Proud of who we are: generalists

What is professional expertise?

Questioning our unique clinical contribution essentially means questioning our own professional identity. From a sociologic point of view, “the tasks of professions are human problems amenable to expert services.”³ The objective basis of all professions is academic knowledge. Each profession establishes its legitimacy by relying on its academic knowledge to propose an approach to defining problems (diagnosis), identifying the causes (inference), and offering solutions (treatment). According to Abbott, these 3 activities or tasks constitute the subjective bases of a profession.³ It is tempting to think that expert professional knowledge is defined by highly specialized content expertise, but above all, it is characterized by the ability to apply discretionary judgment to unique and complex situations.⁴

What about medical expertise? In her essay “How doctors think,” Montgomery explores in depth the practice of medicine, which, she reminds us, is first and foremost more a practice than a science. According to Montgomery, “What characterizes physicians, what makes them physicians, is their clinical judgement: a more multifaceted interpretative reasoning, the logic necessitated by reasoning from effect to cause. Faced with a multitude of generalizing studies of varying quality and uncertain relevance, a physician must figure out how any or all apply to a particular patient.”⁵

If, from a sociologic perspective on professions, each professional is a specialist, an expert, then it must be recognized that there is tension within each profession between the “generalists,” who are close to the field and rely on a broad body of knowledge, and the “specialists,” who limit their expertise and practise closer to the “ivory towers” of academic knowledge.^3,4 Generalists in all professions are in a more uncomfortable position as they are more vulnerable to the expansion of other professionals’ scopes of practice.

What are the foundations of family medicine?

A profession is, therefore, defined by an area of practice, a body of knowledge, and a way of accomplishing the 3 fundamental tasks of all professions. How does our discipline distinguish itself from other professions?

The area of practice for family medicine often appears “scattered” and is not restricted to primary care. The Family Medicine Professional Profile describes 5 areas of practice: primary or front-line care, maternal and newborn care, emergency care, home and long-term care, and hospital care.⁶ I would like to suggest that all these fields of practice come together as a single area: community-based care and services.

Spitzer suggests that family medicine is based on 4 great scientific traditions that make up its academic foundation¹: Biomedical sciences, with more rigorous training in this field than other health professionals. Behavioural sciences, such as anthropology, sociology, and psychology, which allow us, as McWhinney so aptly said, to go “beyond diagnosis.”⁷ This integration of biomedical and behavioural sciences is, in fact, relatively unique among the health professions. Clinical sciences, which Feinstein called “clinimetrics”⁸: the science of signs and symptoms, their predictive value, and their use as measures of the functional impact of the disease and the recovery. And finally epidemiology, the study of the determinants of health and issues within populations that influence individual clinical decision making.

This strong academic foundation allows family physicians to use holistic, integrative, patient-centred reasoning⁶ to arrive at a multidimensional diagnosis, evaluate the multifactorial causes, and propose interventions that take into account the situation as a whole. It is this integrative clinical approach that sets family physicians apart within the medical profession and the system of professions.

What is our unique clinical expertise?

This theoretical and experiential background allows family physicians to efficiently resolve a variety of health problems, from the simplest to the most complex. But the question should not be addressed by attempting to list all these problems. As Loxterkamp suggests, “Perhaps we are wrong about what it means to be a generalist. Is it defined by the size of our basket of services or by the range of ideas and experiences at our disposal?”⁹ What characterizes this range of ideas and experiences? Here are my suggestions.

Undifferentiated symptoms and problems. We must never forget that almost 25% of all primary care consultations are for undifferentiated symptoms and problems.¹⁰ Family physicians are experts in detecting latent, acute, and chronic issues and identifying less common diseases that may be dangerous.¹¹ As McWhinney said, “The recognition of disease in its earlier stages calls for clinical expertise of the highest order.”⁷

The art of prognosis. As Spitzer wrote, “Making the correct diagnosis is useful and important but reaching the correct action decision about a given patient, with attention to prognosis, is the most important yardstick of [family physician] performance.”¹ This ability to predict the potential evolution of symptoms and the gravity of the situation allows us to gauge our interventions, practise watchful waiting, and choose wisely so that the big guns are brought out only when necessary.

The management of uncertainty for community-based care. The management of uncertainty is at the heart of the practice of medicine. But managing uncertainty in the community and at home, where there is more limited availability of resources, is the responsibility of family physicians. Hospitals and emergency departments can no longer be the only answers to potentially unstable situations. It is becoming increasingly necessary to expand our capacity in the community to see patients at the crossroads between primary and acute care.

Complex needs and multimorbidity. In the context of complex needs, it is necessary to offer care that is based on the priorities and objectives identified by patients. Applying a series of practice guidelines does not constitute an appropriate response. Multimorbidity and the high prevalence of concomitant biopsychosocial conditions require the holistic diagnostic and therapeutic approach that characterizes family medicine.

Continuity of care. The continuity of relationships with patients over time, which some refer to as longitudinality,¹² is 1 of the 4 principles of family medicine and contributes to the clinical approach. Without continuity, family medicine would lose some of its effectiveness. It is an invaluable asset that makes it possible to put a new episode into perspective, take the time to wait, and build trust. Continuity goes hand in hand with a wide scope of practice, with versatility, which is the term I prefer to comprehensiveness. It is the breadth of the scope of practice that allows for continuity of care from one episode to the next. However, while continuity and the breadth of the scope of practice should remain at the heart of family medicine, the way they are put into practice should evolve as interprofessional team approaches take on an increasingly substantial role.

Clinical expertise that is needed now more than ever in a changing system

Our clinical expertise will be a highly sought-after value while the evolution of knowledge and technology, and growing inequalities in health care, will result in the management of increasingly more complex issues in the community. It is against this backdrop that most countries have made it a priority to ensure that all citizens are affiliated with a regular source of care close to home, a team that is committed to meeting most of the health care needs while encouraging continuity. This is also what the citizens of Canada want, according to a recent survey.¹³

It is clear that the practice of family medicine is not viable outside of team-based or network-based practice, as proposed by the Patient’s Medical Home vision.¹⁴ But we must re-examine the approach to practising as a team. A substantial number of the people who use our services have less complex health care needs that do not necessarily require medical intervention or the involvement of an entire team.^15,16 One path toward better access to front-line care and more satisfying work would be to redesign our services around client segments with similar health care needs and to optimize the contributions of all the professionals on the team and in the surrounding network.¹⁷ Our clinical experience is key to achieving this reorganization of work; that is, to reimagining continuity of care and ensuring continuity within the team while supporting relational continuity with a responsible provider who is not necessarily the family physician.¹² The results of the pan-Canadian initiative OurCare suggest that Canadians embrace this vision and are ready for team-based care where they would see professionals other than their family physicians.¹³