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.
Eternal Eponyms
In the days before we were smart, doctors used to name things after famous dead doctors.
This gave us Morton’s toe, Virchow’s node, and a million other quirky artifacts. It took decades to break the habit.
Now it is de rigueur to let science name things. But some old names stick: just try forgetting Morton’s poor toe.
In the hole left by Morton and Virchow, generalists rushed to build lists and tools. Evidence based check lists add an air of specialization.
With list in hand, there is no such thing as back pain. There is only Pattern 1, 2, 3, or 4 pain.
Dozens of dementia tools objectify the fact that someone cannot tell you his birthday, or any day for that matter.
Generalists seem to love the tools, checklists, and decision aids. Or perhaps it is the shortest way to approach Morton’s immortality.
Lists and tools help, but they have redefined medicine.
Medicine used to mean anatomy, pathophysiology, pharmacology and a bunch of other scientific fields. Doctors learned how things worked, to diagnose what was wrong, and then treat it.
Now doctors score this or ‘measure’ that. But no one really cares — and almost no one really remembers — how the pathology precisely relates to a patient’s symptoms.
Generalism Needs Redefining?
What does this do to the generalist? Instead of being a walking textbook of pathophysiology, generalists became purveyors of papers and lists. Ticks placed neatly in a row represent ideal care for the prenatal visit.
How many times have you heard someone scold in a sober voice, “Don’t ever say just a GP”?
Instead of changing attitudes, maybe we should change the way we think about generalism? Maybe Robbin’s Pathological Basis of Disease would do more than memorizing the latest checklist?
Perhaps generalists could shake the generalist curse by becoming more like walking textbooks of pathophysiology and less like house inspectors? It might be the only way.
Photo modified from VeryWellFit.com
Shawn,
Clearly I’m rubbing off on you, what with the preoccupation with bowel-and-ass problems.
The lament is understandable, but going back to pathophysiology belies the reality of general medicine being much more about managing the relationship than the diagnoses. Tickbox tedium is the unfortunate by-product of applying rules of evidence to what medicine was never historically comfortable with…chronic disease.
While the CFPC is clinging to a rather laughably unrealistic vision for generalist practice – it reads like the child of Dr. Quinn, Medicine Woman and Obi-Wan Kenobi – the profession of generalist physician is clearly approaching a crossroads. In my own not-so-humble opinion, especially in light of government having no interest in serious payment reform, doctors should focus on revitalizing their status as confident, independent experts. Let the pharmacists and the NPs handle the mindless chronic disease stuff.
Great comments, as always, Frank.
You skirt the edge of immolation with your last comment! 🙂 But I agree with it also. This is exactly how I function in my FHO. I liked your comments about chronic disease and pathophysiology also. Chronic disease doesn’t offer the same excited based on disordered physiology as an acute condition. It gets boring talking about atherosclerosis for the one-millionth time.
I guess I’m struggling with how to find the “status as confident, independent experts” that you describe so well versus the Dr. Quin/Obi-Wan chimera. I find the chimera ruins both brands.
Thanks again for taking time to read and share a comment on such a banal post! 😉
Cheers
General practitioners / specialists , are, in my opinion, becoming increasingly valuable in a world of hyper specialization, where more and more is known about less and less…authorities in hyper focused area of interest , “the left big toe” so to speak, having no expertise in any other toe or any other part of the human anatomy.
Time and time , increasingly so, we refer to specialists who decline to see the patient because “ it is not their ( narrow) field”.
I have a dwindling number of very capable generalist specialists that I can refer to …some are vanishing altogether as in ophthalmology…my generalist internists and surgeons are ageing and retiring.
The older generalists are useful because , if they hit a brick wall, they tend to know which particular specialist is particularly capable in a particular field , and refer them on.
As generalists we do have to know more and more and consequently our depth of knowledge becomes shallower and shallower…we both need each other…neither should mount the high horse when dealing with the other.
Fantastic comment, Andris.
I worry that I floundered with this post a bit. I have been wrestling with trying to pin down what has changed with general practice: Why is its ontology different than before? It seems to have something to do with checklists and decision tools. But there is more, also. I just cannot describe it yet.
Thanks again for taking a moment to comment. Excellent as always.
Cheers
As a generalist for 40 years, I still see arriving at a correct diagnosis through observation, knowledge, experience and sound reasoning as being our forte. I see myself as an advocate for my patient even when a left-great-toe-subspecialist is on the case, but have been troubled by the insidious pressure of third parties, particularly branches of government, obligating me to act as representative for them instead.
Well said.
Patients probably would not be impressed if they knew that we were even partially focussed on serving the needs of government.
Thanks for posting a comment!