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‘Specialists in generalism’ undersells GPs

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’.