four - Generalists and specialists

Summary

Internationally, most people expect successful doctors to be specialists. If you have to admit to being just a GP, they think you must either have fallen off the bottom rung of the ladder of ambition, or never even reached it.

I was a Glyncorrwgologist, the only one in the world. I knew more, did more, and certainly wrote and spoke more about the health problems of Glyncorrwg, than any other doctor. So I became the world expert, a specialist in at least the initial recognition, and often the terminal management, of the entire potential range of health problems in that unique community. I was a broadly informed person able to reassemble into a comprehensible story what an ever-increasing variety of disease-specific specialists had divided. What higher ambition could any doctor have?

Assumptions that community-based generalists are less trained, less skilled, less knowledgeable or less useful than hospital-based specialists rest on apparently logical foundations. If GPs really were generalists, so the conventional argument goes, they would have to know everything. But nobody can know everything. So generalists are bound to fail, and might as well stop trying.

In fact, the existence of effective generalists is a precondition for the existence of effective specialists.And paradoxically, to be effective, GPs have themselves to become specialists, but of a different kind – specialists in their own locality and population, specialists in general responsibility for initial, continuing and terminal care strategies over lifetimes, and for the huge, still under-explored territory between the outer limits of health and fully formed end-stage disease.

To get full value from expert specialists who know more and more about less and less, we need expert generalists who can still see the whole picture, from a standpoint closer to patients, but very much better informed than patients are about what is either possible or probable. Our need for such generalists increases, as specialised divisions of practice multiply. The functions of these generalists must be redefined, from the GPs of the past, who had to cope somehow with whatever chance threw at them, to the resident human biologists of the future.

To get from where we are to where we need to go, British doctors need to understand where British GPs came from – and the same goes for the very different professional histories of other countries.