Generalism in Medical Education: What and Why?

1. Generalism in Medical Education: What and Why? Rakesh Biswas Department of Medicine, LNMCH, Bhopal

2. Learning Objectives: • What Generalism? (Problem Statement) • Why Generalism? (Problem Statement) • How Generalism? (Solution) • Transformation (Solution)

3. What?

4. Generalism: Differentials? • Professionalism? • Specialism? • Scientism? • Alternative...ism

5. Generalism: Road Map? • Role Models? • Problems? • Optimization? • Transformation?

6. In General ‘Role Models’ Painter, sculptor, architect, musician, mathematician, engineer, inventor, anatomist, geologist, and writer. http://commons.wikimedia.org/wiki/File:Francesco_Melzi_-_Portrait_of_Leonardo_-_WGA14795.jpg

7. In General ‘Role Models’ This "Wizard of Menlo Park“developed many devices that greatly influenced life around the world http://commons.wikimedia.org/wiki/File:Thomas_Edison2.jpg

8. In General ‘Role Models’ Physicist, Biologist, Botanist, Archaeologist, Fiction-Writer, Left studying Medicine from University of London http://commons.wikimedia.org/wiki/File:Jagadish_Chandra_Bose_1926.jpg

9. Practical?

10. Can we train people to become Generalists? Or are they born and not made?

11. A school for Generalists?http://www.banglapedia.org/Images/Shahintiniketan.jpg

12. Core Characteristics of a Generalist? • Multidisciplinary Abilities (Jack of All trades?) • No well defined comfort zone (Restless?) • Cannot be typified ( Non-professional?)

13. Core Competencies of a Generalist? • Life Inputs: • Ability to access variety of Inputs supported with Imagination (Knowledge) • Life Processing: • Courage to be different, Collaborator, Continual Carer (Attitude) • Life Outputs: • Expresses Ability to solve a variety of problems and create new tools (Skills)

14. General...ism as a Profession? General...ism ‘in the’ Professions (Healthcare, Hospitality)? http://upload.wikimedia.org/wikipedia/commons/b/b8/Tajik_dastarkhan_meal.jpg

15. General...ism as a Profession Healthcare http://curriculum.racgp.org.au/images/curriculum/learninglife.gif

16. When someone says that he is ‘doing obstetrics’—or whatever, this should not hide the fact that much more is being done besides, not just a little of each of medicine, psychiatry, gynaecology and paediatrics, but also a good deal of work to elicit and act upon the patient’s unspoken hopes and fears. Oxford handbook of Clinical Specialties 9th edition

17. At the operating table he must concentrate minutely on the problem in hand; but later (and before) he must operate on other planes too, in social and psychological dimensions so as to understand how the patient came to need to be on the operating table, and how this might have been prevented.Oxford handbook of Clinical Specialties 9th edition

18. Who is a Generalist HealthCare Professional?

19. Who is a Specialist Healthcare professional?

20. List of Healthcare Specialties • For example: • Clinical Anatomy, Physiology, Biochemistry etc • Clinical Pharmacology, Pathology etc • Obstetrics and Gynaecology, Orthopedics etc • Neurology, Cardiology, Neurosurgery etc

21. List of Generalist Healthcare branches • For example: • General Medicine • Family Medicine • General Surgery • Paediatric Medicine/Surgery

22. Do all doctors need to be generalists?

23. Why?

24. Why do all doctors need to be generalists? Because the only other option is to become a Specifist/Partialist.

25. Why do all doctors need to be generalists? Super-Generalist Super-Specifist/Partialist Learned and full of knowledge Defends own territory Right OR Left brain thinker Whole of a part, Distant Avoids social issues • Life-long-learner hungry for knowledge • Makes new connections • Right AND Left brain thinker • Part of a whole, Empathetic • Fearless , embraces social issues

26. An important problem in medical education today is that specifists are training MBBS students to become specifists like themselves?

27. If we really want to participate in MBBS training we need to have a generalist mindset to orient ourselves to patient-based-learning PBL?

28. Super Generalist MBBS: What it isn’t

29. Super Generalist MBBS: What it isn’t

30. Generalism: What it is

31. MBBS Super-generalist: The final product?

32. Learning Competencies: At the end of the course students will be able to obtain… An overview of clinical problem solving: The student will learn to prepare a patient problem list, identify an anatomical and etiological diagnosis and as one of the stakeholders in the patient’s care facilitate apositive relationship between the patient and his/her primary-secondary-tertiary health professionals through efficient and optimal knowledge sharing between all thesestakeholders)

33. Learning Competencies: At the end of the course students will be able to obtain… Information pertaining to clinical history and examination The student will learn to… assist and facilitate the process of examining the patient’s narrative and also process other information obtained through physical examination with and without the help of modern technological tools such as radiological imaging and laboratory parameters reflecting the patient’s internal chemistry)

34. Learning Competencies: At the end of the course students will be able to obtain… A mastery on information related to anatomy, radiology, physiology and biochemistry that is necessary to reach an anatomical, functional and molecular diagnosis for a given clinical problem at hand.

35. Learning Competencies: At the end of the course students will be able to obtain… • A life long approach and strategy to discover these essentials while practicing online and offline clinical problem solving beginning with the case at hand and travelling right down to basic anatomy, physiology and biochemistry in context of patient-based information collected from clinical, radiological and laboratory data.)

36. Learning Competencies: At the end of the course students will be able to obtain… An approach to solve problems around diseases of: Cardiovascular system (Cardiology) Respiratory system (Pulmonology) Renal and genitourinary system (Nephrology, Urology)Hematological system (Hematology, Immunology) Nervous system (Neurology) Gastrointestinal system (Gastroenterolgy) Reproductive system (Men’s and Women’s health) Skin and Integumentary system Cognitive system (Psychology, Psychiatry) Musculoskeletal system (Rheumatology, Orthopedics)

37. Learning Competencies: At the end of the course students will be able to obtain… A Mastery on the essentials of pathology and microbiology that is necessary to reach an etiological diagnosis A life long ability to discover these inthe context of solving their patient’s problems)

38. Learning Competencies: At the end of the course students will be able to obtain… A mastery of the essentials of Pharmacology, EBM and Net-searching that is necessary to formulate a solution and treatment plan An ability to actively discover these life-long in the context of solving their patient’s problems

39. Learning Competencies: At the end of the course students will be able to obtain… A realization that the process of patient based learning through clinical problem solving largely involves: Actively collating patient experiential narratives on a variety of health problems by localizing them into anatomical areas of origin such as blood disorders or cardiovascular etc. and Searching the net for evidence based (or similar experiential narrative based) information to delve deeper into the problem toward the endpoint of being able to make a positive change in the concerned individual’s health outcome.

40. MBBS Super-generalist: The final current product?

41. Who is closer to the Patient? • Patient • Patient’s relative • Generalist Physician • Specifist Physician

42. Would a specifist want to have the skills of a generalist? • All specifists (as all humans) are likely to become a chronic patient’s relative someday • Being a chronic patient’s relative requires negotiating a wide-network of collaborating clinicians and different kinds of knowledge optimized to the patient’s requirements and care continuum • This is also the prime activity of a generalist physician?

43. Why Generalism? • Enables professionals to get closer to their patients • Enables professionals to obtain continuity of care information from the patient’s network of relatives, generalists and specifists • Enables a patient to benefit from the best of specifism and generalism

44. The case against being a Generalist Super-Generalist Super-Specifist/Partialist Specifism/partialism may have evolved to manage work life balance? Specifists conserve their energy in a smaller area and gain more power? Meeting a variety of patient requirements can be time consuming? Generalists may lose power overspending themselves in their quest to do and learn?

45. Optimizing Generalism? Can generalists achieve a work life balance and yet continue to do all the variety of quality of work they aspire to? Can we fix the current power imbalance between generalists and specifists?

46. How?

47. Exploring Roots of Medicine • Medicine evolved from the first human cry for help from his/her fellow human? • Initially we were all generalists and then as knowledge expanded we became more and more partial and specific • We have come to the point where we are unable to see the Elephant

48. The root of the problem? • The source of the problem lies deep within our current medical education system • Our current medical education trains us to think partially and specifically in terms of disease

49. Can we change the game?

50. Medical Education’s Bloom Game Level 1: R emember Level 2: U nderstand Level 3: A pply (Experience!) Level 4: A nalyse Level 5: E valuate Level 6: C reate