The generalist approach to medical practice has existed for thousands of years, alongside the specialist approach.1 Proponents and critics of both approaches have existed as well, but with overall societal trends towards reductionism and specialisation there had been a perception that the generalist approach was under threat and in crisis.2 At the same time, research was finding that healthcare systems with strong primary care, where generalists operate as the first point-of-contact within the healthcare system, were more efficient and had better health outcomes.3 In addition, demographic trends with ageing populations have resulted in more patients with chronic multisystem diseases that require a generalist approach.
This combination of perceived crisis and need has resulted in many individuals and groups trying to define, promote and strengthen the generalist approach. The Australian Medical Association issued a position statement in 2012 calling for clearly defined generalist training programs and pathways, greater recognition and support for generalists, more comparable remuneration, and further research into generalist workforce requirements.4 Internationally, the Royal College of General Practitioners in Britain issued a report on medical generalism,5 while most recently, the Mason review of Australian government health workforce programs has stated the need to ‘foster more generally an emphasis on generalist medicine and integrated primary care’.6
My own experience as a generalist started in Montreal, Canada. After graduation from McGill University I went on to do a residency in family medicine, followed by a certificate in emergency medicine. Working in the Montreal General Hospital Emergency Department, a level one trauma centre, provided exposure to acute care medicine, while locums in northern Quebec with Cree communities maintained broader skills.
One of the advantages of being a generalist is flexibility, and an around the world trip at the turn of the millennium ultimately led to the decision to swap the cold snaps and ice storms of Montreal for the heatwaves of Australia. Reciprocal recognition of training between general practice accreditation bodies has facilitated movement between certain countries, including Canada and Australia. When I first arrived in Melbourne I decided to pursue further experience in acute care medicine, and had the good fortune of obtaining a position at St Vincent’s Hospital Emergency Department while it was under the leadership of a remarkable doctor. Continuing to work in an academic environment allowed for further research experience, which ultimately led to the completion of a Masters in Public Health.
In my experience, the defining aspect of being a generalist is the capacity for, and interest in, dealing with undifferentiated presentations, which translates into an ability to embrace uncertainty. This capacity to operate within uncertainty allows for an acceptance of the person as a subjective, feeling, complete individual. As medical generalists in the Western tradition, we are required to have a strong grasp of biology and science, but this in no way excludes a broader understanding of the psychological and social aspects of the individual. In fact, biology can be seen as underpinning these broader features, while clearly social circumstances will impact on biology.
‘(Generalists) can recognise their own limits and yours, while orienting their service to your world views and character’.5 This acceptance and accommodation of different world views and experience can be particularly important in certain populations that are often the targets of discrimination, such as recent immigrants or illicit drug users. In this issue of Australian Family Physician, MacLachlan and Cowie7 and Holmes and colleagues8 examine the diagnosis and management of chronic hepatitis B and C infections respectively, which often occur in vulnerable populations. The topic of right upper quadrant problems is continued, with articles on biliary pain by Crawford,9 and the fatty liver by Iser and Ryan.10
The generalist will always play an essential role in healthcare systems. It is important for generalists to promote their work, and the benefits associated with it, as well as addressing the current factors that lessen the appeal as a career option. A career as a generalist allows for a broad range of experiences, as well as ongoing opportunities for diverse intellectual challenges and the development of new skills, all within the context of a comprehensive and empathic approach to patient care. For an individual with the right mindset, it is an ideal career choice.
- Palmer VJ, Naccarella L, Gunn J. Are you my generalist or the specialist of my care? N Z Fam Physician 2007;34:394–7.
- Van Der Weyden MB. Australian general practice: time for renewed purpose. Med J Aust 2003;179:6–7.
- Starfield B. Is primary care essential? Lancet 1994;334:1129–33.
- Australian Medical Association. Position Statement on fostering generalism in the medical workforce. Australian Medical Association, 2012.
- Howe A, et al. Medical generalism: why expertise in whole person medicine matters. London: The Royal College of General Practitioners, 2012.
- Mason J. Review of Australian Government health workforce programs. Canberra: Australian Government Department of Health and Ageing, 2013.
- MacLachlan J, Cowie B. Chronic hepatitis B: what’s new? Aust Fam Physician 2013;42:448–51.
- Holmes J, Thompson A, Bell S. Hepatitis C: an update. Aust Fam Physician 2013;42:452–6.
- Crawford M. Biliary pain: work-up and management in general practice. Aust Fam Physician 2013;42:458–61.
- Iser D, Ryan M. Fatty liver disease: a practical guide for GPs. Aust Fam Physician 2013;42:444–7.