Our senior officer blog for February comes from Dr John Dean, who explores the balance between generalist and specialist practice for physicians.
I feel privileged to be RCP clinical vice president, representing members and fellows, leading our improvement work, and being part of the RCP’s senior leadership team. We develop our approach to key healthcare challenges through conversations with other thought leaders within and outside RCP, collating evidence and understanding emerging practice.
Over the past 12 months I have been focusing on the balance between being a specialist and a general physician. Multiple policy publications over the past 10 years have highlighted that we need more generalists to meet the population’s healthcare needs – but what does this mean for physicians?
Unfortunately, over that time this discussion has become skewed to focus on who should be participating in the acute take. However, that is a separate issue, dependent on the development of local acute medicine and other specialties in each hospital. Some call for differential expansion of certain specialties but this also misses the fundamental issue in my view.
Our patients are living with multiple conditions on multiple treatments and need a holistic approach to their care, no matter which specialist they are seeing. If you haven’t read it, I recommend the chief medical officer’s annual report for 2023 Health in an ageing society, which looks at the current demographics of people with healthcare needs and how that will continue to change over the next 20 years. In his report Professor Chris Whitty states: ‘Medical specialisation, specialised NHS provision, NICE guidelines, and medical research are all optimised for single diseases but that is not the lived reality for the great majority of older adults who often transfer very rapidly from having no significant disease states, to several simultaneously. The increasing specialisation of the medical profession runs counter to optimising treatment for this group of largely older citizens and patients. We must address this seriously as a profession’.
The patients most of us see are predominantly older adults, and this will increasingly be the case over the next 20 years. Our younger patients will commonly have a number of medical conditions, or have a condition or treatments that can have widespread health effects.
I believe physicians take a holistic approach to patients – their assessment, needs and treatments. What I hear from physician colleagues is that they want to guide their patients with multiple conditions, and recognise the increasing complexity of treatments, their complications and the interactions between different conditions. They can feel constrained by their specialisation, or reluctant to give advice outside it in case their knowledge is outdated, or they are missing important factors for the patient’s condition. We have all met patients who’ve seen multiple specialists and had conflicting advice.
At our Med+ conference last year we focused on the generalist aspects of care for the specialist. Delegates told me how this made them feel more positive around their role now and in the future, because we were thinking beyond their core specialist practice, and were certainly not expecting everyone to be on the acute take! We launched the latest update of our acute care toolkit on acute oncology, a perfect illustration as patients with cancer (or on cancer treatments) can present to any specialty, and we need to know what to look out for and when to involve other specialties.
The balance of our specialist and generalist practice, knowledge and skills is very individual, and changes throughout our career. Research tells us it is dependent on three key factors – how we define ourselves as physicians, where we work and who we work with, and the work we do. My talk with Prof Whitty at Med+ explores this and is available to watch on Medical Care – driving change.
There are many core aspects of physician practice that are common across medical specialties, and that I believe also need to be defined as generalist skills. These include safe prescribing, deprescribing and medicines management, shared decision making, managing multiple conditions, caring for patients approaching the end of life, identifying patients at risk of acute deterioration, leading multiprofessional teams, working across specialty and organisational boundaries, coordinating care, advanced communication skills, health inequalities, and assimilating new information for our teams to translate into practice. There are also common conditions we need to understand and incorporate into our clinical practice, such as frailty syndromes, diabetes and chronic kidney disease. And then for each specialist’s area there are ‘cluster conditions’ that are more likely to coexist in our patients, for example COPD and heart failure.
So, what next? Firstly, as your college we need to lead discussions to ensure that physicians are recognised as both specialists and generalists, whatever their individual practice entails. We also need to define more clearly what the current elements of generalist physician practice should be, and how the knowledge and skills in these elements can be gained and developed. Specialties need to identify their cluster conditions, and increase skill development in these areas for their physicians and teams.
I am proud to be a general physician. Throughout my career my specialist practice has changed, and my generalist skills have continually developed and adapted. For much of my professional life diabetes was my specialty, with subspecialties including renal disorders, cardiovascular disease prevention, pregnancy care and community diabetes, but also covering other areas at times. I also continued to practise acute medicine. Today my clinical practice is in acute and general medicine, and recently long COVID. I also have a strong interest in patient safety. So my development needs have changed throughout my career for both my specialist practice and my generalist skills.
As Prof Whitty states, ‘It is essential that doctors maintain their generalist skills alongside their specialist ones’. It’s not about what you do to get your certificate of completion of training (CCT), it’s about your whole career and adapting as your needs change. The RCP must enable you to do that, identifying your personal development needs, and signposting or providing opportunities to meet them.
Our Shape of medicine paper looks at what physicians need for the future. Our work on generalism and specialism will continue, working with the Scottish physician colleges. If you are interested in being involved, please contact me via firstname.lastname@example.org.