In Response to “Champions of Generalism”

We thank Dr Saultz for his editorial on generalism.¹ In response, we offer these additional comments from the perspectives of a community preceptor (J.C.) and a core faculty member (M.T.) with 60 years of combined experience.

Historically, any family physician could join a rural hospital, small-town practice, urban health center, or suburban group, and, with support, meet the needs of their community. True, few performed all aspects of family medicine in their day-to-day work, but we were proud to have the generalist’s capability to be nimble and successful in widely diverse settings.

As Dr Saultz notes, generalism has fallen on hard times. Medical knowledge has grown exponentially. No physician can possibly keep up with everything. Family medicine’s response to this reality has been mixed. Many residencies struggle with adequate inpatient and obstetric experiences and train family physicians exclusively for ambulatory practice, emphasizing care access and distribution to specialists for anything they cannot handle expediently. The result is that our patients, our colleagues, and we ourselves do not know what to expect of us. Rare today is the physician who identifies simply as a family doctor. We are primary care specialists, hospitalists, FM-OBs, palliative care and sports medicine physicians, etc. Pursuing quality, we accept metrics endorsed by specialists and enforced by institutions and insurance companies. Rarely do we perform holistic clinical assessments that honor the generalist core of family medicine.²

Yet the vision of family medicine was never to know everything. What we may not know in any one clinical area, we more than make up for with intimate knowledge of our individual patients across problems, settings, and time: their stories, personalities, decision-making styles, family dynamics, and values. This generalist skill set has extraordinary value.³ Our fear is that we have sacrificed teaching the value and practice of relationship —the end product of our traditional principles of accessible, comprehensive, continuous, coordinated, and contextual care⁴—in the service of generic, population-based metrics. In a divided world of narrow specialists, we believe that family medicine’s generalist expertise is sorely needed.

We offer two ideas. First, we present the idea of the “connected generalist” as a model for family medicine training and practice. In this model, family physicians are not isolated access and distribution doctors but are the center of truly integrated medical communities where they have fewer appointments, provide more comprehensive, continuous, contextual care to their patients, and are directly connected to a cadre of specialists, available electronically in real time, to coordinate complex clinical issues. Modern information technology modalities facilitate this collaborative paradigm shift, and new payment models will compensate both generalists and specialists appropriately for their work. In-person specialty visits and referrals will be fewer, but better. The result will be a real medical home with greater efficiency, lower costs, better outcomes, and more satisfied patients and physicians—all measured holistically.

Second, since words matter, we will all call ourselves family physicians. Some residency graduates may be family physicians with an emphasis on a particular strength, while fellowship graduates will be family physicians with special training in their fellowship area.

Society needs us to rebuild our common identity, honor both our generalist and individual strengths, and take leadership in creating truly integrated medical communities.