Defining the specialist generalist

In commentaries, research papers, and policy reports published across Canada, there exists considerable variation in the ways the discipline of family medicine is perceived. Some scholars describe family physicians as the consummate medical experts: physicians able to respond to patient needs across the age, sex, and community spectrums. In other instances, family medicine is understood as the provision of care that is patient centred and compassionate, foregrounding the role of the family physician in providing holistic care and advocacy for the entire person. In contrast to their subspecialist counterparts, family physicians are trained to address the needs of Canadians by maintaining the breadth of knowledge and skills required to provide comprehensive, continuous care in urban and rural communities.¹ Over the years, practitioners, policy makers, and scholars have shaped these constructions of the discipline into various models for framing, explaining, and justifying clinical practice in family medicine.² The recent College of Family Physicians of Canada publication of the Family Physician Professional Profile brings together all of these ideas in describing that “it is through relational continuity and a commitment to a broad scope of practice that the complexity of care is meaningfully addressed.”³

One common denominator, central to virtually all of these models, is the explicit notion of family medicine as fulfilling a need for “generalist” physicians in the Canadian health care system. The prioritization of generalism in family medicine education means that residency programs are expected to produce physicians who can serve the needs of the whole patient, integrating their understanding of context to provide comprehensive care from cradle to grave, from acute to chronic presentations, and across all care settings.³

Still, many scholars and leaders have expressed concerns that the traditional generalist has become an “endangered species.”⁴ The emergence of evidence-based medicine,⁵ widening income gaps between specialists and generalists,⁶ and changes in medical education⁷ have led to concerns that fewer family physicians are embracing their roles as generalists. Given these calls for concern, we believe it is time to consider reframing the role of generalism and expertise in family medicine.

Generalism is a philosophy of care⁸ encompassing many elements, including the importance of the doctor-patient relationship, portrayal of the whole person in the context of his or her family and environment, continuity and coordination of care, and consideration of prevention and health promotion. Generalist physicians act as advocates for their patients and often work in multidisciplinary teams.

Discussions of the demise of generalism in family medicine typically emphasize scope of practice. Using this lens, family physicians are generalists because they are trained to take on a variety of clinical problems in the widest range of contexts, rather than having a narrow focus. In unpacking this domain of generalism, it becomes clear that what is common across all family physicians is the expectation that they will have the capacity to handle cases that range from the routine and simple (eg, sore throat) to the unusual and highly complex (eg, rare genetic disorders).⁹ Moreover, as generalists, family physicians are frequently expected to diagnose and manage undifferentiated clinical problems that can be ambiguous, making it critical that new graduates be prepared for uncertainty and can use their knowledge flexibly to handle situations for which the obvious solution is unclear. These core activities of generalism—dealing with complexity, novelty, and ambiguity—are easily overlooked when the focus is exclusively on the range of services provided in practice.

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