Reeve’s article does not address several issues, which simultaneously make the approach under-ambitious and have divisive, probably unintended, consequences.1
First, are there specialists and generalists? Many ‘specialists’ practise in ‘generalist’ mode within their discipline, and GPs with a special interest contribute to secondary care.2 The division suggested by Reeve would not incorporate these colleagues who would presumably utilise different philosophical models in different roles. It seems unlikely that these are the only models to answer clinical questions and that there is no spectrum between these approaches. For example, psychiatrists take a biopsychosocial approach to formulating a patient’s diagnosis and management.3
Scholarship-based medicine does not recognise that different approaches are needed at different times. The generalist will likely follow protocol in an emergency resuscitation situation; specialists may need to make a diagnostic decision, then consider the appropriateness of major life-changing treatment incorporating a wide range of factors.
However, our major concern is the implicit criticism that specialists do not consider the whole patient. This type of ‘bashing’ has been the subject of academic debate and widespread campaigns by royal colleges with the aim of improving recruitment.4 Such division is unhelpful to all.
The Chief Medical Officer for Scotland’s realistic medicine strategy5 suggests that patients ask these questions to make the right decisions about care; is this test, treatment, or procedure really needed? What are the potential benefits and risks? What are the possible side effects? Are there simpler, safer, or alternative treatment options? What would happen if I did nothing? Perhaps if patients did ask such questions, or specialists and generalists did, a more scholarship-based medicine approach would follow.
Reeve thus develops a model, which, if it is to be truly effective for patients, should not just be the preserve of the generalist, but of doctors. A more ambitious approach may be not to redefine generalism, but remove criticism of others (not typical of GPs), and ensure that the prospect of generalist-led medicine is made more realistic.
REFERENCES
- 1.Reeve J. Scholarship-based medicine: teaching tomorrow’s generalists why it’s time to retire EBM. Br J Gen Pract. 2018. . [DOI] [PMC free article] [PubMed]
- 2.Royal College of General Practitioners . RCGP framework to support the governance of general practitioners with extended roles. London: RCGP; 2018. [Google Scholar]
- 3.Royal College of Psychiatrists . OP 103 Using formulation in general psychiatric care: good practice. London: RCPsych; 2017. [Google Scholar]
- 4.Ajaz A, David R, Brown D, et al. BASH: badmouthing, attitudes and stigmatisation in healthcare as experienced by medical students. BJPsych Bull. 2016;40(2):97–102. doi: 10.1192/pb.bp.115.053140. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.NHS Scotland . Practising realistic medicine: Chief Medical Officer’s summary report 2016–2017. Edinburgh: Scottish Government; 2018. https://www.gov.scot/Resource/0053/00534350.pdf (accessed 5 Sep 2018) [Google Scholar]