GENERALISTS FOR UK HEALTHCARE - WILL IT WORK?
A rethink of training is happening. We debate that here.
In the USA most doctors undergo four or five years training depending on whether they are medical or surgical fields and become 'generalists' (family practitioner, internal medicine physician or general surgeon). They provide the bulk of care in their areas. Some of course choose to sub-specialise into ever narrowing areas for which they undergo a further 2 to 3 years of 'fellowship' training. When it comes to care delivery the patients do have a choice (at least in theory) of seeing their Family Practioner, 'generalist' or sub-specialist; the family practitioner and/or the Emergency Department has the choice of referring patients to generalist or sub-specialist as the situation demands. Of course the generalists refer on to the specialists as needed.
Moving from the mature economy USA example to the advancing economy of India the situation is more or less the same. Doctors after their MBBS are allowed to practice as GPs and recently there is a trend of emerging opportunities to train further to become an advanced family practitioner. Many doctors obtain post-graduate training and become 'generalists' general physician, general surgeon, etc. Some obtain sub-specialty (though the Indians love the term 'super-speciality', they never call their narrow field as a 'sub-specialty') and become cardiologists, vascular surgeons, et al.
In the UK there has been in the guise of rather misguided and seemingly always wrong work force planning, the training system has, since Calman, delivered 'sub-specialists' to deliver care in the NHS. There are no more 'general physician' or 'general surgeon'. In theory a collaborative approach of all these good people is supposed to deliver high quality integrated care to the patient at the front line. In practice it falls and fails often and more.
At the real front end where direct care is delivered by the trainees and sub-specialty doctors the sub-specialist attitude becomes a big problem. In these young doctors' minds they are very keen to learn their sub-specialty skills and they are not interested or do not have have the time to learn or deliver 'general care'. What it translates into are junior doctors who are unable or unwilling to do 'general' care. I have heard from many about numerous instances of junior doctors and non-consultant doctors being unable to do things like supra-pubic catheterisation, torsion testis, embolectomy, etc despite being on call for their relevant generality in DGHs (or even teaching hospitals). The 'sub-specialist' has to be called out to deliver what is essentially general care.
There are strong arguments for the UK sub-specialist model, mostly emotional. An example such as 'would you like to obtain the best care from the most highly trained person or be messed up by a generalist?' However since we do not train generalists in the UK we do not know what kind of care a generalist might deliver; since there are other countries training generalists, we know that generalists do deliver a high standard of care. What we also know is that care can slip between sub-specialists, care can slip due to non availability 24/7 of sub-specialists in every hospital, care can slip due to difficulty of access to sub-specialists (in the version of centralised care in major hubs) and sub-specialist based care is costly.
Of course my favourite argument is costly care is generally not beneficial at a system level.
The UK is now at the closing stages of the 'Shape of Training' consultation to explore potential future models of training that would suit UK requirements. No favoured models have been decided yet, no decisions have been made. The consultation includes a model where more generalists would be trained to deliver the bulk of care across locations. Even within this model, UK would obviously still train sub-specialists but their numbers and the location of work could be limited.
There are many reasons why the idea of generalists would not work. First and foremost is the culture in UK where the current sub-specialist model is seen as inherently superior and in those circumstances change becomes frustratingly difficult. Sub-specialists seem to carry more glamour, power, earning opportunities and even respect; hence it is a natural aspiration for most doctors; even many general practitioners in UK want to be 'GPwSI'. Broad knowledge seems not be valued as much as deep knowledge (and by the way, broad does not equate to superficial).
However, it is important to question whether in a small country (at least relatively in terms of population and geography) with current economic difficulties it is possible or reasonable to train and maintain sub-specialists 24/7/365 in every location that care is provided; which we will have to do if we have to deliver high quality of healthcare to our population. With care being delivered outside conventional settings closer to the patient and community with concepts such as tele-health, virtual consults, hospital at home, becoming real; with technology enabling remote diagnosis to be made (smart phone ECGs and blood tests at super-store car parks); with Dr Google and crowd sourcing having the potential to be more accurate/knowledgeable than individual specialists we do need to think if the training of doctors in UK needs to move to a 'generalist' model.
I am in support of training generalists who would have in the hierarchy of NHS appointments have a higher or equal level as specialists. They should be charged with the specifics of designing and delivering high quality of care (including management responsibilities). A generalist would be far more likely to interact closely with the patients, general practitioners and specialists than now - that would be a boon and a refreshing change to the passing-the-parcel that is currently played with patients due to a system that is divided into very narrow specialties. There will of course be the rare generalist who is blind to her/his limitations who can be very dealt with proper systems in place.
What do you think will work for UK/NHS? Are generalists a good idea?
Info:
Shape of Training: http://www.shapeoftraining.co.uk/
I provided oral evidence to the Shape of Training consultation as a part of BAPIO team and hence we had a specific remit to support the interests of IMG and BME doctors apart from providing general views on the various proposals and our own views as individuals. This blog does not discuss contents of BAPIO's evidence to the consultation; the above are my personal views.
A rethink of training is happening. We debate that here.
In the USA most doctors undergo four or five years training depending on whether they are medical or surgical fields and become 'generalists' (family practitioner, internal medicine physician or general surgeon). They provide the bulk of care in their areas. Some of course choose to sub-specialise into ever narrowing areas for which they undergo a further 2 to 3 years of 'fellowship' training. When it comes to care delivery the patients do have a choice (at least in theory) of seeing their Family Practioner, 'generalist' or sub-specialist; the family practitioner and/or the Emergency Department has the choice of referring patients to generalist or sub-specialist as the situation demands. Of course the generalists refer on to the specialists as needed.
Moving from the mature economy USA example to the advancing economy of India the situation is more or less the same. Doctors after their MBBS are allowed to practice as GPs and recently there is a trend of emerging opportunities to train further to become an advanced family practitioner. Many doctors obtain post-graduate training and become 'generalists' general physician, general surgeon, etc. Some obtain sub-specialty (though the Indians love the term 'super-speciality', they never call their narrow field as a 'sub-specialty') and become cardiologists, vascular surgeons, et al.
In the UK there has been in the guise of rather misguided and seemingly always wrong work force planning, the training system has, since Calman, delivered 'sub-specialists' to deliver care in the NHS. There are no more 'general physician' or 'general surgeon'. In theory a collaborative approach of all these good people is supposed to deliver high quality integrated care to the patient at the front line. In practice it falls and fails often and more.
At the real front end where direct care is delivered by the trainees and sub-specialty doctors the sub-specialist attitude becomes a big problem. In these young doctors' minds they are very keen to learn their sub-specialty skills and they are not interested or do not have have the time to learn or deliver 'general care'. What it translates into are junior doctors who are unable or unwilling to do 'general' care. I have heard from many about numerous instances of junior doctors and non-consultant doctors being unable to do things like supra-pubic catheterisation, torsion testis, embolectomy, etc despite being on call for their relevant generality in DGHs (or even teaching hospitals). The 'sub-specialist' has to be called out to deliver what is essentially general care.
There are strong arguments for the UK sub-specialist model, mostly emotional. An example such as 'would you like to obtain the best care from the most highly trained person or be messed up by a generalist?' However since we do not train generalists in the UK we do not know what kind of care a generalist might deliver; since there are other countries training generalists, we know that generalists do deliver a high standard of care. What we also know is that care can slip between sub-specialists, care can slip due to non availability 24/7 of sub-specialists in every hospital, care can slip due to difficulty of access to sub-specialists (in the version of centralised care in major hubs) and sub-specialist based care is costly.
Of course my favourite argument is costly care is generally not beneficial at a system level.
The UK is now at the closing stages of the 'Shape of Training' consultation to explore potential future models of training that would suit UK requirements. No favoured models have been decided yet, no decisions have been made. The consultation includes a model where more generalists would be trained to deliver the bulk of care across locations. Even within this model, UK would obviously still train sub-specialists but their numbers and the location of work could be limited.
There are many reasons why the idea of generalists would not work. First and foremost is the culture in UK where the current sub-specialist model is seen as inherently superior and in those circumstances change becomes frustratingly difficult. Sub-specialists seem to carry more glamour, power, earning opportunities and even respect; hence it is a natural aspiration for most doctors; even many general practitioners in UK want to be 'GPwSI'. Broad knowledge seems not be valued as much as deep knowledge (and by the way, broad does not equate to superficial).
However, it is important to question whether in a small country (at least relatively in terms of population and geography) with current economic difficulties it is possible or reasonable to train and maintain sub-specialists 24/7/365 in every location that care is provided; which we will have to do if we have to deliver high quality of healthcare to our population. With care being delivered outside conventional settings closer to the patient and community with concepts such as tele-health, virtual consults, hospital at home, becoming real; with technology enabling remote diagnosis to be made (smart phone ECGs and blood tests at super-store car parks); with Dr Google and crowd sourcing having the potential to be more accurate/knowledgeable than individual specialists we do need to think if the training of doctors in UK needs to move to a 'generalist' model.
I am in support of training generalists who would have in the hierarchy of NHS appointments have a higher or equal level as specialists. They should be charged with the specifics of designing and delivering high quality of care (including management responsibilities). A generalist would be far more likely to interact closely with the patients, general practitioners and specialists than now - that would be a boon and a refreshing change to the passing-the-parcel that is currently played with patients due to a system that is divided into very narrow specialties. There will of course be the rare generalist who is blind to her/his limitations who can be very dealt with proper systems in place.
What do you think will work for UK/NHS? Are generalists a good idea?
©M HEMADRI
Follow me on twitter @HemadriTweetsInfo:
Shape of Training: http://www.shapeoftraining.co.uk/
I provided oral evidence to the Shape of Training consultation as a part of BAPIO team and hence we had a specific remit to support the interests of IMG and BME doctors apart from providing general views on the various proposals and our own views as individuals. This blog does not discuss contents of BAPIO's evidence to the consultation; the above are my personal views.
3 comments:
Interesting debate, to adopt the generalist model people's attitude and expectations towards healthcare will have to change.
In some ways would it not be better for a specialist to continue doing surgeries which you have mentioned in your post (rationale of more experience and training) ? A generalist's time training would probably get divided gaining skills in more than one procedure and at the end be a jack of all trades and king of none.
I fear it will become yet another advanced triaging system and access to specialists and specialist healthcare will become even more delayed. Where the generalist will fit in in the current system is probably as a bridge between medical and surgical specialties for eg, Internal medicine physician attending to medical problems in post op patients.
Do not you think it will be u turn in health sector,
According to ethical point of view every body need best treatment from the best and expert people. This was the main reasoning for centralisation of services and closure of secondary care,
Like suprapubic catheterisation done by general surgeon but due to few complication now guideline has changed in 2010.
I personally feel we are at this juncture due to knee jerk reflex of past and agenda of change without foresee.
So before any new change or introduction need well thought and researched planning.
Do not you think it will be u turn in health sector,
According to ethical point of view every body need best treatment from the best and expert people. This was the main reasoning for centralisation of services and closure of secondary care,
Like suprapubic catheterisation done by general surgeon but due to few complication now guideline has changed in 2010.
I personally feel we are at this juncture due to knee jerk reflex of past and agenda of change without foresee.
So before any new change or introduction need well thought and researched planning.
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