For your health, generalists have great lasting value

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Category : Medical Rants

First, we must address semantics.  This post – Generalists vs. Specialists – stimulated these thoughts.  Often in organized medicine we (especially internists and family physicians) emphasize that internists (whether inpatient or outpatient focused), family physicians, pediatricians, general surgeons, etc. are specialists, while we reserve the term sub-specialists for cardiologists, or vascular surgeons, or gastroenterologists.  For the sake of consistency with common usage, I will refer to generalists and specialists rather than specialists and sub-specialists.

The essay’s point (as I interpret it) focuses on the value and danger of specialization.  While the essay does not talk directly about health care, one can easily gain some important lessons.

When do we need a specialist?  I would say that for a discrete problem that requires a depth of knowledge and sufficient experience caring for that discrete problem, a specialist is highly desirable.  In internal medicine, if you have a disease with rapidly evolving treatment options (e.g. Crohn’s disease, HIV, acute coronary syndrome, rheumatoid arthritis, severe psoriasis), then a physician who specializes in that disease will have more experience and more resources to help you design the proper treatment strategy.

When do we need a generalist?  The number one reason for first consulting a generalist is to decipher symptoms and develop a diagnostic strategy.  All physicians hear about patients who first consult a specialist because they think they know what their diagnosis is.  However, when you go to a specialist, they will focus primarily on their specialty. As Maslow said, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”

But all chest pain does not come from the heart; all shortness of breath is not a lung problem; all abdominal pain does not require surgery.  The generalist more often will consider the broad range of possibilities diagnostically.

We also need a generalist when we have several chronic diseases, and many patient fit that description.  One generalist generally trumps three specialists.  Let us assume you have heart failure, COPD, CKD stage 3, type II diabetes mellitus and severe osteoarthritis.  How do we balance your treatments and diagnostic strategies?  Such a patient needs one excellent physician who will consider the benefits and harms of treating each of the problem with respect to all the other problems.

Generalists and specialists each have their role in health care delivery.  In the best health systems we work together with the generalist taking the lead and involving specialists when we need their expertise.  This concept works in both outpatient and inpatient medicine.

 

Comments (10)

Dr. Centor observes, above, that “The number one reason for first consulting a generalist is to decipher symptoms and develop a diagnostic strategy.” I think that’s true but would broaden it a bit. We all need someone who can “take stock” of our overall situation as it relates to our health care: How are we coping with our medical needs in the context of the other stressors in our life? If not so well, what can be done to help? Are there particular barriers, areas of confusion, gaps in needed support to address? Also, the generalist (if they know their job) can provide “safe passage” through a mammoth sometimes predatory health care system that is often on the prowl for something to biopsy, image, cut-out or remove. The generalist is that unconditional advocate with the big picture view of the situation. They (ideally) see the patient’s context.

I agree strongly with your analysis. I would argue that your “taking stock” is part of a complete diagnostic process. We should consider diagnostic excellence to have a broad meaning, not just focused on disease, but also the issues that you have mentioned.

A doctor should be GOOD – be it generalist or specialist, fortunately I have seen both of them in good number although the numbers seem to be dwindling. Dr C – had you become a sub specialist, you would be a very good one. With your knowledge base and its application, you will be much better in diagnostic and management skills than a whole lot of specialists I know of. Somehow we have overvalued the procedures done by specialist and given them a godly status diluting the generalist in public perception. Around half the procedures ( anecdotal – where I work as a specialist, we were doing twice the number of inpatient bronchoscopies before I started five years ago) in medicine do not benefit the patient.

I think a better comparison will be cognitive specialities ( pulmonary medicine and ID) vs procedural specialities ( cardiologist and GI)

I appreciate your perspective that “taking stock” is a part of the diagnostic (and care management) process. What we’ve learned, however, is that it’s too often forgotten. Much of the time these non-biomedical issues are overlooked even when they are essential to figuring out and addressing what is going on with a patient. In our research we refer to this process of considering factors that are not biomedical but expressed “outside of the skin” (e.g. a person’s ability to pay for their meds, their capacity to self-manage their care when they lose social support, their competing responsibilities etc…) as “patient context” and we refer to the process of taking patient context into account during the care planning process as “contextualizing care.” We’ve found that less than half of the time are these contextual factors taken into account during care planning EVEN when the clinician has correctly identified and addressed the biomedical issues. In sum, physicians tend to have a “biomedical bias” meaning that they tend to place a greater emphasis on responding to biomedical compared to contextual information, even when both are equally relevant to the care plan. All of this is to say, that this need to “take stock” (ie contextualize care) is too often forgotten when doctors are “diagnosing” and “treating” illness. The result is that the patient walks out with a care plan that look good on paper, but it isn’t likely to work given unaddressed contextual issues. I and my colleagues have dedicated a lot of our work to exploring and addressing this problem http://www.contextualizingcare.org.

To which I can only say “spot on”

While I theoretically agree with your distinction of generalist as diagnosticians and overall manager, and this is how it is “taught” in academic medical centers, the reality is that it is not true in real life at least not in my practice as a rheumatologist with referrals from family practioners, PA, NP, and self referrals.

General medical care practiced by internist and family practitioners as diagnosticians of symptoms complexes and overall managers of disease is dead, simply because there is no such thing anymore. It is “primary care” with insistence on “quality” and “population management” and documenting these things. In essence, the bottom of general medical care had dropped.

A patient does not go to their PCP for a symptom, because they know they will be referred anyway. Their PCP sits in front a computer, asks them useless questions about seatbelts, smoking, etc. while the patient is more concerned about their toe pain. After this, there is a rheum consult, not because their is any suspicion for a disease that is rheum, but rather they have toe pain and there is no time for an H&P. They have no time to deal with denial of services. The manta is KISS (keep is simple stupid).

The ACO definition of Primary Care physician is more than likely to push complex patients back and forth between physicians to have them deal with their issues, keeping only easy patients on their panel (the definition of PCP in ACO is the physician who has provided the most E&M services in a specific outpatient category in that year. It is very likely that specialist will be PCP because they may see their oncologist, rheum, card, pulm, endo, 1 more time than their generalist for that year).

It is my prediction that general internist will exist only as inpatient hospitalists, at academic teaching medical centers, and the VA. At other places (hospital owned or private practice) it will be NP/PA who will focus on chart buffing since that is how money will be paid, and dealing with social services/lifestyle issues/hand holding. Patients will not go to these PCP for symptoms or disease management, since they will realize how quickly will be referred. Then the specialists will be under great pressure to minimize diagnostic and therapeutic services.

The idealism of the generalist is a quaint idea, whose time has come, not because it is wrong, but there is nothing in the present medical care situation that values general medical care that does not come with a myriad of regulations, expectations, and financial risk that is placed upon providers who want to provide that care—except for direct payment practices. The focus has been on providing the best care for the most, if not all, people, using laws, rather than providing the freedom for physicians, nurse, and patients to figure that out on their own.

Agree with Ernie G; I am pretty sure that current model of IM outpatient practice in real world is much different than how it is done in real academic centers. I foresee that the market pressures will bring the quality of academic centers down instead of the other way around.

@ ErnieG:
“The idealism of the generalist is a quaint idea, whose time has come”

Judging by the rest of the post, Ernie, I think you meant to say the idealism of the generalist is a quaint idea whose time has come and gone.

@ Cory– Yes, I meant come and gone. Or “whose time is up”, etc.

Good comments. You have all hit the patient experience nail on the head.

Steve Lucas

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