Questions sting at high school reunions: Are you just a GP? Did you specialize, or are you just a general internist?
It is part of the generalist curse. General surgeons sometimes feel the curse too.
In this case, size matters. Big hospital: generalists grovel. Small hospital: generalists rule.
Generalists grovel out of need, not desire. They grovel to get the scraps left after hospitals fund, build, and promote fancy programs.
Fancy programs fill hospital flyers and decorate fundraising events. Donors want to donate to shiny machines that whir and beep. Clinical care that only requires a brain and a bed does not raise funds.
Generalist Curse
Generalists exist in a space between ‘the miracle of medicine’ and the yuck of medicine. We do things no one else wants to know about. We disimpact octogenarian bowels and lance hemorrhoids. Specialists reattach limbs and transplant people’s faces.
Banality is bad. The generalist’s sense of impostor syndrome mixed with a fear of incompetence is worse. Generalists know they know less about everything than some other doctor.
We might not know the ‘other doctor’, but we know she exists. Generalists are doomed to offer patients a bit less than the hemorrhoid sub-specialist, assuming hemorrhoids are at hand. Continue reading “The Generalist Curse”
George Grant believed Canada risked being swallowed by America. He said North America was being universalized and homogenized by unreflective faith in progress. Technological progress replaces local flavour in a modern world. And Canadians live beside the most progress-driven, technological, modern society ever.
Warning: it’s a classic, not a modern, magazine-style read.
Homogenized Care
Medicine faces the same challenge. We drop traditions amputated by evidence based medicine. And so we should. If medical tradition harms patients, get rid of it.
But as Grant lamented about Canada, how can we expect to retain the nature/ethos/tradition of medicine in the face of unrelenting homogenization of treatment? Is there even a tradition of medicine worth saving?
Lament for a Nation inspired many to prove Grant wrong. Critics insisted Grant was confused. A culture can retain its distinct character despite adopting technology, commerce and societal change from its neighbour. Canada can have its progressive cake and retain its culture too.
Was Grant right?
Today, Canada shares enormous similarities with America including entertainment, travel and commerce. But as a society, Canada mimics socialist Britain more than individualist USA. We do not value freedom and self-reliance anywhere near as much as Americans.
Queue “I am Canadian”:
Resistance is Futile?
George Grant lamented the impossibility of conserving Canada. He said that uncritical acceptance of the newest and latest inevitably leads to homogenization. Progress accepts uniformity. It’s fine if everyone and everything is the same as long as we’re all modern.
With WWII less than 20 years before, Grant assumes legitimate worry about homogenization and universalization given the experience of totalitarian parties in Germany and Russia. Cold, hard science has been unkind to citizens when applied by large, unfeeling bureaucracies.
What would Grant say about Medicine today? Champions of uniformity in the name of science and ‘evidence’ sing much more loudly than champions of personalized care or patient service. Uniformity saves money. It’s efficient and safe, or at least that’s what they say.
Lament for Healthcare
A lament falls between despair and certainty. Those convinced of hopelessness do not lament; they commit suicide. On the other end, saints assured of providential design must not lament.
“A lament arises from a condition that is common to the majority of men, for we are situated between despair and absolute certainty.”
A lament assumes imperfect understanding. Maybe we don’t hear laments for healthcare because everyone remains so convinced of their own opinions? Those convinced that Medicare is unsustainable keep quiet mostly; they sit and wait for it to fail. Pundits certain of Medicare’s perfection speak up all the time, but only to correct the painful ignorance they see in those who disagree with them.
A lament implies that something good remains. Will anyone lament for healthcare in Canada?
Clinicians and bureaucrats wrestle for control with talk of quality and accountability. Both sides crave concrete definitions. Accountability zealots want control of provider’s performance as if chaos would reign without policing.
Healthcare delivery gets shaped using concrete metrics like HbA1c levels, blood pressure readings, or surgical complication rates.
People start to see medicine as nothing-but fixing high blood pressure, or normalizing sugar levels, or replacing hips.
But, if medicine is nothing-but controlling blood pressure or HbA1c, then it’s a product to be managed like any other.
If medicine is nothing-but matching patients with evidence, then quants can match populations with resources without input from physicians or nurses.
If we reduce medicine to technical outcomes, bureaucrats regulate with impunity.
Medicine is more than applied physiology.
Medicine applies science, but it is much more than applied science.
“[Medicine] is the totality of this unique combination which constitutes the clinical moment and the clinical encounter, without which authentic medicine does not exist. No simplistic neo-Cartesian reduction of medicine to sciences of mind, arithmetically added to science of the body and tied together with a ribbon of moral science, is adequate to explain this synthesis. Nor is this merely biology. Neither plants nor animals – granted they become ill as well as humans – can enter into a relationship with the healer in which the patient participates as subject and object simultaneously.” A Philosophical Basis of Medical Practice, Pellegrino and Thomasma.
Sure, we must improve clinical metrics. But, meaningful outcomes for patients are often qualitative, subjective, or impossible to measure. How do we measure surgical judgment beyond complication rates? How do we measure communication skills? Reasoning ability? Aptitude at interpreting non-verbal cues?
We need to learn how to articulate what medicine is. And, it must be hard. It needs to be tough and complicated to capture everything we do for patients. Narrow-minded medicine makes patients secondary.
We need a definition of medicine that starts with the clinical encounter and puts patients’ interests at the centre.
Questions sting at high school reunions: Are you just a GP? Did you specialize, or are you just a general internist?
in 1965. Many on both left and right see it as the spark that cemented a trend in Canadian nationalism for decades.