Valuing our past, sustaining our future

A country doctor on his rounds …

And everybody knows

His voice, his smile, the way he walks,

His presence in the Vale;

They will remember evermore,

His name in Wensleydale.

Joan Pomfret (1913-1993)¹

It is rare for a GP to be the subject of a poem but Dr William Pickles, memorialized by Joan Pomfret,² was legendary. He not only looked after the people of the Yorkshire village of Wensleydale, UK, and its surroundings for more than 50 years but also made careful observations on infectious diseases. He is probably most famous for his description of the clinical presentation, natural history, and epidemiology of “catarrhal jaundice,” which we know today is caused by hepatitis A virus.³ In 1968, the Royal College of General Practitioners established the annual William Pickles Lecture in his honour. Pickles epitomized the dedicated generalist who was also an astute and meticulous observer of illness in his community.¹ But how do we define generalist for the modern day?

Like many young family medicine residents, I was drawn to the kind of generalist medical practice epitomized by Pickles. This interest was further galvanized during my teaching practice in a small and picturesque Ontario town and by the intoxicating effect of first reading John Berger’s A Fortunate Man⁴ around the same time.

In her 2017 William Pickles Lecture, Dr Clare Gerada, a British GP and the head of the National Health Service Practitioner Health Programme, provided a thoughtful critique of the mythology of general practice that hangs over our work to this day.⁵ Several important influences in Gerada’s life led her to become a doctor. The first was her GP father; she used to accompany him on his rounds. Pickles was another strong influence in her life, as was John Sassall, the GP protagonist of A Fortunate Man—the very same influences as mine. But, as she points out, medical life stories have contributed to the “folklore” of our profession and that “building a future on the foundations of a distorted version of the past makes life difficult for this, and the next, generation of GPs.”⁵

The challenge is that societies need generalists now more than ever. But the demands of being a generalist were probably never realistic, and the role was frequently achieved at great personal expense or at the expense of spouses and families. The demands of being a generalist today are even greater. Faced with pandemics, an aging population, the rapid pace of biomedical advances, a death-denying and death-controlling culture, an increasingly fragmented and unequal society, and the expectation that FPs will take on additional nonmedical roles, the work of generalists is more daunting than ever. As a result, we are now seeing fewer family medicine trainees interested in the broad generalist role that was the norm.⁶

Is there a way forward so that we can take the best of the past, but repurpose generalists for the future?

One way forward, as Dr Gerada says, is to redefine our vocation as one ”adapted to the times we live in. One that reflects the fact that we are all human beings trying to do the best for our patients. If we expect doctors to give their all to others, then the quid quo pro is that we have to protect the doctor—and the connections that sustain them.“⁵

A second and equally valuable way forward is to redefine generalists, not by the scope of our practice or the number of roles we take on, but by our skill set and our worldview. This skill set and this worldview are brilliantly articulated in “Defining the specialist generalist. The imperative for adaptive expertise in family medicine” by Dr Nicole Woods et al in this issue (page 321).⁷ This work is complemented by a valuable article by Dr Melissa Nutik et al entitled “Assessing undergraduate medical education through a generalist lens,” which describes a tool they developed and evaluated to assess the generalist content of undergraduate medical curricula (page 357).⁸ Finally, editorial fellow Dr Sarah Fraser shines a light on one of the darker aspects of being a generalist (page 367).⁹

Every generation of family physicians and GPs faces challenges—medical, cultural, and societal—that force us to reevaluate what it means to be a generalist. The work of Drs Gerada, Woods, Nutik, and their colleagues can help show us the way forward.

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