Generalism, Generalists, Specialists, and Medical Education

The medical school environment faces incredible challenges in this century. The great strides during the reform years from 1910 - 1950 resulted from the marriage of science, education, public health, and service to the underserved. Medicine, medical education, and a spirit of altruism and public responsibility guided the development of a fledgling health care industry. Various distortions and distractions were kept in check because the forces were modified through the lens of generalism, the dominant force in the approach to medical education. This focus allowed the great development of research and technology and promoted the awesome and complex diversity of medicine

Generalism has long been forgotten in the pursuit of technology, innovation, information, profit, and control. As a result medical schools have lost balance. Many are calling for healing in the healing profession.

Generalists and generalist movements are different from generalism. They face their own tremendous internal and external challenges, but they can provide help in returning medical education to the generalist approaches that restore balance. Understanding of the similarities and differences between generalists and the generalist approach is an important part of this process. Generalism, generalists, and specialists working together can yet take medical education to heights not even imagined.

The first 50 years

1. Marriage of science, industry, health, public need, government incentives
2. Constant debates regarding the developing relationships in medical school Flexner, Osler
3. Students given great opportunities to learn by actually taking care of patients
4. Priority on teaching students
5.  
6.  

The medical school environment is currently in a state of confusion Examples of the changes and the impact on medical education - Ludmerer also

1. Massively divided fiefdoms
2. Separated from local, state, and national needs
3. Leadership living in a different world
4. Federal incentives and initiatives have contributed to the distortion and confusion (NIH funds, GME funds, IMG dependence,
5. Medical schools have not been held accountable ignoring workforce (COGME),
6. Their intimacy with technology and information and each other has not served them well. They have lost touch with patients, communities, and changes in health care in great degree to their willingness to listen to a relatively limited group of advisors in financial, hospital, and business circles. While this may have resulted in all doing well, pack mentality in a few bad decisions has impacted the whole lot.

These changes have occurred gradually over many decades.

Generalism remembered

1. Generalism defined
2. Focus on broad approach not narrow in teaching and research
3. Focus on service and involvement and application, not isolation and achievement for its own means
4. Single or few teachers and integrated approach rather than specialist and isolated segments
5. Multidimensional approaches
6. Healer vs detective vs technologist - Robinson
7. Teaching unifies research and service

What a Generalist approach could bring to many of the challenges of medical education.

1. Table on Millenium Conference

How medical education has grown deaf to generalists

How generalists have lost their focus on generalism, have become more focused on turf and more subject to specialism

1. Training in fp - a specialty fragmented by misguided generalism, divided by attempts to be focus on continuity attempts rather than examples of continuity in existing practices, compromise in training - taking students who have endured much to attempt to become generalists and then farming them out to specialists to train
2. family medicine specializing in various areas such as academics, predoc, research, women's health, debates over ob or not,
3. Academization of FP where faculty wall themselves off from others, departments, rarely do faculty from one department venture to another for grand rounds, except when asked or paid to be a speaker.
4.  

How accreditation impedes cooperation and change

1. focus on infrastructure not process
2. even with demonstrated outcomes and published research, not willing to accept, replicate

How a focus on the underserved can unify the efforts of generalism, generalists, and medical education

How the marriage of all three can provide

1. top quality education - why a preceptorship
2.  

Five generations work and reflections on Flexner

Although we in family medicine often argue for more medical school leadership roles, curricular emphasis, etc., in some ways our efforts to gain turf may be pushing medical education the wrong way. Dan's quote by Peabody in the 1920's is not isolated by any means. Generalism ruled medical education for most of the last century. I believe it was the combination of the generalist approach, married to science and technology, and medical facilities, that made American medicine the great thing that it was for many decades. I would also assert that many of the problems of American medicine have come from the loss of this focus in medical education and a poor understanding of the generalist focus of medical education by current medical school leadership.

Now for the other side. Family medicine considers itself the only and true pure form of generalism. We have linked our success in departments and programs and political efforts to family medicine. Our conflicts have become generalist conflicts even though we ourselves are straying farther and farther from generalism. By pushing family medicine to the exclusion of generalism, we are causing problems for medical education which desperately needs to rediscover the value of such an approach.

Generalism is not FP + general IM + general Peds or general practice. It is an approach that is broader than these. It is the only approach that can provide an adequate framework to support the ever expanding dimensions of medicine. It is the only approach that can combat reductions that will omit important segments of training. This may have the greatest impact on those preparing for primary care careers, but it also will impact specialists as well, their preparation, ability to make decisions, and attitude toward other physicians, not just in primary care.

reduces medical

There is no better focus for medical education than generalism. This does not mean that only those wearing the badge of generalism should run the show. Deans, faculty, or leaders can implement medical education based on generalism, attempting to meet the broad needs of students and those they will serve. The needs of the local communities, the state, and the nation should also drive the approach.

Battles for control of medical education do little good. All have roles to play.

Generalism was the basis of medical education of the first half of the last century, then it changed and with it, the quality, coordination, and focus of medical education. We in rural medical education, both physicians and faculty, understand generalism, we have important generalist models, and these models are some of the best medical education possible. The past 50 years has become town vs gown. Yet our best models have been town plus gown. We need the accountability that academic connections provide, but we need the devotion to practice and service and teaching that our community practitioners bring. 

Several schools had attained significant generalist impact and leadership. Just as great progress was being made in generalism, managed care came along. Although primary care got a great boost from its identification with managed care, there was an even greater backlash. 

We were close, but in many ways we were doomed to failure. It is not generalists than need to rule, but generalism. We were a means to a necessary end. .

Generalist principles need to be adopted by all academic faculty and leaders. There must be some degree of separation of generalist principles from generalist physicians.

Just like preceptorships were thrown out like a baby with the bath water a century ago Why a Preceptorship, all of primary care has been ejected, and generalism as well. Of course the impact was far more on medical education and medicine than currently understood.

Medical education has little idea how important it is to retain those who can still comprehend generalism. Underserved generalists are also the the connection between

1. the underserved and ivory towers, between
2. rural and academic communities, between
3. doctor and patient.

Generalists are some of the best examples of serving in medicine. More and more medical education is separating from patients, service, teaching, and care of the underserved.  

Science and technology without soul and caring are not only
ineffective and expensive, they are dangerous. 

As more and more patients die unnecessarily at the hands of health care providers and physicians, it is more and more apparent that we are selecting doctors less and less for their abilities to care and serve and communicate. Is there a relationship? No single study can prove this, but those of us that pay attention to our patients, our communities, and medical education are in the best place to determine this. And because of this we must rock the ivory towers and get them to relate to those in the trenches who need us. 

My greatest fear is that we will devote billions to the study of medical errors when the solutions are already staring us in the face. We do not need more layers of systems or bureaucracy to tell us how to avoid errors, we just need doctors and health professionals to be so devoted to service and caring that they will not allow themselves to make such errors.

My great frustration with Family Medicine is that we are spending millions on planning the future when we know what we need to do. We need to devote as much time and energy and resources as possible to getting the students admitted to medical school that care and serve and communicate. A second role is to attempt to reform medical education and the "hidden curriculum" to do what we can not to train caring and service and relational values out of our future physicians.  

The major losers in this process are not rural medical educators. The major losers are people in underserved communities, and with them all of America as we are crushed under the burden of health care. We understand that the needs of a few drive the costs for all of us, but we pay attention to shaving costs from the many. We should be spending more time  preventing major costs and problems from the few, especially in areas where health, education, and the legal system overlap. The burden of poverty and hopelessness in this nation is enormous, and remains one of the great unrecognized problems.

It is not a coincidence that our role in Family Medicine is also the major area that medical education needs to address. More than support of our programs, medical education needs to pay attention to us.

Family medicine can be most helpful in this approach.

1. We hold the best solutions to care of the underserved.
2. We have the best medical education models.
3. We hold the best approach to quality care of Americans at an affordable price.
4. We have the physicians that are more likely to care and serve and communicate.
5. We have departments and programs and centers and faculty that continue to overcome significant obstacles to attempt to meet the needs of states, communities, and peoples. 

It is not a time to be paralyzed. We need to plan action. Action is what each of us can and will do and what we hope groups of us will do. 

The power of generalist and community-based approaches is enormous and holds to potential to address even the most serious problems in our nation and world.

Restoration of Communities, Nations, People: Role of Rural Family Docs

Back to Hope: Students From the Underserved, For the Underserved

Specialist Vs Generalist Perspective - Table of comparison

Objectives for Rural Programs and Curricula

www.ruralmedicaleducation.org