defining medical generalism
 

why a definition is needed

The virtues of a given profession are those personal qualities that enable members of that profession to fulfil their professional role well, to achieve the goals of their profession, and to meet their professional challenges. If we can identify the professional role of the medical generalist then we should be able to arrive at an understanding of the professional virtues of medical generalism, the personal qualities required to be an excellent generalist. There are many different ways of identifying the role of the medical generalist but it would be sensible to begin by trying to come up with a working definition of medical generalism. In the UK, the best-known medical generalists are General Practitioners (GPs). What do GPs do? What is their expertise and how they differ from specialists? If we can answer these questions then we should also be able to develop a clearer understanding of the professional virtues of general practice.

where to start

The Royal College of General Practitioners defines medical generalism as: 

expertise in whole person medicine, which requires an approach to the delivery of health care that routinely applies a broad and holistic perspective to the patient’s problems’ (MG, p. 3). 
 

The Medical Schools Council suggests the following definition:

Medical generalists are doctors who are prepared to deal with any problem presented to them, unrestricted by particular body systems, and including problems with psychological and social causes as well as physical causes. They take a holistic approach, mindful of the context of the local community. Medical generalism is therefore distinct from specialist care restricted to a particular body system or subset of medical practice, or restricted by virtue of having access to, or involvement in, providing particular types of interventions in particular settings’ (MSC, 1(a)).


These are just two examples of many attempts to define medical generalism. Although such definitions are undoubtedly helpful and cover many important points, it is hard to say everything that needs to be said in a brief definition. Such definitions need to be supplemented in various ways, and a promising way to do that is to look at a series of specific dimensions in relation to which the key distinguishing features of medical generalism can be specified. 

What are the relevant dimensions? To pin these down we might ask the following basic questions:

  • What is the professional role of medical generalists? How does their professional role differ from that of the specialist?

  • What are the distinctive challenges faced by medical generalists?

  • What are the distinctive goals or objectives of the medical generalist?

  • What is the distinctive orientation of the medical generalist? What is the focus of the medical generalist’s attention? 

  • What are the medical generalist’s distinctive methods or ways of working

  • What kinds of knowledge or understanding do medical generalists seek and rely on in their work? How is the generalist’s understanding different from the specialist’s understanding? 

  • What are the distinctive values of the medical generalist? 

It’s hard to give definitive answers to these questions. It’s better to think of them as invitations to reflect on different aspects of medical generalism. What follows is one series of reflections, and an invitation to users of this site to engage in their own thinking about these difficult issues.

the professional role of the generalist

The medical generalist’s professional role is to a considerable extent determined by the institutional context in which he or she operates. In the UK context, GPs are usually the first point of medical contact for the patient, and their role includes assessing and arranging appropriate next steps for the large variety of conditions that are presented to them. This may or may not involve referral to a specialist. In the words of the Medical Schools Council, medical generalists optimize the use of resources by ‘referring only those patients likely to need specialist help into the secondary care system’ (MSC, 1 (a)). This has been described as the generalist’s ‘gatekeeping’ role. 


In many cases the GPs are themselves able to give the appropriate medical advice and prescribe appropriate drugs. They may also decide that the problem they are confronted with is not a medical problem. In the words of one submission to the RCGP’s Commission on Generalism, ‘GPs are risk managers and recognize that not all symptomology requires investigation, referral or treatment but requires…. the allaying of fears and explanations of the problem’ (quoted in MG, p. 10). However, perhaps the most useful and comprehensive account of the professional role of the medical generalist is this one, from the Medical Schools Council’s response to the RCGP’s Commission on Generalism: 

 

General medical practitioners provide first contact and ongoing, continuous integrated care for a comprehensive range of problems to all members of the population for whom they are responsible. In well-developed primary care systems they undertake long term responsibility for a defined, registered list of patients, restricted only by geographical area, addressing both acute and chronic conditions and increasingly co-morbidity’ (MSC, 1 (a)).

the challenges of medical generalism

The challenges facing the medical generalist have been well described by Joanne Reeve. She notes that since GPs manage all aspects of a person’s illness experience, the central challenge is ‘dealing with the complexity of multiple pathology, or dynamic, changing complex illness’(IM. p. 1). One conclusion that some have drawn from this is that generalism is about breadth, whereas specialism is about depth:

What distinguishes generalism from specialism? The most obvious contrast is that where specialism is about depth, generalism is about breadth: the greater the depth of expertise in a branch of medicine, the more specialist the doctor; the greater the breadth of expertise, the more generalist. At the extreme, and to accentuate the distinction, this can be portrayed as a cultural divide’ (GPTC, 2.4). 


This is not to say, however, that the generalist’s knowledge is superficial, or that generalism is not a form of expertise in its own right. The expert generalist requires special skills to deal with the wide range of medical and other problems they encounter. Breadth is not incompatible with depth.

 
Furthermore, as Reeve notes, much of the generalist’s time is spent ‘dealing with “indistinct” illness – stress and distress, tiredness, pain’ where ‘no clear pathology or causal chain can be identified’ (IM, p. 1). The generalist deals with the individual patient, but clinical guidelines are derived from observation of populations. There is therefore always the challenge of ‘applying knowledge about normal function and disease to this individual’s illness’ (IM, p. 11). There is more below about the significance of this point in the section on the orientation of medical generalism.

the goals of medical generalism

Patients typically visit their GPs when they feel unwell or are concerned about their health. Feeling unwell, or having the sense that there is something wrong with one’s bodily self, is a problem for patients not just because of the associated pain or discomfort. It also gets in the way of daily living. In some cases, the person seeking the help of the medical generalist feels unwell because of an underlying disease or clear pathology. The distinction between illness and disease has been explained as follows by Iona Heath:


Illness is a perception of something being wrong, a sense of unease in the functioning of the body or mind; disease is a theoretical construct, a unit in the taxonomy of scientific medicine, which offers both the benefits and the risks of that endeavor. GPs see much more illness than disease but for specialists, the opposite is true’ (DWF, p. 578).

Where a disease requires specialist treatment the goal of the medical generalist is to establish that this is the case and refer to patient to an appropriate specialist, while providing any appropriate advice and support. With illness, especially indistinct illness, treatment might not be a realistic objective. Many of a medical generalist’s patients live with illness and pain. These patients face the challenge of coping with their condition and living their lives. In these cases, Reeve notes, the medical generalist’s objective is to ‘support individuals in their efforts to maintain continuity of daily life’ (IM, p. 8). Supporting individuals in this way means supporting them in their efforts to cope with their condition. There are many different ways in which medical generalists can do this but the key point is that the GP supports the individual in what Reeve describes as ‘the dynamic process of living life’ (IM, p. 10).

Peter Toon argues that ‘health care exists to promote good health in the same way as architecture exists to produce good buildings’ (AFP, p. 39). Specifically, health care contributes to human flourishing in at least three different ways: it relieves suffering and cures disease, it prevents illness and disease, and it helps patients to make sense of what is happening to them. The third of these objectives is an important purpose of health care, and one in relation to which the medical generalist plays a key role. To quote Toon again:


Many people go to their GP not principally because they want to change what is happening to them but because they want to understand it. Is it serious or is it trivial? Will it get better, and how quickly? What impact will it have on their work, their family life, their social and sporting activities? Answering questions like these is an important aspect of health care for which clinicians are ill-equipped by their basic education. It is part of the third aspect of health care, the interpretive function – giving prognostic information and helping patients understand their illness’ (AFP, p. 45).

It is debatable whether patients with treatable conditions do not go to their GP principally because they want to change what is happening to them. Nevertheless, sense-making is an important objective of health care generally and medical generalism in particular. The human desire for self-understanding includes the desire to understand their own bodies, especially during periods of ill health, and it is an important insight that many patients visit their GPs for self-understanding.

the orientation of medical generalism

It follows from what has been said so far that the medical generalist is illness-focused rather than disease-centred. In addition, most accounts agree that medical generalism has what the RCGP describes as a ‘person-focused orientation’. In other words, ‘generalists are professionals who are committed to you as a person’ (MG, p. 3). In this context, ‘person’ means whole person, hence the popular notion that the medical generalist delivers ‘whole-person’ care. But what exactly is whole-person care? Isn’t it also a type a care that many specialists provide? The whole person as opposed to what? To answer these questions, it would be helpful to know what is meant by ‘person’. There is a separate page devoted to this. But even without going into this in detail at this point, there is still quite a bit that can be said about the ‘whole person’ orientation of medical generalism.

In the literature on medical generalism, one popular way of explaining its focus on the person is by means of a series of contrasts: one is between the person and the illness. The medical generalist, it is said, must have ‘an overriding interest in the person rather than the illness’ (GPTC, 2.3). A different contrast is between the person and the disease. The medical generalist, it is suggested, focuses on the person rather than the disease conceived at the level of organs and tissues. It is the former rather than the latter that is the object matter of generalist medicine.

Yet, despite their popularity, the significance of these contrasts is not entirely clear. A sceptical response to the person/ illness contrast might be to point out that it is entirely appropriate, when dealing with a patient who is feeling unwell, to focus on their illness. How can it be right to have an overriding interest in the patient rather than their illness when it is only because of their illness that the patient has sought out their GP? The same goes for the patient/ disease contrast. As has been noted, GPs see much more illness than disease. However, when the medical generalist is confronted by evidence of disease it would be perverse not to focus on the disease, especially if it is potentially serious.

Perhaps, in that case, the real point of insisting that the medical generalist should concentrate on the patient rather than the illness or disease is a different one. It is possible to interpret it as making a contextual point: ‘the generalist sees health and ill-health in the context of people’s wider lives’ (GPTC, 2.9), that is, ‘in the context of his or her family and wider social environment’ (MG, p. 8). Yet the relevance of family and wider social environment varies from patient to patient and condition to condition. Such factors might be of great relevance for patients with severe health problems or disabilities, but much less relevant to a generalist’s response to minor ailments. Dealing with a sore throat does not, on the face of it, require the GP to engage with the context of people’s wider lives. What remains true, however, is that the medical generalist must be willing and able to see health and ill-health in the context of people’s wider lives where this perspective is relevant and appropriate. 

Other aspects of generalist medicine can be understood in the same spirit. In her article on the ‘Subjectivity of patients and doctors’, Iona Heath emphasizes the individuality and the subjectivity of patients and doctors. She writes that ‘the task of the clinician is to engage with the details of the fears, hopes, needs, and values of each individual patient’ and that ‘within any consultation, the moral obligation of the professional is to do his or her best for that particular real living person’ (SPD, p. 84). She emphasizes the ‘fine-grained particularity of each unique human self’ (SPD, p. 85) and quotes Tolstoy in support of the notion that ‘no two individuals ever experience illness or disease in the same way’ (DWF, p. 276). 

Again, one might wonder whether individuality and subjectivity are relevant to the same extent with all patients. There are, on the face of it, some ailments which most individuals experience in, if not exactly the same way, then in ways that aren’t significantly different. One person’s subjective experience of running a high temperature is, presumably, not hugely different from another person’s subjective experience of running the same temperature, even if the causes are not the same. Again, the details of an individual’s hopes, needs and fears may be highly relevant when it comes to some medical decisions but not others. Perhaps, therefore, it would be more accurate to say not that the medical generalist must always engage with the patient’s subjectivity but must always be prepared to do so where such engagement is helpful and relevant.

In engaging, or being prepared to engage, with a patient’s subjective reality and fine-grained particularity the expert medical generalist does not lose sight of the underlying physical or physiological story. Whole person medicine is not a matter of focusing on the patient rather than their illness but of having two perspectives on one and the same patient, and being able to move seamlessly from one to the other as the need arises. This is what Heath is getting at in the following passage:


Within every clinical consultation both professional and patient oscillate between perceiving the human body as an object and as a subject. When the body is perceived as an object, the gaze of biomedical science sees only what the particular patient has in common with other patients. On the other hand, when we seek to understand the body as a subject, we speak about what is unique about this person – their life context, its story and the meanings that adhere to both’ (SPD, p. 92).

When the body feels pain or fear it is the body as subject. The body as tissues and organs and other physiological components is the body as object, as a mechanical system.  The body is both a subject and an object or, as the philosopher Merleau-Ponty puts it, a ‘subject-object’. This means that the essence of medical generalism is to be able engage with both the subjective and the objective dimension of the body and the person whose body it is. Which, if either, of the two dimensions is prioritized in an individual case will depend on the specifics of the case.

the medical generalist’s way of working

In his preface to Person-centred Primary Care, Dowrick notes that ‘primary health care professionals, including general practitioners and family doctors, are encouraged to work collaboratively with their patients, fostering shared decision-making and promoting self-management’ (PCPC, p. vii). The implication of this approach is that medical generalists are, or should be, engaged in a dialogue with their patients. The care provided by the medical generalist is continuous rather than episodic and is responsive to the patient’s own experience and understanding of their condition. Unlike specialists, GPs don’t discharge their patients and they may see the same patients over a long period of time. Medical generalists may get to know their patients as people, and must work with them in an effort to find solutions to their problems. 


According to Joanne Reeve, ‘general practice is about interpretation of illness, not identification of disease; knowledge is not uncovered (‘mined’) but constructed as the clinician and patient “travel” together, creating a joint account of illness that meets the needs of both’ (IM, p. 7). The key idea here is that of co-construction. Rather than the patient being a passive recipient of medical advice from the medical generalist he or she is actively involved in interpreting their condition and fixing on an appropriate medical or non-medical response. 


As Toon notes, ‘this view of health care as a collaborative practice involving both patients and professionals has implications for how patients and professionals relate to each other. It casts professionals and patients as collaborators in a struggle against suffering and incapacity: as “co-producers” of health’ (AFP, p. 34). 


One concern about the collaborative approach is that it privileges the confident, the articulate and the educated. Some patients may be too diffident to be actively involved in creating a joint account of their illness, or might take the view that it is for the expert GP to do the interpreting for them. A challenge for the interpretive model is to explain how it applies in such cases. 

knowledge and understanding in medical generalism

Is there such a thing as ‘generalist knowledge’ or ‘generalist understanding’? If so, what distinguishes it from other kinds of medical or non-medical knowledge? On one interpretation, generalist knowledge is a particular type of knowledge or understanding that the expert generalist has of his or her patients. We can call this generalist patient knowledge. On the other hand, there is also the generalist’s medical knowledge, the biotechnical knowledge that expert generalists rely on in diagnosing, treating and advising their patients. We can call this generalist medical knowledge. Giving this distinction, a natural way to work out what is so special about medical generalism is to work out what is so special and distinctive about generalist patient knowledge and generalist medical knowledge. 


Starting with generalist patient knowledge, it has been suggested that the medical generalist’s special way of knowing his or her patients includes having a longitudinal relationship with them over many years, knowing their patients’ family and community, knowing the context of their patients’ lives, and knowing ‘the nature of their problems in depth’ (MG, p. 12). The RCGP concludes that the ability to form appropriate, strong interpersonal bonds with patients is therefore ‘an increasingly important aspect of the role of the medical generalist within the wider health system, especially in the context of the need to develop an approach to health care that is more person centred and focused increasingly on prevention’ (MG, p. 13).

Related to the notion that medical generalists ‘know’ their patients in a special way is the idea that their understanding of their patients isn’t purely ‘biomedical’. Rather, their biomedical understanding must be coordinated with, and supplemented by, what Heath calls ‘biographical understanding’ (DWF, p. 582). This is the basis on which Hjörleifsson and Lea complain about the fact that too often ‘biological approaches trump biographical interpretations of patients’ problems, rendering the latter invisible or their relevance inconceivable, leading to harmful overdiagnosis and medicalization of human suffering’ (MIGP, p. 28).


Several questions now arise: what is the biomedical understanding of patients or, as it is sometimes called, the ‘biomedical model’? What exactly is ‘biographical understanding’, and why is this type of understanding indispensable for medical generalism? Once these questions about generalist patient knowledge have been answered attention can then turn to generalist medical knowledge.

A classic account of the biomedical model is this one given by George L. Engel in 1977:    


[T]he dominant model of disease today is biomedical, with molecular biology its base scientific discipline. It assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables. It leaves no room within its framework for the social, psychological, and behavioral dimensions of illness. The biomedical model not only requires that disease be dealt with as an entity independent of social behavior, it also demands that behavioral aberrations be explained on the basis of disordered somatic (biochemical or neurophysiological) processes’ (quoted in MIGM, p. 25).


Thus, the biomedical model conceives of patients primarily as biological rather than social organisms and their illnesses as fully accountable at the biological or biochemical level. 

Biographical understanding is harder to define. According to Iona Heath, the first and second person pronouns, I and you, are ‘the stuff of biography, of human relationships and of clinical medicine, rather than the impersonal third person of he, she, or it, which is the stuff of biology and biomedical science’ (SPD, p. 85). Yet biographies are usually written from a third person perspective, so it isn’t obviously correct to equate biographical understanding with the ability to relate to other people second personally rather than third personally. Equally, it is possible to address another person as ‘you’ without having the slightest interest in their life story or any biographical understanding of them.


This points to a much more straightforward understanding of biographical understanding: biographical understanding of patients means understanding them in the context of their lives and personal histories. It means understanding and engaging with their fears, hopes, needs, and values. Above all, it means attending to what Heath calls their ‘subjective reality’ (SPD, p. 88). To think of another person’s subjective reality is to think of them as not simply as biological organisms but irreducibly as subjects of experience, with their unique perspective on the world and experience of illness.

Why do medical generalists have to have a biographical understanding of their patients? Heath’s answer to this question is that biographical understanding is necessary because ‘individual biography affects biology’ (SPD, p. 94). Negative psychological states such as chronic stress can ‘undermine the healthy functioning of the human body’, and an understanding of a person’s biography can help the generalist to understand some illnesses by understanding how some aspects of their patients’ lives might have contributed to their ill health. No doubt there are conditions that can be diagnosed, understood and treated with little or no biographical understanding but it is important that the generalist can bring biographical knowledge to bear where appropriate.


Another consideration is that many sources of physical discomfort to patients are poorly understood in biomedical terms. For example, conditions like burning mouth syndrome (BMS), for which there is no effective treatment, might nevertheless cause those who suffer from it considerable discomfort and distress. Since stress and anxiety are among the known risk factors for BMS, a generalist’s biographical understanding of a sufferer might be more useful in practice than a biomedical perspective. In most cases, however, both perspectives are necessary and the challenge is to integrate the biomedical and the biographical.

Among the distinctive features of generalist medical knowledge is what Reeve calls its ‘epistemological uncertainty’, the uncertainty that ‘comes in seeking to apply “certain” knowledge derived from the study of populations to understand this individual patient’ (IM, p. 2). General practice is not an exact science, especially when dealing with patients with indistinct conditions, multiple morbidities and chronic illnesses. As the RCGP notes, most patients with complex multisystem problems ‘need generalists to care for them, so that all issues can be addressed and the pros and cons of treating each problem fully understood’ (MG, p. 17). 


This is the type of scenario that has led some to conclude that generalists rely less on biomedical evidence than specialists and more on social-science based evidence. According to one formulation, ‘whereas the specialist relies heavily on scientific evidence to arrive at a precise explanation of an illness within a limited range of possibilities, the generalist (especially the GP) takes a far broader approach to arrive at one or more probabilities and decide whether or not action is needed’ (GPTC, 2.5). 

These are among the considerations that have led some accounts of medical generalism to highlight its breadth while downplaying its depth. It has even been suggested that among the core values of medical generalism is ‘a willingness to eschew opportunities to develop the deepest knowledge of particular problems required to be a specialist practitioner, and to avoid sub-specialisation’ (MSC, 2). Yet, as noted above, breadth is not incompatible with depth and it is arguable that what distinguishes the generalist from the specialist is not depth of knowledge per se but the kinds of knowledge they rely on and seek.

The values of medical generalism

One’s values are one’s fundamental guiding principles. They are usually an expression of one’s ethical outlook, and their function is to guide one’s judgements, decisions and actions. For example, one might rule out a certain course of action because it conflicts with one’s values. Other courses of action might strike one as obligatory on account of one’s values.


The fundamental value of medical generalism, and indeed of all varieties of medicine, is the principle that every patient, regardless of age, sex, class or race, is worthy of equal concern and respect on account of their shared humanity. This guiding principle is derived from the work of the great 18th century philosopher Immanuel Kant, who insisted that each and every person possesses a dignity or absolute inner worth on account of which they are worthy of respect. Such respect includes respect for their autonomy, and this has important practical implications for person-centred medicine. One implication is that medical generalists must make every effort to respect their patients’ choices and preferences. Different things are important to different people, and what might be right for one patient might not be right for another. To put it another way, respect for persons requires taking account of what Heath describes as the ‘fine-grained particularity of each unique human self’ (SPD, p. 85).


This core generalist value has its limits, however. For example, respect for the fine-grained particularity of each unique human self does not require the medical generalist to defer to a patient’s desire take harmful or addictive drugs even if the patient insists that not being given access to such drugs is a violation of their autonomy. Nor is the medical generalist required to help a patient to die even if this is what the patient genuinely desires. On a Kantian view, helping a person to die is itself incompatible with the principle of respect for persons, and so can’t be required by it. These are among the difficult ethical issues that the generalist faces. What they illustrate is the need for the generalist to be equipped not just with a set of guiding principles but also with the philosophical tools needed to work out how they apply in a given case.

references & further reading

 
 
 
 
 
 
 
 

© 2019 Professor Quassim Cassam

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