Do we need more generalists in our hospitals?

Medicine is becoming increasingly specialised: there are now almost 30 sub-specialties within the Royal College of Physicians alone. This is partly in response to the exponential rate at which scientific knowledge is produced – it is simply not possible to stay on top of the latest developments beyond a limited scope of practice.

Greater standardisation and new knowledge management tools could change this in future, but for now there are benefits to specialising. Once you have a diagnosis you are probably better off seeing someone who has expert knowledge and up-to-date skills in treating your condition. But is ever-increasing specialisation in the best interests of patients?

I was part of a commission on the state of medical generalism, set up by the Royal College of General Practitioners and the Health Foundation, that considered just such questions. Its report, Guiding patients through complexity: Modern medical generalism, was published last week. The Commission sets out one of the key principles of generalism as 'seeing the person as a whole and in the context of their family and wider social environment'. While patient-centred care is a feature of all good medical care, the particular value of a generalist is the ability to provide holistic care. Generalists have an important role in helping to co-ordinate input from a range of professionals and to ensure that patients' wider needs are met.

Increasingly, patients within hospitals have multiple conditions that need the care of several specialists. The loss of generalists in hospitals means that patients often find themselves being shuttled from one specialist to the next, with no one taking overall responsibility for their care. There is also a real risk that important aspects of patients' care are neglected – for example their mental health needs or basic requirements such as diet, hydration and urinary function. These aspects of care are vital to patients' recovery and mobility while in hospital, and to a timely discharge.

So do we need to bring back general physicians in hospitals? I would suggest that rather than bringing back the old model of general medicine we need to reinvent generalism in a hospital setting.

The Commission was interested by the role of 'hospitalists' in the US who actively manage patients while in hospital. Studies have shown that hospitalists reduce the length and average cost of a hospital stay, but do they also improve outcomes for patients? While a senior nurse could take on a role similar to a case manager or care co-ordinator within the hospital, extending the role of the general practitioner to follow their patients into hospital would be a more radical approach. This would only be possible with a radical rethink of the role of GPs and the skill mix of the primary care team.

However, generalism is not just something delivered by an individual. Given the growing complexity of some patients' needs it might be more appropriate to develop multi-disciplinary teams, similar to virtual wards in the community but within the walls of hospitals, who case manage complex patients holistically during and immediately after discharge. These different models need to be tested and evaluated.Patients need support and care from specialists and generalists regardless of where they are being cared for. We need to find ways of integrating specialist and generalist care so patients benefit from excellent clinical outcomes and holistic care.

This blog was also published on the British Medical Journal website

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Comments

#568 Richard Jones
Cons cardiologist and Chief of Medicine
Portsmouth Hospitals NHS Trust

I would be interested to know what proportion of patient with multiple conditions fall into the older age groups. I suspect that the generalists you propose are already here in the form of our Elderly Care colleagues. They do a superb job at seeing the bigger picture and actively managing the multiple conditions with which so many patients present. We should be growing their numbers and not re-inventing the general physician.

In order to maximise specialist productivity we should be looking to quickly remove patients from the specialists beds once the main condition has been treated. An example may be a 90 year old with multiple falls and heart block. Once the pacemaker is implanted there is a need for rapid rehabilitation and optimisation of other conditions. Cardiologists are not usually good at this. Such patients are often suitable for some form of intermediate care but tend to languish in acute beds whilst awaiting community services.

#573 MB
PCT Commissioner

Certainly a more coordinated approach from the hospital specialists is needed to deliver the care pathway and support a single care plan approach that the patient understands and can follow and on discharge can be practically translated by community and primary care specialist and generalist teams. The key concern I have is where consultants of Old Age as generalists (Geriatricians to use an outdate term) do not refer people with complex needs to specialists and put everything down to 'old age' where more explicit discussions around their options, diagnosis and future choices of care are not had. I know I am commenting generally as this is not the case in all acute hospitals, but does hinder advanced case management and choices that people may make. As with everything it is about the need to join up expertise and knowledge, around the patient rather than sending the patient here, there and everywhere. In the community, generalist district nurses and Matrons carry out this key worker function, ensuring the people and expertise is available to deliver the care plan in a timely and patient centred way and this principle, however it is delivered, is a good model for hospitals as well.

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