Generalism is defined as “a philosophy of care … distinguished by a commitment to the breadth of practice within each discipline and collaboration with the larger health care team in order to respond to patient and community needs.”1 Generalists are physicians whose practice is broad in scope—they diagnose and manage diverse, undifferentiated, and often complex clinical problems, and provide a comprehensive range of services. Generalist practice is associated with improved patient outcomes and efficient health care system use.2 There is widespread support for learners to be exposed to, and to graduate with, generalist competencies that carry forward to whichever specialty they choose.3,4 Despite this, the concept of generalism is often not readily apparent; while learners experience generalist practice in family medicine or in other generalist contexts, there is rarely explicit attention paid to the underpinning constructs that constitute generalism. Praxis is the process by which a theory, lesson, or skill is enacted, embodied, or realized. Family physicians can articulate the praxis of generalism using 6 key concepts during their teaching (the “6 Cs”; Table 1).5 The purpose of this article is to provide a framework for explicit discussions about how generalism is enacted in family medicine with learners.
Generalism concepts and examples of 6 Cs
Comprehensive care
Generalist family medicine is whole-person medicine. A hallmark of comprehensive care is a holistic approach to assessment and management. While learners may understand comprehensive care as managing patients across the life cycle, an important yet often underexposed aspect of family medicine is the comprehensive unpacking of concerns and determination of the nature of the problem; not all chest pain is cardiac, and not all pain is physical. Whether or not biological pathology is recognized, the family physician works with patients to explore and manage their distress.6 This approach differs from the more disease-focused, deductive form of hypothesis testing of specialist care; often, when a specialist cannot detect the cause of a patient’s symptom in relation to the body system of their expertise, the patient is discharged back to the family doctor. The goal of family medicine is less focused on disease and more on patients’ well-being, to improve their health-related capacity for daily living.7 This type of comprehensive care requires intellectual flexibility and creative thinking and can be immensely rewarding. Family physicians can share stories with learners about providing comprehensive care, including about working with patients with unexplained symptoms, and about how bearing witness to a symptom over time can deepen physician-patient relationships and improve patient outcomes.
Complexity
Generalists manage complex patients. Learners new to family medicine may feel overwhelmed by complex patients and not know where to start.8 Confronted by a patient with, say, 5 or more illnesses, 10 medications, and difficult social circumstances, learners can feel uncertain. Managing multimorbidity and negotiating uncertainty are hallmarks of generalist practice in family medicine. Undergraduate medical education predominantly focuses on single diseases addressed in isolation from other conditions, devoid of context, reinforced by single-disease guidelines and clinical care pathways. Our systematic review on teaching of multimorbidity found only 2 studies, both at a postgraduate level.9 Family physicians can model how generalists manage complexity and help learners to develop a structured approach to multimorbidity by breaking complex histories into manageable chunks through clustering similar illness groups, applying shared decision-making skills, and being frank with patients about uncertainty. Involving residents in these discussions can be particularly helpful for junior learners because often residents are grappling with similar challenges; their near-peer insights can help reassure learners and encourage them to share their questions.
Context
Generalists integrate content and context expertise. In medical school, the focus of most learning is mastery of content. In family medicine, the focus is on applying content expertise to the specific circumstances of the individual patient. Context can be viewed through many lenses: patient context, practice context, educational setting, physical location, and sociopolitical and cultural context.10 Family physicians respond to variability in context by using adaptive expertise. Family physicians can demonstrate contextual adaptability to learners by asking “what if?” in relation to patient care: what if the learner needed to manage this patient in a rural or urban setting, what if the patient has no access to full insurance benefits, child care, and so on. Asking “what if?” helps learners articulate their tacit knowledge and reflect on the ways things are done in different settings, as well as their respective pros and cons.
Continuity of care
Continuity of care is defined as repeated contact between an individual patient and a doctor over time.11 Recurring consultations give patients and doctors opportunities to understand each other. Physicians use this accumulated knowledge to tailor patient care in subsequent visits. Continuity can be considered a proxy measure for the strength of patient-doctor relationships12 and is associated with a range of improved patient outcomes, including patient satisfaction, improved health promotion, increased adherence to medication, reduced hospital use, and lower mortality.11 While the value of continuity of care is obvious to family physicians, with the exception of longitudinal clerkships, the opportunities for many medical learners to engage in continuity of care at undergraduate level are rather limited. Although many schools offer preclerkship opportunities to spend time in the same family physician office or to follow a patient journey, learners might only get limited opportunities to develop longitudinal relationships with patients. Family physicians can make the concept of continuity more explicit by talking about the relationships they have had with patients (and their families) over time. They can explain how their personal knowledge of the patient impacts the recommendations they make about patient care during a visit; often the relationship between that continuity and those recommendations is implicit to the family physician, but mysterious to a learner.
Communication
Clear, unbiased communicating is important for a teacher to model; here, we focus on physician-to-physician and interprofessional communication. There is a well-established literature on the hidden curriculum that denigrates family medicine, such that it is seen as a lesser or backup career option.8 But negative comments about specialties are not specific to family medicine. Recently the term specialty disrespect13 has been used to describe unwarranted negative comments made by trainees and physicians of different specialties. A survey of medical students in the United States found that encountering specialty disrespect had a moderate or strong impact on their specialty choice.13 What is more, disrespectful comments can not only decrease students’ interest in the specialty that is the target of the remarks but also decrease interest in the specialty that is the source of the remarks; the disrespect creates a mutually destructive pattern. Family physicians can, even subconsciously, engage with specialty disrespect when making disparaging comments about a patient’s care by specialists, other family physicians, or allied health professional colleagues. Promoting specialty respect means respecting all health professional colleagues, regardless of their discipline. Family physicians should speak respectfully about other professions and explain, from a family medicine perspective, how a patient’s care could be improved (thereby reframing the issue).
Collaboration
Collaboration is inherent to generalist practice as physicians help patients navigate health care systems. Increasingly, generalists work in teams within the Patient’s Medical Home model.5 The Patient’s Medical Home model may be unfamiliar to learners and spending some time explaining team structures and making behind-the-scenes work explicit can help raise learners’ awareness of the clinical and administrative effort that is necessary to provide seamless collaborative care.
Conclusion
Generalism is integral to family medicine and is associated with improved patient outcomes and increased efficiency of the health care system. However, it is often unclear to learners and so familiar to preceptors that it becomes tacit, leaving learners without an understanding about how to enact generalism. The 6 Cs (Table 1)5 provide a shared vocabulary to help generalist physicians structure and articulate the nature of generalism to learners so that they can become effective generalists and contribute to improved patient outcomes.
Notes
Teaching tips
▸ Generalism as a philosophy of care is integral to family medicine but often unclear to learners. Six key concepts (the 6 Cs) provide a shared vocabulary to help generalist physicians structure and articulate the nature of generalism to learners.
▸ During teaching, family physicians can be role models by enacting the 6 Cs—comprehensive care, complexity, context, continuity of care, communication, and collaboration. They can encourage frank and open discussion with learners of the unique challenges and rewards of practising generalism, using their own experiences as illustration.
▸ Involving residents in these discussions can be particularly helpful for junior learners because often residents are grappling with similar challenges; their near-peer insights can help reassure learners and encourage them to share their questions.
Additional resources
Horrey K, Davidson C, Tan A. Twelve points to consider when talking to a medical student about a career in family medicine. Can Fam Physician 2020;66:74-6 (Eng), e41-3 (Fr).
Graves L, Power L. Layered learning: Integrating learners into your clinical practice [video]. YouTube; 2020. Available from: https://www.youtube.com/watch?v=2woNwQMtaWM. Accessed 2021 Sep 8.
Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Viola Antao, Teaching Moment Coordinator, at viola.antao{at}utoronto.ca.
Footnotes
Competing interests
None declared
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’octobre 2021 à la page e288.
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