The nature of generalism

1. Developing the modern generalist for the community setting Kay MohannaPrincipal lecturer in medical education Staffordshire UniversityAssociate Dean for GP assessment West Midlands Deanery

2. The nature of generalism • What is a generalist? • ‘Holism’ in medicine • How does the new GP curriculum support training for generalists?

3. Generalism The ability to care for undifferentiated patients Maybe with vague, multiple or hidden diagnoses

4. 65% of over 65 year olds have two or more conditions • 60% GP presentations ‘MUS’ Not unreal, or unimportant, or insensitive to medical intervention. They are simply ‘diseases without name.’

5. Franz Kafka. A Country Doctor “…To write prescriptions is easy, but to come to an understanding with people is hard…”

6. A ‘high tech’ world Often uses algorithms Imagined diagrams of how the doctor might think, and how the doctor might make choices. They are interesting abstractions. But they do not truly reflect the complex pathways of clinical reasoning required in general practice

7. Increasing likelihood of pathology Breadth of focus of investigation

8. Competence GPs need expertise in excluding the presence of serious disease Specialists need expertise in confirming its presence

9. Balancing risk “…Specialists aim to reduce uncertainty, explore possibility and marginalise error, [the generalist aims] to accept uncertainty, explore probability and marginalise danger…” Marshall Marinker. Bayliss Lecture. RCP, 1994

10. Co-ordinator of care. Specialists: Increasingly expert in ever-diminishing areas of expertise - care can become fragmented. Barriers between sub-specialties grow, healthcare systems can become more inflexible. Generalists: increase communication between and within specialities bringing their wider perspective to the discussion of patient care

11. So what does society want from doctors?

12. “Medicine is not only a science; it is also a healing art. It deals with the very processes of life, which must be understood before they may be guided.” Paracelcus Born 1493 in Einsiedeln, Switzerland • alchemist, physician, astrologer,and occultist

13. Tomorrow’s Doctors… Should show respect for patients and colleagues that encompasses without prejudice, diversity of background and opportunity,language, culture and way of life GMC 1993

14. Tomorrow’s Doctors… Must have a recognition that a blend of scientific and humanitarian approaches is required, involving a critical approach to learning, open-mindedness, compassion and concern for the dignity of the patient GMC 1993

15. In addition…..

17. The thing is… ….medicine is a difficult job

18. “For my entire career I have been convinced that general practice is the hardest specialty to do well, and probably the easiest to do badly. GPs deal in uncertainty all the time—the next patient could have schizophrenia or piles, unhappiness or cardiac arrest, anything and everything, and in no particular order. So the question of which specialty needs the best training … is something of a no-brainer, as our neurology colleagues might say” David Haslam BMJ Career Focus 2005;331:151-152

19. Education…. Facilitates a change in an individual so that she or he may function fully Rogers 1983

20. “Healthcare professionals exercise their judgment based on skills and training, but they are also whole personalities, and quality as perceived by patients is determined by their whole approach. Holism is a two way street - the whole practitioner deals with the whole patient.” Jenkins 1999

21. Domains of learning • Cognitive • Psychomotor • Affective

22. Back to Paracelsus “The universities do not teach all things, so a doctor must seek out old wives, gypsies, sorcerers, wandering tribes, old robbers, and such outlaws and take lessons from them. A doctor must be a traveller... knowledge is experience.”

24. “To be a good doctor you have to be a compassionate chameleon, a shape shifter - a shaman. Even if your adaptation to your patients' world happens at an unconscious level you should always work within their system of ideas, never against it...” Cecil Helman

25. …So how do we reach beyond the ordinary? It's when we create or laugh or are inspired.” Joanna Shipleyhttp://www.shaman.org.uk

26. Poetry has the power to remind us that we are hunters and gatherers of values. That our very solitude and distresses are creditable, in so far as they, too, are an earnest of our veritable human being. Seamus Heaney 1995

27. “It is at the point where medicine and art collide, that doctors can re-attach themselves to the human race and re-feel those emotions which motivate or terrify our patients….Every contact with patients has an ethical and artistic side as well as a technical one.” Fairle J. www.bmj.com rapid response,November 1999

29. 1945 Dr Clarke-Kennedy ‘The Art of Medicine in relation to the progress of human thought’ The art of medicine is unique in that it alone seems to occupy a middle place. Medicine has to deal with human personality and human hopes, human fears and human failings, in conjunction with the material body which is liable to so many disasters in the physical environment of our existence….. so that a purely scientific education is inadequate for a profession which deals with so close a relationship between mind and matter’ ’

30. Pennsylvania State University College of Medicine “There is continuing concern that medical technology, and the need to keep abreast of current scientific developments, threatens to pre-empt medicine’straditional concern for human values.” 1967

31. This concern extends to assessments of learning in medicine too.

32. ‘In our over-eager embrace of the rational, scientific and technological our concept of the learning process itself has been distorted.’ Kolb, D. A. (1984). Experiential learning: experience as the source of learning and development. Cited by David Sales former nMRCGP Convener

33. “Video assessment in GP training risks leading to a gross distortion in learning the consultation process” Mike Deighan Former RCGP Curriculum Fellow

34. Patient – “I’m bordering on serious violence” Doctor – “Are you still taking the hormone tablets?”

35. Doctor – “How are things at home?” Patient – “Okay - We went away for a last ditch attempt to sort things out.” Doctor – “So you’re quite relaxed?”

36. Patient (with headaches) “My husband says I should come up – just in case it’s something different” Doctor – “ What’s your job?”

37. Doctor - “Any problem?” Patient – “Just, Dad died” Doctor – “Any symptoms?”

38. Patient – “I’m going to be redundant in June” Doctor – “Are you all catarrhal?”

39. The most basic skill is the ability to have comfort with uncertainty, to recognise it with humility, to be open to the ever-present possibility of the surprising and the mysterious and even the holy, and meet people there Rachel Reman, oncologist (in Suburban Shaman. Oscar London.)

40. The search for meaning “Living with chronic illness is not simply a physical affair .. it is our ontology, a condition of our being in the world.” R.F. Murphy, The Body Silent. (New York: Henry Holt, 1987.)

41. John McCann University of Windsor, CanadaLiving with chronic illness: subjective contributions toward a patient- centered ethic 1999 “Nothing so concentrates experience and clarifies the central conditions of living as serious illness. The study of the process by which meaning is created in illness brings us into the everyday reality of individuals like ourselves, who must deal with the exigent life circumstances created by suffering, disability, difficult loss, and the threat of death. Yes, chronic illness teaches us about death; but the process of mourning for losses is also central to healing”

42. Personal loss

43. Medical Humanities We define the term "medical humanities" broadly to include an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, personal narrative, psychology, sociology), and the arts (literature, theatre, film, and visual arts) and their application to medical education and practice. Literature, Arts & Medicine Database http://medhum.med.nyu.edu

44. Pennsylvania State University college of Medicine The Healing Arts Centre www.hmc.psu.edu/humanities The healing arts centre

45. www.ravenhousearts.com Blooming Soul: Lynda Hoffman-Snodgrass

46. The MAP Foundation Using the creative arts to express and communicate complex and painful issues relating to serious illness and dying Picture10.jpg http://www.mapfoundation.org

47. Michele Petrone “The illness stole a place and a time that should have been destined for better things.”

48. This illness has invaded my life, knocked me off balance and made me feel out of control. I no longer feel the strength and direction I once had, I'm just a passive passenger, being carried whichever way these arms take me. But I still feel a need to direct my life, to feel this life of mine is still mine, so please: "carry me this way". 

49. “I need to know that this body is my body. And I need to know everything that is happening to my body. But most of all I need to know that you know that within my body there is me.”

50. “The physical illness is visible and life threatening. The emotional feelings, the electrical impulses of my soul, cannot be seen. As they are invisible it is easy to pretend that they are not really there. They don't at first seem to be as important as the cancer on the microscope slide. Yet they can be just as life threatening as the visible cancer itself.”