Family doctors deserve more of our respect
Alternative title: The generalist is an important specialist
Dr. Trevor Hancock
31 January 2018
Last November the Royal College of General Practitioners (RCGP) and the Medical Schools Council in the UK released a disturbing report. They surveyed 3,680 medical students from 30 medical schools throughout the UK, finding that by the time they reach their final year “more than three quarters of medical students report hearing negative comments about general practice” – what we would call family practice – “from clinicians, educational trainers, and/or academics”.
The report – Destination GP – built on a 2016 report from Health Education England and the Medical Schools Council that noted “Recruitment into general practice has become a major issue”. That earlier report found what it called ‘professional tribalism’ from specialists who “perceive primary care of ‘lower status’”; this, the report says, is unacceptable.
The level of denigration is astounding; Nine out of 10 of those surveyed felt their fellow students had negative perceptions of general practice, more half found doctors in specialty areas where they were placed were negative about general practice, and of the three-quarters who heard negative comments, 25 percent heard it suggested that GPs were of lower status and 15 percent heard general practice described as “undemanding and easy”.
As a result, says the RCGP, “some medical students considering a career in general practice are being discouraged and deterred from joining the profession, or abandoning it for other medical specialties”. This adds to the challenges faced by the NHS in recruiting GPs for a variety of reasons, including workload and status.
This situation will be familiar to the many patients across Canada who are having trouble finding a family physician. Sadly, it seems, some of the same attitudes to family practice exist within the medical profession here in Canada, according to an article by Roger Collier in the Canadian Medical Association Journal this January. It also is familiar to me, both as a former family physician and as a public health physician; we too are sometimes seen as not being ‘real doctors’ and not practicing ‘real medicine’.
What I think is really going on here is a wider phenomenon, found across many professions and disciplines, rooted in a societal tendency to value specialism over generalism. This attitude fails to recognize that generalism, perhaps better described as holistic thinking, is a specialty in its own right. Rather than knowing more and more about less and less, holistic thinkers know about a great many different things and work to synthesise and integrate them, looking for what Gregory Bateson called ‘the pattern that connects’. That is the value of family practice – understanding the whole person and their family in the context of their life and work.
I also see this holistic, generalist thinking under-valued in academe, another institution where specialization is (over) valued. Students tend to get funneled into narrowly conceived channels where funding and publication is to be found, while interdisciplinary programs – while given rhetorical support – are in practice difficult to establish and maintain.
Yet many of the challenges we face in the 21st century are complex, cut across and involve many sectors, and interact as complex systems. They cannot be solved by narrow specialists, who indeed may make the problem worse. We need people trained in holistic thinking who understand complex systems and how to manage them.
This is certainly true of public health, my specialty for 35 years. In a column in the Canadian Medical Association Journal a recently, I pointed out our vast scope of practice. In addition to being trained in medicine, public health physicians need to have a broad knowledge of the social sciences, from anthropology to psychology, community development to political science.
Because of the importance for health of the built environment, we need a grounding in the design professions (architecture, engineering, and urban planning), while our interactions with the natural environment require knowledge of toxicology, environmental health and ecology. Finally, because of our involvement in policy-making and regulation, we need an understanding of public administration and public communication.
I believe that family practice and public health are among the most challenging and complex specialties in all of medicine, requiring the best and brightest as their practitioners. They deserve far more respect, both within and beyond the medical profession, as specialties in their own right.
© Trevor Hancock, 2018