Jettison the generalist: time to rework general and family practice


n this era of personalized medicine there is nothing general anymore. So why do we persist with terms so wholly inappropriate to the kind of care delivered in the community by doctors? “Family medicine” as a term has the scope to address the newer genetic aspects of our work but still misses out on the bulk of what we do. Is it because continuing, episodic, comorbid personal physicians is a mouthful?

So young doctors are turning away from general and family practice. Is it because the humane rewards for practicing this kind of complexity are just not there? In a more and more rigidly controlled environment, dealing with more than one problem in one patient is far more complicated than merely the presence of two co-occurring diseases within a person. And yet, it is the fundamental basis of general practice eg patients with heart failure are eight times more likely to have chronic obstructive pulmonary disease and cardiac rhythm disturbances than patients without heart failure.

A good start would be a new direction which prioritises people, processes and outcomes not diseases, diagnoses and institutions.

Despite the historical separation of community services from tertiary based care there is a great opportunity to introduce something more workable for all. The first task would be to jettison the reliance on disease to direct how we provide our health care. It just doesn’t work in the community anymore as we have found in mental health.

The uptake of guidelines illuminate the dilemma general practitioners face between adhering to disease-based and standardized treatments whilst still maintaining individual care eg the uptake in general practice of guidance on cancer varies between 20 and 80%.

Disease has moved care too far away from the individual. The personal focus needs to grow as we learn more about the genetic basis of health problems and how to manage them. We already know that the impact of environments both inside the body, as comorbidity, and outside, as toxins are highly individual.

It not an easy task to give up on disease which is a basic tenet of modern medicine but we must. A good start would be a new generic classification which prioritises people, processes and outcomes not diseases, diagnoses and institutions. The colleges of general practice and family medicine could lead the way and WHO support them by supporting a new International classification system fit for purpose in the 21st century.

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