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Let medical students see what it takes to be a great generalist



A major hurdle to improving GP recruitment, which is going to be crucial if primary care is ever to recover from its current crisis, is the negative impression of general practice that some medical students form during their largely hospital-based early careers. I’ve never understood why breadth of knowledge is so undervalued. Ironically, my own decision to go into general practice was shaped by a hospital doctor who despised GPs.

He was a sub-specialist within a small specialty, and had the kind of narrow view which that kind of position occasionally fosters. A master of about half-a-dozen exceedingly rare diseases, he had undiluted disdain for anybody who didn’t know as much about his pet pathologies as he did. It never seemed to occur to him that every case he saw had been pre-filtered by layers of other clinicians. Or that the only reason he could specialise so minutely is that there were armies of generalists dealing with everything else.

I once sat in on a clinic of his, in which he was happily mocking the GP referral letters that accompanied the day’s patients. A particular delight of his was to use these letters as a springboard for some old-fashioned teaching by humiliation. Halfway through a morning of this, he found a letter that particularly pleased him.

‘This one can’t even spell!’ he crowed gleefully.

The three or four of us sitting in with him kept quiet.

‘You,’ he said, turning to me, ‘spell “ophthalmology”.’

‘O-P-’… I said, watching him lean forward and start to grin with anticipation; ‘H-’ I continued.

He stopped me with a wave and sat back, disappointed, then grunted and turned back to face away from us again, silently passing the letter back for us to read.

Even with the little bit of knowledge we had then, it was clear that this patient’s GP was exceptional. She’d dictated a thorough, perceptive letter, and tentatively suggested the unlikely yet correct diagnosis. Somewhere at the bottom of the first page was the offending spelling error, which she had signed off without correcting. As if it mattered.

We also knew the GP would have had to do this in limited time, whilst sifting a huge mass of normality to find an unlikely nugget of pathology. I knew then which was the more skillful doctor, and the one I most wanted to be like.   

Dr Nick Ramscar is a GP in Bracknell, Berkshire