The right upper quadrant

July 2013

Up front

Challenges and rewards

A career as a generalist

Volume 42, No.7, July 2013 Pages 439-439

Glenn Duns

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.

References

  1. Palmer VJ, Naccarella L, Gunn J. Are you my generalist or the specialist of my care? N Z Fam Physician 2007;34:394–7.
  2. Van Der Weyden MB. Australian general practice: time for renewed purpose. Med J Aust 2003;179:6–7.
  3. Starfield B. Is primary care essential? Lancet 1994;334:1129–33.
  4. Australian Medical Association. Position Statement on fostering generalism in the medical workforce. Australian Medical Association, 2012.
  5. Howe A, et al. Medical generalism: why expertise in whole person medicine matters. London: The Royal College of General Practitioners, 2012.
  6. Mason J. Review of Australian Government health workforce programs. Canberra: Australian Government Department of Health and Ageing, 2013.
  7. MacLachlan J, Cowie B. Chronic hepatitis B: what’s new? Aust Fam Physician 2013;42:448–51.
  8. Holmes J, Thompson A, Bell S. Hepatitis C: an update. Aust Fam Physician 2013;42:452–6.
  9. Crawford M. Biliary pain: work-up and management in general practice. Aust Fam Physician 2013;42:458–61.
  10. Iser D, Ryan M. Fatty liver disease: a practical guide for GPs. Aust Fam Physician 2013;42:444–7.

Correspondence afp@racgp.org.au

10 October 2013 05:06

Re: Challenges and rewards

Heather Grusauskas

Acting Director of Graduate Studies

Department of General Practice, Monash University

Dear Editor

I am writing in response to your recent article on “Challenges and rewards, a career as a generalist”, July 2013. I was particularly interested in your comments in relation to generalists promoting their work and also the important issue of addressing factors that lessen the appeal of general practice as a career option.

As a starting point what is “hot’ about general practice and what is not? Let’s look at this through the lens of our medical students. The number of graduates entering general practice varies among Australian universities, indicating that the undergraduate experience affects career choice. 1 Positive experience on clinical placements are shown to be a strongly influential factor in affecting students’ career choice. 2 Moreover, it has been anecdotally reported that students with a greater rural clinical exposure are more likely to pursue general practice than metropolitan based students due to the greater opportunities to generalist work in rural areas. 3

There are various factors that have been implicated in deciding a speciality choice, including demographic characteristics, personal and occupational factors. In terms of demographics, the students who are older and of rural origin are more inclined to choose general practice as a career.3 However, a Dutch study found that gender is not as definitive as a predictor of specialty choice as compared to students’ attitudes towards general practice work and preferred type of patient. 4 Whilst females demonstrated more interest in becoming a general practitioner during the undergraduate years, they are more likely than males to change their interests after graduation in favour of other specialities. 4

It has been shown that students interested in different specialities value different aspects of the career. 5 For general practice, these determinants are broadly classified as personal and occupational factors. As for personal factors, many younger doctors prefer working fewer hours, and the flexibility of GP’s working hours is seen as attractive. 6 Relatively short length and ease of entering GP training program is also viewed favourably by some students. 7 In contrast to other specialties, it has been shown that students and junior doctors aspiring to become a GP often regard remuneration among the lowest on their priority. 6 A false perception of low pay is also said to be one of the major deterrents to selecting a career in general practice, when in fact the pay discrepancy may not be as great when factoring in other opportunity costs of GP, such as family life and flexibility in secondary career options.8

The major positive occupational factors in general practice include job variety, ability to perform procedures, continuity of care and perceived intellectual challenge. Students who prefer variety in their work often find GP attractive due the diversity and breadth of general medical knowledge in GP work (Rodriguez, 2012).7 The opportunity to perform procedures is also viewed as important especially by the male students. 6 While the majority of students desire an intellectually stimulating specialty (AMAWA 2009), general practice often carries a stigma as being boring and less prestigious than other specialties. 9

A recent cross-sectional electronic survey was undertaken of medical students enrolled at Monash University between the period of January 14th and 28th 2013. 10 The overall results were as follows; general practice was reported as the most popular specialty (22.9%), followed by surgery (21.2%) and finally hospital medicine (17%). Additional influences affecting speciality choice were also identified as follows: the most attractive aspects of a career in general practice where seen as flexibility, diversity and life style; clinical placement; continuity of patient care; community engagement. The least attractive aspects of a career in general practice where viewed as: lack of prestige; perceptions on specialization; lack of complexity and finally low remuneration. We found overall that our students had strong, often, diametrically opposed views on general practice as a career choice.

So where does this leave us? Yes, we now have a much better understanding of the relevant factors influencing students’ career choice. This will assist all of us as key stakeholders to target and promote general practice material to students and prevocational doctors encouraging students’ identification and engagement with general practice as a viable career choice. At an operational level can I suggest that we look very carefully at what experiences we are offering our medical students and also re-think how we are marketing general practice as a future specialty to our students and prevocational doctors?



References
1. Australian Medical Workforce Advisory Committee. Career decision making by
doctors in vocational training – AMWAC medical careers survey, 2002. North
Sydney: AMWAC, 2003.

2. Medical Deans of Australia and New Zealand. 2011 PGY1 National Data Report.
Poole P, McHardy K, Janssen A. General physicians: born or made? The use of a tracking database to answer medical workforce questions. Intern Med J. 2009 Jul; 39(7):447-52.

3. Bunker, J. and N. Shadbolt, Choosing general practice as a career: Influences of education and training. Australian Family Physician, 2009. 38(5): p. 341-344.

4. Maiorova, T., ET al., Shortage in general practice despite the feminisation of the workforce: a seeming paradox? A cohort study. BMC Health Services Research, 2008. 8: p. 262-269.

5. Kiolbassa K, Miksch A, Hermann K, Loh A, Szecsenyi J, Joos S, Goetz K. Becoming a general practitioner - Which factors have most impact on career choice of medical students? BMC Fam Pract. 2011; 12:25.

6. Thistlethwaite, J., et al., Enhancing the choice of general practice as a career. Australian
Family Physician, 2008. 37(11): p. 964-968.

7. Shadbolt N,; Bunker J . Choosing general practice — a review of career choice determinants. Aust Fam Physician 2009; 38:53–5.

8. Kim GY. Wolf KE. Kuo T. Factors that influence career selection among medical students. Family Medicine. 42(4):236-7, 2010 Apr.


9. Furmedge DS. General Practice Stigma at Medical School and Beyond — Do We Need to Take Action? Br J Gen Pract. 2008 August 1; 58(553): 581.

10. Grusauskas, H, Harris, N and Kovitwanichkanont. Factors influencing medical students when choosing a career in general practice, academic paper, GPET conference, September, Perth, 2013




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