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Supplement: The Future of Generalism in Medicine |

The Future of Generalism in Medicine FREE

Eric B. Larson, MD, MPH; Kevin Grumbach, MD; and Kenneth B. Roberts, MD
[+] Article and Author Information

From Group Health Cooperative, Seattle, Washington; University of California, San Francisco, San Francisco, California; and University of North Carolina School of Medicine, Chapel Hill, North Carolina.


Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Eric B. Larson, MD, MPH, Group Health Cooperative, Center for Health Studies, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1448; e-mail, larson.e@ghc.org.

Addresses: Dr. Larson: Group Health Cooperative, Center for Health Studies, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1448.

Dr. Grumbach: Department of Family and Community Medicine, Family and Community Medicine, San Francisco General Hospital, Ward 83, 1001 Potrero Avenue, San Francisco, CA 94110.

Dr. Roberts: Pediatric Teaching Program, Moses Cone Health System, 1200 North Elm Street, Greensboro, NC 27401.


Ann Intern Med. 2005;142(8):689-690. doi:10.7326/0003-4819-142-8-200504190-00036
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What is the future of generalism in medicine? There was a time when financial analysts predicted that 90% of U.S. health care would be organized as managed care built on a primary care, generalist model (1). In the wake of these predictions, residency positions in family medicine and other generalist disciplines grew rapidly. Hospitals and health systems bought or built practices and added so-called primary care capacity to their operations (2).

Today, however, the intellectual stratosphere and, more important, the medical marketplace resound with a very different language. Recent publications about generalism are resplendent with words like “crisis” (3), “distress” (4), “dissolution, disillusion” (5), “crossroads” (6), “prosperity and despair” (7), and “reconstruction, renewal, and renaissance” (8). The authors seem preoccupied with the notion that the generalist fields, while offering great value, need to change or may not survive (36, 9).

The picture is also grim for many generalist physicians and patients in the world of medical practice. The cost of care and the number of persons without health insurance continue to rise, creating obstacles to patients' receipt of recommended care. Now, we also know that more care is not necessarily better—in fact, when care is fragmented and probably redundant, more care may be worse (1011). In the meantime, generalist primary care physicians, while remaining committed to providing high-quality patient care, are struggling. Individual practitioners struggle with low reimbursement for their services, administrative burdens always seem to increase, and inflexible appointment schedules and brief visits satisfy neither patient nor provider (1213). Following a decade of increasing interest in generalist residency training, applications to residency programs designed specifically to produce generalists have fallen off dramatically (14).

An ever-increasing evidence base indicates that care organized around generalist primary care is the best (15). Despite challenging market forces that make it difficult for generalist physicians to practice the best possible care (2), large and small groups of talented providers, often organized into effective teams, continue to deliver comprehensive, generalist care. Thoughtful individuals devote considerable intellectual energy reviewing published scientific papers and commentary to find examples of generalist care that meets patient expectations and yields good outcomes. Others work on demonstrations and proposing solutions (4, 89, 1617) that suggest answers to the question “Whither generalism in medicine, whither primary care?” The answers could lead to ways to improve and deliver more nearly ideal care to all Americans.

This supplement contains examples of intellectual energy devoted to proposing solutions. In the fall of 2003, the Robert Wood Johnson Generalist Physician Faculty Scholars program (1819), a program designed to promote academic development of talented junior faculty in generalist disciplines, asked current and past scholars and its National Advisory Committee to develop a series of white papers addressing different aspects of the future of generalism and ways to improve and deliver ideal primary care to all Americans. Ten groups of scholars, with each group including at least 1 family physician, general internist, general pediatrician, and senior advisory board member, developed proposals that were presented and critiqued at an annual meeting. Ultimately, 9 of these presentations became papers. The topics that emerged were not too surprising, ranging from generalist research to student interest in generalism to a variety of approaches to develop better systems, improve coordination, move to more “ideal” primary care, and develop more integrated “whole-patient” care.

This supplement contains the 4 papers that we, the supplement editors, believed best addressed the question “What is the future of generalism in medicine?” These papers address some of the critical elements that are widely recognized as necessary to produce more ideal care: integration (20), coordination (21), and the need for effective communication to achieve whole-person care (22). The fourth paper focuses on the challenge of creating a system of health care practice and medical education that works to make primary care specialties more attractive to students “short of a major overhaul of economic incentives in favor of generalist careers” (23).

A system based in primary, generalist physician practice is arguably the ideal system (15)—whether it is based in a large health care system or in smaller offices and networks. Indeed, primary medical care is essential, and patients want it (24). The papers in this supplement are noteworthy because they offer perspectives on the future of generalism in medicine from persons representing all 3 major primary care disciplines. Their perspective is idealistic and aspirational. In general, the articles contain suggestions that are reasonable ways to work within the existing system of care. They do not suggest changes that are simply not feasible given today's political climate. The papers are particularly timely today, and they provide a welcome response to the need for innovative thinking and constructive policy formulation to help ensure high-quality care for the public by preserving and enhancing generalist practice.

References

Abramowitz KS.  The Future of Health Care Delivery in America. New York: Bernstein Research, Sanford C. Bernstein; 1993.
 
Larson EB.  Medicine as a profession—back to basics: preserving the physician-patient relationship in a challenging medical marketplace. Am J Med. 2003; 114:168-72. PubMed
CrossRef
 
Moore G, Showstack J.  Primary care medicine in crisis: toward reconstruction and renewal. Ann Intern Med. 2003; 138:244-7. PubMed
 
Martin JC, Avant RF, Bowman MA, Bucholtz JR, Dickinson JR, Evans KL. et al.  The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004; 2:Suppl 1S3-32. PubMed
 
Sandy LG, Schroeder SA.  Primary care in a new era: disillusion and dissolution? Ann Intern Med. 2003; 138:262-7. PubMed
 
Schroeder SA.  Primary care at a crossroads. Acad Med. 2002; 77:767-73. PubMed
 
Larson EB.  General internal medicine at the crossroads of prosperity and despair: caring for patients with chronic diseases in an aging society. Ann Intern Med. 2001; 134:997-1000. PubMed
 
Showstack J, Lurie N, Larson EB, Rothman AA, Hassmiller S.  Primary care: the next renaissance. Ann Intern Med. 2003; 138:268-72. PubMed
 
Larson EB, Fihn SD, Kirk LM, Levinson W, Loge RV, Reynolds E. et al.  The future of general internal medicine. Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. J Gen Intern Med. 2004; 19:69-77. PubMed
 
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL.  The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003; 138:273-87. PubMed
 
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL.  The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003; 138:288-98. PubMed
 
Larson EB.  Health care system chaos should spur innovation: summary of a report of the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine. Ann Intern Med. 2004; 140:639-43. PubMed
 
Anderson GF.  Physician, public, and policymaker perspectives on chronic conditions. Arch Intern Med. 2003; 163:437-42. PubMed
 
Whitcomb ME.  Primary care medicine in the United States: where are we headed? [Editorial]. Acad Med. 2002; 77:759-60. PubMed
 
Starfield B.  Is primary care essential? Lancet. 1994; 344:1129-33. PubMed
 
Grumbach K, Bodenheimer T.  A primary care home for Americans: putting the house in order. JAMA. 2002; 288:889-93. PubMed
 
Rothman AA, Wagner EH.  Chronic illness management in primary care. Showstack J, Rothman AA, Hussmiller SB The Future of Primary Care. San Francisco: Jossey-Bass; 2004; 180-202.
 
Colwill JM, Perkoff GT, Blake RL Jr, Paden C, Beachler M.  Modifying the culture of medical education: the first three years of the RWJ Generalist Physician Initiative. Acad Med. 1997; 72:745-53. PubMed
 
Robert Wood Johnson Foundation: Generalist Physician Initiative National Program Report. Last updated July 2003. Accessed athttp://www.rwjf.org/report/npreports/gpi.htmon 1 July 2004.
 
Ferrer RL, Hambidge S, Maly R.  The essential role of generalists in health care systems. Ann Intern Med. 2005; 142:691-9.
 
Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG.  Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med. 2005; 142:700-8.
 
Weiner SJ, Barnet B, Cheng TL, Daaleman TP.  Processes for effective communication in primary care. Ann Intern Med. 2005; 142:709-14.
 
Schwartz MD, Basco WT Jr, Grey MR, Elmore JG, Rubenstein A.  Rekindling student interest in generalist careers. Ann Intern Med. 2005; 142:715-24.
 
Safran DG.  Defining the future of primary care: what can we learn from patients? Ann Intern Med. 2003; 138:248-55. PubMed
 

Figures

Tables

References

Abramowitz KS.  The Future of Health Care Delivery in America. New York: Bernstein Research, Sanford C. Bernstein; 1993.
 
Larson EB.  Medicine as a profession—back to basics: preserving the physician-patient relationship in a challenging medical marketplace. Am J Med. 2003; 114:168-72. PubMed
CrossRef
 
Moore G, Showstack J.  Primary care medicine in crisis: toward reconstruction and renewal. Ann Intern Med. 2003; 138:244-7. PubMed
 
Martin JC, Avant RF, Bowman MA, Bucholtz JR, Dickinson JR, Evans KL. et al.  The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004; 2:Suppl 1S3-32. PubMed
 
Sandy LG, Schroeder SA.  Primary care in a new era: disillusion and dissolution? Ann Intern Med. 2003; 138:262-7. PubMed
 
Schroeder SA.  Primary care at a crossroads. Acad Med. 2002; 77:767-73. PubMed
 
Larson EB.  General internal medicine at the crossroads of prosperity and despair: caring for patients with chronic diseases in an aging society. Ann Intern Med. 2001; 134:997-1000. PubMed
 
Showstack J, Lurie N, Larson EB, Rothman AA, Hassmiller S.  Primary care: the next renaissance. Ann Intern Med. 2003; 138:268-72. PubMed
 
Larson EB, Fihn SD, Kirk LM, Levinson W, Loge RV, Reynolds E. et al.  The future of general internal medicine. Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. J Gen Intern Med. 2004; 19:69-77. PubMed
 
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL.  The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003; 138:273-87. PubMed
 
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL.  The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003; 138:288-98. PubMed
 
Larson EB.  Health care system chaos should spur innovation: summary of a report of the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine. Ann Intern Med. 2004; 140:639-43. PubMed
 
Anderson GF.  Physician, public, and policymaker perspectives on chronic conditions. Arch Intern Med. 2003; 163:437-42. PubMed
 
Whitcomb ME.  Primary care medicine in the United States: where are we headed? [Editorial]. Acad Med. 2002; 77:759-60. PubMed
 
Starfield B.  Is primary care essential? Lancet. 1994; 344:1129-33. PubMed
 
Grumbach K, Bodenheimer T.  A primary care home for Americans: putting the house in order. JAMA. 2002; 288:889-93. PubMed
 
Rothman AA, Wagner EH.  Chronic illness management in primary care. Showstack J, Rothman AA, Hussmiller SB The Future of Primary Care. San Francisco: Jossey-Bass; 2004; 180-202.
 
Colwill JM, Perkoff GT, Blake RL Jr, Paden C, Beachler M.  Modifying the culture of medical education: the first three years of the RWJ Generalist Physician Initiative. Acad Med. 1997; 72:745-53. PubMed
 
Robert Wood Johnson Foundation: Generalist Physician Initiative National Program Report. Last updated July 2003. Accessed athttp://www.rwjf.org/report/npreports/gpi.htmon 1 July 2004.
 
Ferrer RL, Hambidge S, Maly R.  The essential role of generalists in health care systems. Ann Intern Med. 2005; 142:691-9.
 
Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG.  Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med. 2005; 142:700-8.
 
Weiner SJ, Barnet B, Cheng TL, Daaleman TP.  Processes for effective communication in primary care. Ann Intern Med. 2005; 142:709-14.
 
Schwartz MD, Basco WT Jr, Grey MR, Elmore JG, Rubenstein A.  Rekindling student interest in generalist careers. Ann Intern Med. 2005; 142:715-24.
 
Safran DG.  Defining the future of primary care: what can we learn from patients? Ann Intern Med. 2003; 138:248-55. PubMed
 

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