Training medical practitioners: which comes first, the generalist or the specialist?

Increasing specialisation

In the 19th century, every doctor could be expected to have comprehensive skills and knowledge. An individual practitioner could have a sound grasp of the whole scope of medical science and deliver care across the whole spectrum of disease. John Snow (1813–1858), who is chiefly remembered today for his contributions to public health by his identification of the Broad Street pump as the source of a cholera outbreak was a general practitioner throughout his career. He was also a pioneer in anaesthesia, who anaesthetised Queen Victoria for the birth of her last two children.¹

As the science and practice of medicine progressed, it became more and more difficult for a single individual to be at the forefront of practice for all conditions. By the beginning of the 20th century, medicine, surgery and obstetrics had developed into separate disciplines. The process of fragmentation continued. The first surgical subspecialty to gain recognition as an independent entity probably was orthopaedic surgery led by pioneers such as Hugh Owen Thomas (1834–1891) and his nephew Robert Jones² in Liverpool. The process of subspecialisation continues and now within orthopaedic surgery there are recognised subspecialties for the spine, the hand and each of the major joints.

Subspecialisation of the traditional disciplines has been paralleled by the emergence of new disciplines as medical science has advanced. As a result, there are now more than 60 specialities and subspecialties with training curricula recognised by the Postgraduate Board of the GMC.

There are good reasons why this change took place. Common sense suggests that the more often you do something, the better you will get at it. This idea is supported by empirical evidence that patient outcomes are better for those treated in specialised units.³

However, the case for subspecialisation may not be as strong as it seems at first. Simple repetition of a task is not sufficient. Improvement in performance occurs as a result of deliberate practice⁴ which includes reflection on the task as performed, preferably with a mentor or coach.⁵ This is more likely to happen in a specialised unit but sheer volume of throughput is not enough to guarantee expertise. The improved results in specialist units may relate to the use of evidence-based protocols⁶ and formal multidisciplinary team meetings⁷ rather than the experience of individual specialists.

Super-specialisation results in the care of the patient becoming fragmented. Dame Philippa Russell, Chair of the Standing Commission on Carers, regards this as deleterious:

From my experience as the Disability Rights Commissioner … it was absolutely vital for patients and their families to have somebody who was interested in the generality of their health and well-being irrespective of particular diseases.⁸

The need for the generalist

There are at least three reasons why we need generalists.

1. Changing demography. The proportion of older people in the population is increasing across the developed world. In the UK it is predicted that the proportion of people aged over 65 years will rise from 1 in 6 to 1 in 4 by 2050.⁹ As the population ages, the number of individuals with long-term conditions and multiple pathologies increases. It is estimated that 58% of individuals over 60 have at least one long-term condition requiring treatment¹⁰ so any new condition in an older person is likely to be associated with an already existent one. Adequate management of the patient requires an overview of the co-morbidities and their interaction.

2. Changing medical and social perspectives. Paternalism has been replaced by patient-centred medicine. Disease-centred medicine has been replaced by whole-person medicine.¹¹ Responsibility only to the individual patient has been replaced by social accountability.¹² All three of these changes require a breadth of vision and understanding.

3. On-going demands for healthcare. The generalist has a crucial role in three areas of existing healthcare demand. In chronic illness continuity of care is essential. In undifferentiated disease a generalist is more likely to be able to consider the full range of differential diagnoses than is a subspecialist who runs the risk of inaccurate pattern recognition leading to premature closure with an incorrect diagnosis. In emergency medicine urgent cases are often undifferentiated at the time of presentation. Acute cardiac conditions can mimic acute upper abdominal conditions and vice versa. The management of the management of the acutely ill patient may require a range of different specialist skills. Coordinating the deployment of those skills ought to be the role of the generalist.

Education and training of generalists

All doctors are taught general consultation and clinical reasoning skills. Efforts have been made to identify a core of knowledge that is essential for all medical practitioners.¹³ This remains a subject of debate but it is clear that the new graduate is not a generalist in any real meaning of the word.

Patients with multiple pathologies present challenges of complexity. Patients with acute illnesses present challenges of uncertainty. When patients with multiple pre-existing pathologies develop acute illnesses the complexity and uncertainty are compounded. Managing such patients demands a sound understanding of risk and probability, which is a major competency of a good generalist as noted in a recent report of the Royal College of General Practitioners.¹⁴

Historically, new graduates were able to practise independently but developments in medical science made it increasingly unlikely that they would have the necessary skills and knowledge. The Goodenough report in 1944¹⁵ suggested a period of supervised practice before independent practice as a general practitioner and led to the introduction of the pre-registration year in 1953. The exponential growth in medical knowledge since then has exacerbated the problem. General practice in the UK is no longer the default position of the new graduate but a specialty in its own right with its own postgraduate curriculum.

Education and training of specialists

The trend in specialist training has reflected the trend in practice towards increasing subspecialisation. The problems caused by this have been recognised in the recent Greenaway Report into the future of medical training.¹⁶ The solution proposed is broad-based specialty training under broad care themes. There would be opportunities for individuals to develop areas of special interest after the award of the certificate of completion of training. The model appears to break down the community/hospital divide by rotating training through both settings. However, the current role of the general practitioner/family physician seems to have been lost and it is not clear how this model will produce a sufficient number of true generalists who are competent across different care themes.

A radical alternative

The current model of medical training is the product of tradition and evolution rather than empirical design. The undergraduate medical course is still predicated on the concept that graduates must have abroad understanding across all of the medical disciplines although it is recognised that this will not equip them for independent practice. As already noted, when they do attain independence many doctors focus on a narrow area of practice. Do they need the broad training in order to do this? Practitioners from a variety of healthcare professions now undertake what were formerly considered to be doctors’ tasks.^17–19 Task-orientated training enables them to perform their role safely and effectively. It is, therefore, possible to conceive of an entirely different route through training.

An individual would first train for a specific function within the healthcare team. This may be a procedural role or may relate to the management of a particular condition such as asthma or diabetes. The training would focus on the knowledge and skills (including consultation and communication) needed for that specific role. Because the training is focused it can achieve a greater level of competency for that role in a shorter time than the current training route.

Individuals may choose to practise their specialty for their entire career. Others may practise for a time and then choose to take further training. The procedural practitioner may broaden their scope of practice to include other procedures or decide that they want to become involved with investigation and diagnosis rather than focusing entirely on treatment. The asthma specialist may undertake further training to undertake the management of patients with other respiratory conditions such as COPD.

This process of gaining experience and then undergoing further training can continue incrementally until the individual eventually has a level of competence equivalent to what we currently recognise as specialists including, within their own area, a holistic bio-psycho-socio-spiritual approach to health. Some experienced specialists may choose to undertake further training in order to become generalists. These generalists will be responsible for coordinating the care of patients with complex medical histories referring them to relevant specialists when necessary. Such generalists seem to fit the definition of a doctor as set out in Tomorrow’s Doctors 2009 ‘using their ability to provide leadership and to analyse complex and uncertain situations’.¹

The proposed training programme

For this to work completion of training must be based on the achievement of necessary competencies rather than time spent in training. Adaptive computer programmes allow the assessment of competency and the learning needed to achieve it to be tailored to an individual student. It is no longer necessary to teach everything to everybody to ensure that all the learning needs of the group have been met. The theoretical aspects of the course can be covered by each student in their own time and at their own pace. Standards are maintained by requiring each student to pass the relevant assessment before proceeding to the next stage of training. In theory, it is possible to produce computer-based learning that would enable a trainee to plan their own trajectory from subspecialist to generalist provided that the necessary adjustments to clinical posts were made.

While this would be the most common training pathway there may be a separate ‘fast-track’ for individuals who wish from the outset to train as generalists that might take a form more like the current pathway.

Barriers to change

One significant barrier to change is the current hierarchy within the medical profession. At present, sub-specialists have the highest status and the highest pay. Neither those in post nor those in the training grades who are expecting to be appointed in due course are going to welcome an inversion that places generalists at the top of the hierarchy. A second barrier is the existence of strong professional boundaries. It is not entirely clear why a medical gastroenterologist should identify professionally with an orthopaedic surgeon rather than with a nurse endoscopist who performs the same procedures on the same group of patients but doctors are doctors and nurses are nurses. In part, this is due to the third barrier to change which is the existence of separate regulators for each profession. In the UK, doctors are responsible to the General Medical Council, nurses are responsible to the Nursing and Midwifery Council and other health professionals to the Health Professions Council. It is not clear which body would regulate the proposed specialist practitioners whose training and job description would be different from any current healthcare professional or at what point they would come under the authority of one of the existing regulators.

Conclusion

Increasing specialisation within healthcare has led to major advances in the care and cure of patients. However, we may be reaching a point where practitioners have become so specialised that the care of patients is suffering. There is an urgent need to recognise the importance of generalists who are able to deliver holistic care as advocated by Hippocrates while orchestrating the delivery of cutting edge technological care by the specialists.

Declarations

Competing interests

None declared

Funding

None declared

Guarantor

SL

Ethical approval

Ethical approval was not required as no research was undertaken.

Contributorship

Sole authorship

Provenance

Not commissioned; peer-reviewed by Rhona Knight