Generalism in the age of increasing Specialization

Braam de Klerk always signs off his emails with this quote from Heinlein.  While I cannot literally conn a ship, I think the rest is doable.  Now…. how do we translate this into medicine?  Maybe I do conn a ship.

Starfield proved that the number of physicians involved in a patient’s care is inversely proportional to health outcomes.  Yes, the more physicians involved with increasingly narrow areas of expertise, the more specialists there are, the poorer the outcomes.  Its understandable though: the greater the number of physicians involved, the greater the number of potential miscommunications and delays as care coordination is planned. 

Following the acute care setting, gaps in communication between the hospital based specialist and the community based primary care doctor can result in further delays in care and at the least, an embarrassing office visit.  As unbelievable as it seems, I have had patients arrive for a post-op check when I have not even received the consult letter after a referral that took six months to execute.

Can you imagine what it would be like as a patient?  Can you imagine what it is like to navigate our complicated heath care system as a person with no medical knowledge.  Who is in charge of your care if the attending changes daily?  Who does the patient call?  Who does the family call?  Who do I, as the primary care doc, call?

All of us should try being a patient … it is definitely not the same on the other side of the table. But one thing is for sure, you will also wish you had a primary care physician, someone to walk with you in the hospital and outside the hospital, someone that understands your context, and someone that knows you well enough to be precise in their discussions and recommendations.

Continuity of care needs to be studied and defined much more closely. It is often used as the surrogate for continuity of relationship but it is not.  There is also continuity of record, continuity of care, and continuity of physician that are also used. But underneath all this, is continuity of relationship.

In a health crisis, patients will trade continuity of care giver for immediate access. But, the “patient–physician relationship is built largely on trust, and levels of trust are usually lower among strangers.”  Add to this the hospitalist shift structure and the rotating attending schedules and everyday starts with a new stranger.  Often, the most continuous presence for medicine is the learner!

All this underscores the need for the generalist presence in care.  Our system is built around the research imperative of the specialist attending, the life style of the hospitalist and union rules of all care givers.  The general internist, the general surgeon and the general practitioner have a role to improve communication by decreasing the number of potential miscommunications and increasing the understanding of the patients’ context to raise the precision of care.  As learners, you will often be seen as the generalist that synthesizes all of the recommendations for all of the specialists.  You will need to advocate for your patient, you will nee to conn the ship.