Scholarship-based medicine: teaching tomorrow's generalists why it's time to retire EBM.

Abstract

We need whole-person, generalist medicine, now more than ever.1–3 Yet the dominant model defining quality in medical education and practice — evidence-based medicine (EBM) — has become a barrier to expert generalist practice through its assertion of a hierarchy of knowledge defining best practice.4 EBM was developed as a model for lifelong learning, and later clinical decision making, within the field of specialist medicine.5 It is acknowledged that specialist and generalist medicine are grounded in different models of scientific thinking.1,6,7 They therefore require different approaches; different hierarchies for judging between knowledge and so defining best practice. If we are to revitalise generalist practice, we must retire EBM. To train the next generation of generalists — and indeed to support the current generation — generalists must now assert our own model of best practice in lifelong learning and clinical decision making. We can learn from the successes of the implementation of the EBM movement. There is a need for clear statements of practice, stepped learning tools, and support for training the trainer as well as the trainee, in order to disseminate learning and practice. But we need to redefine quality of practice. I propose the need for a new model of scholarship-based medicine (SBM): a model of practice that places the intellectual task of generalist medicine at the top of a knowledge hierarchy (Box 1). This will redefine quality in practice to support the revitalisation of generalist medicine and reverse the reported decline in person-centred care in the primary care setting,8 …