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'Specialists in generalism' undersells GPs

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The other day I was chatting to a group of 16-year-olds about general practice.

’Isn’t it boring?,’ one of them asked.

’Why do you say that?’

’Well, it can’t be as exciting as being a real specialist, like a cardiologist or neurosurgeon. It doesn’t seem as cool.’

I was about to give her the line I’ve heard a few times now: GPs are specialists in generalism. But I stopped myself.

I’m not convinced. I can see that the word ‘specialist’ is sexy - so it’s tempting to preface our label to read ‘specialists in generalism’. But when you think about it, it’s an oxymoron.

We all start out as generalists in medical school. It’s the default, and we’re all proud of it. But somewhere along the way, the enticing glow of expertise seems to outshine those who carry on the generalist’s journey. Some of the class step into the forest, making their way closer and closer to the bark. They feed a yearning to understand every nook, groove, and nodule.

But there are others who hang back. Those who make sure we all remember that the bark is just one layer of a tree. And how and where that tree is embedded in the forest.

By branding GPs as ‘specialists in generalism’, I think we’re underselling ourselves.  We are specialists - but in people, and in the system.

A recent story reminded me of this. A friend of mine had a problem with his shoulder. He had tried to brush it off as a cricket injury for months. It was only when his first child was born six weeks later and he couldn’t lift her above his shoulder, that he decided to do something. He self-referred to a sports physio using private insurance from work. After seeing little improvement, she sent him to a sports injury clinic, who then referred him to an orthopaedic surgeon. He was advised to have an operation on the nerves supplying his shoulder. 

When my friend told us about the consultation with the orthopaedic surgeon, a core medical trainee friend and I looked at each other. It wasn’t like a scene from ‘House’ - neither of us knew what was wrong. But the timing, the symptoms, and the obvious winging of his scapula just didn’t add up. I’d heard enough sports injury stories in general practice to know that something wasn’t right.

After taking our advice, our friend agreed to see his GP before going ahead.

The GP listened carefully to his story.

’I can’t tell you exactly what’s wrong. But I think we need to take a step back - let’s start with a neurologist.’

One consultation later, he was diagnosed with a rare type of genetic muscular dystrophy. No surgeon would ever be able to help.

A rare case, perhaps. And looking back, the individual steps in his care were reasonable, when surveyed with the careful eyes of each expert. But the whole path set out in the wrong direction. His story missed out the first chapter   - seeing a generalist. There was no one to decide which door to open.

He needed someone to see the wood from the trees.

Now, when he and his wife come in, their GP knows the rest of their story without them having to explain. She knows, when he brings his baby in, how much it hurts him to ask for help in lifting her out of the pram. And why they hover so closely at her elbow when she carries out her baby checks, searching her eyes for reassurance.

I tried to explain this to the students.

’Think of it like this. Imagine you have a leak at home, and you’re not sure how to fix it. There are no plumbers. So you go to a big DIY store. You’ve never fixed something like this before. You find yourself drifting down the aisles, pulled in by the offers and the snazzy marketing. There are experts in each aisle who can tell you all you need to know about their products. You just need to work out who to listen to.

’You get lost, and it takes ages. You get home and have a go at fixing it. But chances are you won’t succeed. And you won’t know where it went wrong.

’Instead, what if you were greeted at the door by someone who’s worked there for years? You might have even met them before. They know the common problems people have, and can probably work out what’s causing your leak when you tell them the story.

’They know the layout of the store inside out. They help you to navigate through it, so that the whole experience is as smooth as possible. When you get home, you can still call them.  And if you have a leak again, you can go back.

’That’s your GP.”

I don’t know if the students were convinced.

But after that day, I’ve stopped using the phrase ‘specialists in generalism’ altogether. Because we’re not.

We are specialists in people, and in the system.

And actually - as I told them - that’s very ‘cool’.

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Readers' comments (13)

  • Where the analogy goes wrong is that there is frequently nobody to help navigate the various plumbing products in a B&Q. People rely on searching Google for advice on what products to buy. If all else fails they will call a plumber and that process normally entails another Google search. Of course the reason they do this in the first place is to save money. GP consultations are free, which is why we are in high demand.

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  • Have you heard the old joke?

    How many doctors does it take to commission services?

    If you go to hospital you need as many as there are specialities...!!!

    If you go to primary care you just need ONE


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  • Thank you Nishma, this is a very thought-provoking viewpoint. However, I do feel that you contradict your own argument. The value of Generalism is a hot debate at the moment, not only in Primary Care, but also secondary care amongst both Physicians and Surgeons. Many are now realising (as some predicted some 20 years ago) that the push for superspecialisation is leaving gaps in assessment and management of people, whole humans, not just parts or systems, and leading to increasing over treatment and over investigation.
    The term 'specialist' denotes special knowledge, experience and skills. How many speciality trainees are specifically trained to look at a person's presentation and health in general in the context of their lives, social circumstances, community? How many college membership examinations specifically test skills in eliciting the person's symptoms and what they mean to that individual and those around them? These valuable skills in generalism make the difference between us as Primary Care Physicians and a super specialist Shoulder Surgeon. With the degree of genaralist training and experience we have, we have become Specialists in the field of overview medicine. Then there is the 'soft' but undeniable social status implied in the term 'Specialist'. While you may not agree that a word should have such a power, that it's all just semantics, it is foolhardy to ignore the effects such a word has on a profession's image to the lay-person.
    With that said, the title 'General Practioner' is laden with nearly a century of degraded status, to both public and hospital colleagues.
    So with that said, I see our profession's future as Specialists (Consultants) in Primary Care

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  • One thing to tell your students- We are the specialists in Primary contact, 1st to see most things. You can't get more raw front-line than that!

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  • I don't much like being called a specialist in anything - I'm proud to be a generalist.

    Remember - if all the specialists resigned, there would still be a functioning NHS, albeit an imperfect one. If all the generalists resigned, there would be no functioning NHS.

    What does this tell us? It tells us that specialists are optional. Generalists are essential.

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  • Really well written - well done.

    I think I'm a specialist in common sense, a specialist in taking risks, a specialist in carrying the can, a specialist in not ordering serum get the drift!

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  • Azeem Majeed

    Thank you Nishma. A very well-written article.

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  • Dylan - Love it!!!!

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  • AlanAlmond

    I love your analysis and agree with it entirely

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  • Vinci Ho

    Thank you , enjoy your writings, as always .
    (1) The fundamental principle of medicine in ancient China was 'Look , Listen , Question and Diagnose' (望聞問切)(though I always have big reservations on the mythical physiology and pharmacology of Traditional Chinese Medicine, TCM) , whether you are specialist or generalist .
    (2) The determinants in here are down to two of the four in my definition of resources, expertise(also experience) and time. In addition to that is of course , continuity which many would want to sacrifice for quantity of consultants.
    (2) Call me a lefty on this issue , as I said in the past, we ,GPs, are doctors of people , especially in a system like NHS.

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  • It's not the name of General Practitioners we need to change.
    We simply need to change the title of "Specialist" to "Doctors with a limited scope of practice".

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  • I would like to dissect the case cited by the author of the above piece and the 'case of the shoulder'.Before the astute analysis by the hero of the tale it would be reasonable to bear in mind the following:

    1.a physio felt it needed an orthopaedic opinion;
    2. the orthopaedic opinion identified a problem with the nerves (and apparently suggested an operation);

    The hero then entered this gripping mystery and having noticed a glaringly obvious physical sign, and being forewarned of the physios and orthopaedic opinions decided a neurology opinion was in order.

    The only conceivable error the hero GP could have possibly made would have been to refer to rheumatology.

    I hope the readers forgive my cynical take on this but I would remind all readers that grasping onto the title specialist will only lead to greater expectations which will quite often not be met, for a number of reasons.A case of giving a dog a name to live up to coupled with old dogs struggling to learn new tricks.And yes, the metaphors will need a centrifuge to separate them.

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  • Just because we don't know everything about a subject (the old word for speciality, or specialty) doesn't mean we don't know anything. Don't sell GPs short - we do a huge amount of general medicine, especially all the QOF stuff. It's laughable seeing letters from say a chest physician advising us how to mange a simple diabetes problem, assuming that because he's a consultant physician that he will know more about the out patient management of diabetes than we will. I'm not saying that every GP knows that sulphonylureas can cause hypoglycaemia, but a third of hospital doctors didn't in a recent survey, and I accept that Orthopods use the BNF to stop a desk from wobbling if one leg is too short, but even so, when you look at all the stuff we haven't forgotten from medical school, and then add what we've learnt since, we know a hell of a lot. It does annoy me though the difference in pay I get for a joint injection, and what the BUPA orthopod charges the same patient.

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