The acute general team juniors are having a training morning. A lot of the sessions are interesting, plus there’s free tea and biscuits and a change of routine, so on the whole everyone’s happy. But as the day goes on, one thing starts, ever so subtly, to chafe.
Each session is on a different topic – crises in cancer patients, surgical emergencies, initial approach to heart failure – you know the sort of thing. Each is relevant to the acute general team’s work but, to ensure we’re getting access to the most up-to-minute expertise, each is taught by a specialist: a cardiologist for heart failure, an oncologist for cancer, and so on. They’re mostly good speakers, but with many of the talks a faint note of superiority, even of reproach, creeps in.
The oncologist notes sadly that many patients present multiple times before their cancer is recognised. The cardiologist has a brief rant about how often arrhythmias are mismanaged. The surgeon cracks a joke about our inadequate abdominal examination skills. None of them are wrong, but the cumulative effect is, for the assembled generalists, slightly depressing.
It’s very easy for specialists to feel superior. Part of this dates back to the olden days when a ‘general practitioner’ was the local doctor who really did handle everything, from twins to typhoid outbreaks, as best they could with limited resources, while the ‘specialist’ was the smartly-dressed type with consulting rooms in Harley Street, called in for particularly interesting cases – if the patient could pay. That was 70 years ago, but the division hasn’t entirely faded yet.
In theory, we all know that if you exclusively manage, say, metabolic disorders of the toenail then a) you probably know an awful lot about them and b) you may well be fairly useless at everything else. But it’s somehow dangerously easy for both specialist and generalist to forget the second bit, and this can have unfortunate effects on the self-esteem of both groups.
Generalists are not cut-price specialists. They are people who can cope with an undifferentiated stream of patients with potentially anything or nothing wrong with them, who can manage common conditions, and who know where to send the ones they can’t deal with alone. The NHS, and every other health system ever built, relies on these people’s skills, their breadth of expertise and their mental flexibility.
So if you work in a highly (or narrowly) specialised bit of medicine, next time you feel tempted to raise your eyebrows at an imperfect referral, think twice. Maybe the referring generalist hasn’t mastered every detail of your favourite condition, but how would you get on in their shoes?
By the Secret Doctor
Read the blog and follow @TheSecretDr on Twitter and on Facebook
Spot on - well said.
As a Generalist I am often surprised by the narrowness of my Partialist colleagues knowledge base!
This is so true. As a current specialist I have the utmost respect for my general colleagues who have a really difficult job. And probably do not receive the recognition that they deserve.
It's actually worse than this with the super-specialisation that has become the norm in hospitals and the tendency to treat illnesses and lab results rather than patients. Which is why General Practice is so rewarding but can be so frustrating. Specialists treat their area of expertise with little regard for other aspects of a patient's care. Here lies polypharmacy, drug inter-reactions and all the iatrogenic problems associated with such an approach. So generalists are actually the true masters here - never feel inferior when a specialist turns his/her nose up at you because you are not an expert in their field.
Can I hope that there is now some focussed career advice for juniors to help them identify whether they are potential generalists or whether they really prefer to know "more and more about less and less"? If you leave this decision too late you will find yourself facing a slammed door because part of specialism is experience in the correct junior jobs - or so it used to be.
It's a pity it took the RCP a decade to recognise the importance of the generalist and promote acute medicine.
some doctors are generalists and specialists ...boundary spanners
If you think that's bad, try being an EM consultant! If one were to dissect what we do into tiny component parts, there would probably be somebody within the hospital who had more specialist knowledge on that particular area than us. Which makes an in-patient specialist, when confronted with a tiny part of a patient (already stabilised, and presumably diagnosed sufficiently to reach Prof Sir Lancelot Sprat in the first place) feel comfortably superior.
Of course, if patients came as neatly-labelled boxes containing a Diagnosis, they'd be right.
We need more work like this to foster mutual respect and good relationships within the NHS!
A very good article, thank you. May I add that the merging of GP practices to form super-practices and relying more on community based care is therefore foolhardy. We do our Specialist colleagues a disservice by pretending that GPs can specialise to the same degree in the community; we are cheaper than secondary and tertiary care and it can be tempting to believe the flattery that we can manage more and more in primary care. I think some of the slights against GPs may be rooted in the deepening insecurity of our highly skilled hospital based colleagues that their funding will be reduced or withdrawn and re-invested in community based services. This is a very real fear that I have heard voiced by bright and talented consultants who should have no reason for doubting their own skills. We are not specialists. We may be able to manage a Special Interest (I am a GPwSI and portfolio GP) but this should not be at the expense of our generalism.
Too b****y true !
After 35 years in general practice I was always relieved when an older general physician(who worked out of our local community hospital offering out-patient clinics) was prepared to see a patient and ensure that I had not missed anything awful, and was able to make suitable suggestions on management. He retired 20 years ago ! His kind need to be resurrected
Agreed, and I think GPs in particular do an amazing yet impossible job of dealing with everything, in 10 minutes, with minimal access to Speciality advice/ diagnostics.
I disagree with the Sir Lancelot Spratt comment however- A&E increasingly seems to be about very junior doctors referring an unworked up patient, with no senior A&E input, as quickly possible to a specialty to deflect the 4 hour clock/ taking responsibility for a decision. So many mild abdo pain referrals are viewed as , " refer to gynae or surgery?" When they could/ should be managed with GP/ outpatient follow-up, and a GP could have sorted it out in ten minutes.