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Generalism in Medicine has it a future?

Generalism in Medicine has it a future?. George Freeman Emeritus professor of general practice Department of Primary Care and Public Health seminar 12 th October 2011. medical generalism. has a past - but specialists are rampant today!

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Generalism in Medicine has it a future?

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  1. Generalism in Medicinehas it a future? George Freeman Emeritus professor of general practice Department of Primary Care and Public Health seminar 12th October 2011

  2. medical generalism • has a past - but specialists are rampant today! • an expert generalist or just Jack of all trades? - special attributes but not a specialism • not confined to primary care • gatekeeping • evidence for – largely from Starfield • generalism and the marketplace • non-medical generalists • Generalism Commission 2011 - recommendations for the future

  3. 1 history - of specialism • the archetypal medical practitioner is a generalist – but specialism goes back at least to the 5th century BCE (Herodotus) • specialism took off from mid 18th century starting with paediatrics in France • now form majority in all developed medical economies – less so in UK than most • generalists have long struggled for ‘parity’

  4. 2a expert - or lowest common denominator? • widely distributed - generals, general managers • senior, wise, experienced with overview • but low status in medicine in recent past • public perceptions vary a lot (Nickols 1981)

  5. 2b expert – special attributes • broad diagnostic framework • patent centred values • practise in context • output is technical and emotional • not specific to but most expressed in general practice

  6. 3 not confined to primary care think of A&E care of the elderly acute medical intake medical managers secondary care tendency to put generalist at the front end contrast primary care with nurse triage

  7. 4 gatekeeping • gatekeeper role means strong general practice – both money and prestige • contrast GP in Belgium and Netherlands • integral part of most comprehensive or managed care systems • GP commissioning is highest form yet • not always popular with patients • recent questions about diagnosis • the Gatekeeper and the Wizard(Mathers & Hodgkin 1989)

  8. 5 evidence for Starfield better care outcomes with more primary care physicians international comparisons of comprehensiveness, family orientation • better access • better quality of generalist care • prevention in primary care • better early management • primary care is more appropriate care • reduction of inappropriate specialist care

  9. 6 generalism and the marketplace • public faith in ‘expertise’ & ‘science’ • specialists cannot survive unless patients believe they are better • AMA has opposed • public health centres • public programmes for care of the poor • Health Maintenance Organisations • the market place favours specialisation(Gordon Moore 1992)

  10. 7 non-medical generalists Nurse Practitioners • increasing in first contact role • different training • run some PCOs • no evidence of inferiority to GPs • cheaper? better? better evidence needed!

  11. 8 Generalism Commission 2011 11 recommendations include • importance of early accurate diagnosis • generalism needs continuity of care • more imaginative use of IT • revise perverse reward systems • training – more general for all; longer for GPs • boost for academic GP & research • multi-morbidity; non-medical generalists

  12. references Herodotus - see p 49 inPorter R. The greatest benefit to mankind: a medical history of humanity from antiquity to the present. Harper Collins, London, 1997. Nickols FW (1981). Generalist vs Specialist: Whom do I consult?” Performance & Instruction. Washington, D.C.: National Society for Performance & Instruction. (Updated version 2003 accessed on line 11.10.2011 viahttp://www.nickols.us/generalist.pdf ) Mathers N, Hodgkin. The Gatekeeper and the Wizard: a fairy tale. BMJ 1989;298:172-4 StarfieldB, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Millbank Quarterly 2005;83:457-502 Moore GT The case of the disappearing generalist: does it need to be solved? The Millbank Quarterly 1982;70:361-79 Guiding patients through complexity: modern medical generalism. Report of an independent commission for the RCGP and the Health Foundation. http://www.health.org.uk/public/cms/75/76/4299/2763/COMMISSION%20REPORT%20ON%20MEDICAL%20GENERALISM%20OCTOBER%202011.pdf?realName=xbuUe5.pdfHealth Foundation October 2011

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