Generalists crucial to tackling complex diagnoses

EMBRACING generalism is crucial in tackling the complex diagnoses often required in an ageing population and in meeting the community’s priority health care needs into the future, write two experts in this week’s MJA.

In one Perspective, Associate Professor Ian Scott, director of Internal Medicine and Clinical Epidemiology at Brisbane’s Princess Alexandra Hospital, wrote that specialists needed to broaden their expertise beyond single organ systems to enable them to formulate differential diagnoses in challenging cases.

“Patients with different comorbidities may present with problems reflecting disease–disease, drug–disease or drug–drug interactions,” wrote Professor Scott, who is also professor of Medicine at the University of Queensland. “Clinicians trained as generalists seem better at navigating this complex mixture of issues than single content domain specialists.”

In a second Perspective, Professor Roger Strasser, Dean of the Northern Ontario School of Medicine, wrote of the importance of generalism skills and a streamlined approach to training in producing a medical workforce that would be fit-for-purpose in 2025.

He said that a fit-for-purpose medical workforce was defined as one with “the right skills, providing the right care, in the right place, at the right time”.

“There is an urgent need to establish full streamlined education and training pathways in all medical disciplines,” he wrote, noting that general practice had two such pathways in the Remote Vocational Training Scheme and the rural generalist training pathway.

“Learning generalism skills will encourage adaptability and the potential for medical workforce redeployment in response to changing population health needs.”

He wrote that Australia’s current workforce supply arrangements were “complicated and fragmented”, that vocational training was overseen by 24 medical colleges, and trainees faced year-by-year employment uncertainty.

In Canada, he said, university medical schools were responsible for delivering all levels of medical education, there were just two medical colleges, and trainees enjoyed guaranteed employment for the term of their training.

• Podcast with Professor Roger Strasser

Royal Australian College of GPs (RACGP) President Dr Bastian Seidel agreed that a more coordinated and flexible response to medical training was required to meet community health needs. He said, however, that there was a raft of challenges ahead.

“Medical training can take 12 years for a non-GP specialist, and not much less time for a GP; this is important to produce good and safe doctors,” Dr Seidel said. “Community needs can change quickly and the response time to produce suitably trained doctors to meet these needs can be very slow.”

Other challenges included increasing specialisation and a bottleneck in clinical training positions.

Dr Seidel said that a greater emphasis on generalism was important to meet the needs of a rapidly ageing population with multiple morbidities.

“As GPs, we are the mainstay of continuous care of multiple diseases in our patients, and the need for generalism among non-GP specialists is becoming increasingly important, especially in very complex patients,” said Dr Seidel, adding that there also needed to be a focus on multidisciplinary and coordinated care.

“While the RACGP welcomes the increasing of generalist skills [among] specialists, the need for constant communication, multidisciplinary and continuous shared care with a GP is the safest way to ensure a patient’s holistic care,” he said. “GPs have been managing and coordinating complex patients for a long time, often when a non-GP specialist only manages one aspect of the patient.”

Speaking in an MJA InSight podcast, Professor Scott said it was not necessary for a specialist to be a “jack of all trades”.

“It’s more just to have an [open mind] to … perhaps go back to the general practitioner to say, ‘Look, I don’t think we are going to win going down in this path – what are your feelings on this patient? Do you think there are other things we should consider?’” Professor Scott said.

Also, he said, well-skilled GPs needed to, with the support of specialists, take on a greater role in the management of patients with complex care needs.

Professor Michelle Leech, Deputy Dean, Faculty of Medicine and Health Sciences, Monash University, welcomed both articles, saying the authors had identified key problems with the lack of consistency in medical training and the shift towards a super-specialist workforce.

“I agree that we need a fit-for-purpose workforce, and a lot of that is about flexibility and team-based care being engendered across the training spectrum,” Professor Leech said.

Both articles focused on the development of skills, she said, but greater emphasis should be given to promoting the attributes of a flexible workforce.

“Skills are important, don’t get me wrong, but at the end of the day, what creates a flexible workforce that can essentially turn their hand to anything, is not the skills, it’s the attributes,” Professor Leech said.

“Are you a collaborative person? Do you use time as a diagnostic tool? Do you disinvest in expensive tests? Do you have humility? Do you take ownership? Do you maintain curiosity? No matter which organisation is involved, if people don’t drive the right attributes, you won’t have the right workforce.”

Generalism, however, was not always the answer, said Dr John Quinn, executive director for Surgical Affairs for the Royal Australasian College of Surgeons.

“The discussion about generalism and specialisation … has been going on for a long time,” Dr Quinn said.  “In surgery, there is still a requirement for generalism, as well as specialisation, but it’s probably more geographically based.”

He said that it was important to consider that in procedural specialties, such as surgery, greater specialisation had resulted in improved outcomes.

“It’s well known worldwide that the results are poorer when [a doctor] is such a generalist that they do [a particular procedure] every 2 years … as opposed to twice a week,” he said.

Professor Jane Andrews, assistant director of Gastroenterology and Hepatology and head of Inflammatory Bowel Disease at Royal Adelaide Hospital and Clinical Professor of Medicine at the University of Adelaide, said that she agreed with many of the sentiments in Professor Scott’s article, but it was not clear the extent to which he believed specialists should pursue generalist skills.

“The cost of everyone being more generalist is that we will lose subspecialty expertise and that will have consequences,” Professor Andrews told MJA InSight.

“I don’t see that he has considered the costs of doing what he recommends, such as the increased training time,” she said. “Does he recommend that every doctor does less clinical work so we can do more ongoing reading, go to more conferences in different specialties?” she said.

Professor Andrews said that while gastroenterology was named in Professor Scott’s article as one of the three specialties with higher than average rates of changes in diagnoses where patients had sought a second opinion, often these changes were appropriate.

Professor Scott wrote: “Certain specialties, such as gastroenterology, neurology and rheumatology, attracted higher than average rates of diagnosis change (22–26%) with higher rates of moderate and major impact (22–27%)”.

Professor Andrews said that even in the worst-case scenarios presented, only about 7% of diagnoses were changed, meaning 93% were not.

“These may be specialties that are more willing to reconsider on the basis of more evidence,” Professor Andrews said. “In my area, someone can be thought to have irritable bowel syndrome because all the appropriate tests are normal and the symptoms are not alarming, and then 6 months later it can be very obvious that they have ileal Crohn’s disease.” This does not make the initial assessment wrong, she said, just an acknowledgement that disease processes evolve and declare themselves.

Professor Andrews said that many of the challenges and issues raised in the articles could be managed with improved collaboration and communication between specialists and GPs.

“I don’t necessarily think we need different people, I think we need people to communicate well and be clear about what is the question they are seeking when they refer a patient,” said Professor Andrews, who is also a member of the Gastroenterology Society of Australia board.

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