning. Such training needs to address both the values (principles) and skills of interpretive practice. In our experience, EGP is also an approach that excites and interests early career medics considering a career in general practice.

We propose the need to recognise heterogeneity within current GP roles. We suggest that there are (at least) three ways of working in general practice. There is the all-rounder GP with expertise in consultation skills increasingly viewed as a technician delivering specialist-defined care across a broad range of need. Then there is the GP with special interests, combining expert consultation skills with some specialist knowledge. And finally there is the expert generalist using interpretive practice to define and address need specifically for each individual. How would you describe your own practice?

WHY DOES IT MATTER?

As health systems struggle to balance resources with ever increasing demands, there is a growing need to take a critical look at how we deliver primary care. Other health professionals are now delivering technical care supported by excellent consultation skills. By recognising different patterns of working, we open practice up to a critical consideration of impact, but also questions of who can and should deliver care. Perhaps we need to evolve the all-rounder GP role into a primary care expert generalist practitioner role? Maybe in this way we can finally dismantle Lord Moran’s ladder.

Provenance

Freely submitted; not externally peer reviewed.

Competing interests

In the spirit of the recent SAPC conference, we offer this as a Dangerous Idea (http://www.sapc.ac.uk/index.php/conference2012/dangerous-ideas) intended to spark discussion and debate. The thoughts are our own and do not necessarily represent the views of the organisations we work for.