Expert Generalist Research Articles

Primary care transformation in Scotland: a qualitative evaluation of the views of patients.

The new Scottish GP contract introduced in April 2018 aims to improve quality of care through expansion of the multidisciplinary team (MDT) to enable GPs to spend more time as expert medical generalists with patients with complex needs. To explore patients' views on the changes in general practice in Scotland since the inception of the new contract. Qualitative study with 30 patients (10 living in urban deprived areas, 10 living in urban affluent/mixed urban areas, and 10 living in remote and rural areas). In-depth semi-structured interviews with thematic analysis. Patients were generally unaware of the new GP contract, attributing recent changes in general practice to the COVID-19 pandemic. Ongoing concerns included access to GP consultations (especially face-to-face ones), short consultation length with GPs, and damage to continuity of care and the GP-patient relationship. Most patients spoke positively about consultations with MDT staff but still wanted to see a known GP for health concerns that they considered potentially serious. These issues were especially concerning for patients with multiple complex problems, particularly those from deprived areas. Following the introduction of the new Scottish GP contract, patients in this study's sample were accepting of first contact care from the MDT but still wanted continuity of care and longer face-to-face consultations with GPs. These findings suggest that the expert generalist role of the GP is not being adequately supported by the new contract, especially in deprived areas, though further quantitative research is required to confirm this.

A case study of the impact of a dietitian in the multi-disciplinary team within primary care: a service evaluation.

Expanding the primary care workforce to alleviate general practitioner (GP) workload, improve access and improve quality of care is a current UK strategy. Evidence suggests dietitians can improve patient outcomes and make cost savings. The present study aimed to evaluate a dietitian working as an expert generalist and first contact practitioner (FCP) in a general practice multi-disciplinary team (MDT) to provide appropriate care to patients and reduce GP workload. A dietitian was employed for 6 months at 0.6 full-time equivalents in a group of general practices in Devon, UK. Data were collected on the referral source, patient satisfaction, health outcomes and changes in prescribing data for all patients seen by the dietitian. Focus groups and interviews provided data to understand the experience of introducing a dietitian into the team. This model of service delivery showed the dietitian acting as an expert generalist, a FCP and able to educate the MDT. A range of professionals within the MDT referred patients with a wide range of diagnoses (both paediatric and adults) and the dietitian acted as a FCP for 29% of patients. Saving were made for the optimisation of medicine management. The dietitian can improve patient-centred care for several patient groups; enhance learning for staff around nutrition and dietary issues; and contribute to more efficient working and cost savings around prescription of nutritional products. This was an evaluation of one service and further research is needed to understand the value dietitians can contribute and the factors supporting effective and efficient working in this context.

The family physician as a primary care consultant - the Mossel Bay experience.

The South African family physician (FP) is an expert generalist who has a number of roles to strengthen the district health system. A research study on FPs in district hospitals has previously demonstrated an impact; however, more evidence on impact in primary health care (PHC) is needed. By serving as a consultant for the PHC team, the FP may improve access to care, capacitate team members, enhance comprehensiveness of care, and improve coordination and continuity of care. This report narrates the story of how one of the FPs at a rural district hospital recorded his experience of being a consultant to the PHC team and was able to self-audit the experience. A self-designed audit tool analysed 1000 patient consultations with the FP and enabled a reflection on the coronavirus disease 2019 (COVID-19)-related changes to the consultant role. There was a clear need for FPs to consult patients with complex multi-morbidity and multifaceted psychosocial aspects to their illness, in consultation with their team members. Patients were referred to them by medical officers, other specialists, family medicine registrars, allied healthcare professionals and nurse practitioners. The FP’s ability to strengthen the PHC service outside the district hospital may be enhanced by creating more FP posts at a subdistrict level to support high-quality, team-based primary care in line with the PHC policy directions.

Perspectives on expert generalist practice among Japanese family doctor educators: a qualitative study.

BackgroundExpert generalist practice (EGP) is increasingly being viewed as the defining expertise of generalist care. In Japan, several prominent family doctors consider it important and relevant in the Japanese context. However, no study has examined Japanese family doctor educators’ perceptions of EGP.AimTo explore Japanese family doctor educators’ perceptions of EGP.Design & settingA qualitative study among family doctor educators in Japan.MethodFocus group interviews were conducted using a semi-structured interview guide following a short lecture on EGP. A qualitative description method was adopted and the framework method was used to conduct thematic analysis.ResultsParticipants were 18 family medicine doctor educators, including 11 directors and six associate directors of family medicine training programmes. The results suggested that the concept of EGP was important and applicable to primary care in Japan. Participants’ perceptions on EGP pertained to the following four areas: impact of EGP, triggers for EGP, enablers for EGP, and educational strategies for EGP.ConclusionThe concept of EGP may be useful in clinical practice in Japan, especially in complex patient care. A clearer framework for or description of EGP, and of non-traditional methods, such as ascetic practice and awareness of the self, were proposed as possible educational strategies.

What influences nurses' decisions to work in rural and remote settings? A systematic review and meta-synthesis of qualitative research.

Due to global nursing shortages, recruitment and retention of nurses is a major international concern, exacerbated in rural and remote areas. Existing research reveals that individual factors influence healthcare professionals' decision making to work in rural and remote settings. However, existing evidence does not fully consider the multiple influences that may impact nurses' decisions to remain or leave rural and remote areas. This limits the effectiveness of recruitment and retention strategies. The objectives of this study were to explore the influences on nurses' decisions to work in rural and remote healthcare settings, using a systematic review and thematic meta-synthesis of qualitative studies. Databases Medline, Journals@OVID Full text, PsycInfo and specialist journals were searched from January 1990 to January 2020. Inclusion criteria were applied to all records by two independent reviewers. The Critical Appraisal Skills Programme checklist for qualitative studies was used for independent quality critique by two reviewers. Thematic synthesis was conducted using a three step process: (1) the results sections of each article were extracted and inductively coded line by line; (2) master themes and subthemes were organised into tables; (3) relationships between the themes were identified and examined to develop an overarching analytical framework. A total of 121 articles were screened and 40 were included for data extraction and thematic synthesis. Thematic analysis identified three interrelated dimensions that influenced nurses' retention and migration decision-making, namely 'person/al', 'profession/al' and 'place' with 18 inter-related domains. The 'person/al' dimension contained five domains: a sense of belonging/connectedness, knowledge of rural culture, blurring of personal and professional lives, anonymity and job satisfaction/stress. The 'profession/al' dimension contained eight domains: expert generalist, advanced nurse practitioner, professional isolation, mentorship, education, autonomy and empowerment, role conflict, and recruitment and retention. The 'place' dimension identified five domains: terrain and weather, fewer resources, geographical isolation, safety and rural culture. The data informed the development of the MacKay's 3P (person/al, profession/al and place) model to capture the complex phenomenon of the influences on nurses' decision making to work in rural and remote settings. Multiple dimensions and domains influence nurses' decision making to work in rural and remote settings. MacKay's 3P model provides a theoretical framework to explore the complex interplay between the person/al, profession/al and place-related dimensions of rural nursing. These findings can inform the development of future recruitment and retention initiatives.

Expert Characteristics: Implications for Expert Systems.

While expert systems are artificial intelligence (AI) agents, they share many common characteristics with human experts. As technology progresses, such systems are not just able to make simple decisions following "simplistic" linear logical protocols; they "behave" as real experts in at least two ways: by demonstrating superb decision-making skills and by conforming to the social norms for expertise, i.e., they "feel" as human experts. A review of the common characteristics of human experts may have important implications for the direction of the development for such systems. Implications for bioinformatics and future research (especially concerning the accompanying concept of "expert generalist") are also discussed.

TOWARDS THE MODEL OF CONTRIBUTORY EXPERT GENERALISTS

The study of expertise has focused on the concept of specialization and specialists, both from a sociological and a biological perspective. It has been taken for granted that expertise concerns only specialization; even an individual characterized as a “polymath” or homo universalis is considered to be an expert specialist in many fields. Can expert specialists in many fields exist today? This question is deceitful or irrelevant since it cannot accommodate the concept of individuals who are neither specialists nor “poly-specialists”, but have knowledge of a different level: not analytic, but, rather, synthetic and abstract stemming out from general surveillance, not from specific experience. Here, a new type of expert is proposed: a contributory expert generalist. Their necessity stems from the methodology of epistēmē proper. Their characteristics will be identified and discussed, some empirical examples will be given and their expert status is going to be discussed using various theoretical approaches on expertise, namely SEA, SEE and STS (Science of Exceptional Achievement, Study of Expertise and Experience, Science Technology and Society).

Avoiding harm: Tackling problematic polypharmacy through strengthening expert generalist practice.

Problematic polypharmacy is a growing challenge. Medication that is intended to improve patients' health and wellbeing is instead becoming part of the problem. The way we practice medicine has become a driver for the problem. Dealing with the challenge will need us to think differently about how we do clinical care. A 2013 Kings Fund report stated that tackling problematic polypharmacy requires us to actively build a principle of compromise into the way we use medicines. There are implications for how we consult and make decisions with patients, in how we design health practice and systems to support that decision making, and, in our understanding of the process of research, how we generate the knowledge that informs practice. This review considers the current state of play in all 3 areas and identifies some of the work we still need to do in order to generate the practice-based evidence needed to tackle this most challenging problem. Finding a way to redesign practice to address problematic polypharmacy could offer a template for tackling other related complex issues facing medical practice such as multimorbidity, chronic pain and complex mental health.

The expert medical generalist.

The proposed new Scottish GP contract1 has suggested that GPs be considered ‘expert medical generalists’ (EMGs). Helen Stokes-Lampard, Chair of the Royal College of General Practitioners (RCGP), has named GPs ‘consultants in general practice’.2 These new titles beg the question of whether they are granted simply for the completion of vocational training involving 18 months in the field in which we are experts, after a total of 3 years’ training post-foundation, or whether there is more involved in developing this expertise. Much importance has been placed on the regard with which general practice is held within universities and hospitals, and its effect on GP recruitment, and so it is likely that unfavourable comparisons will be drawn between the experience and training required to become a consultant in general practice and a consultant in anything else. Although not based on any evidence, Malcolm Gladwell’s 10 000-hour expert theory,3 representing as it does about 5 years of full-time general practice, would, nonetheless, accord with the time at which many of us begin to feel that we have obtained some mastery of our subject. Gladwell’s theory, however, does not simply mean working at the job for 10 000 hours but practising, that is, actively pursuing improvement in order to become expert. This aspect bears some closer consideration. Reeve et al 4 describe three different views of the GP role and suggest that there are …

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

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 …

The role of the district nurse in Northern Ireland.

A district nurse is an expert generalist practitioner who uses advanced clinical skills and knowledge to fulfil an ever-evolving role. The district nurse is accountable for the care planning, coordination and management of people with multi-faceted and intricate health care needs. In addition, an interprofessional approach to health and social care is required to enable the district nurse to co-ordinate care and enable patients to be cared for and remain within their homes. As the demand on primary and community services increases, care is further enriched by working in partnership with families, carers and voluntary service providers. The nurse patient relationship is the founding component for person-centred, holistic care. Through holistic assessment and shared decision making, co-produced care planning permits people to fundamentally take ownership of their health and enhances formal care provision. This case study reflects the role of the district nurse in Northern Ireland, through comprehensive assessment in clinical practice and highlights how a therapeutic relationship, being centred on the patient and shared decision-making impact positively on the care process.

Patents, Disclosure, and Biopiracy

One of the core requirements of patentability is that patent applicants provide background and contextual information about their invention to the patent office. This disclosure is expected to allow a patent examiner to ensure that the application meets patentability standards. However, because of the information asymmetry between expert patent applicants and generalist patent examiners, applicants can withhold useful information while still receiving the benefits of exclusive patent rights. While this is a problem in the patent system in general, the challenge is even worse in a subset of inventions. The information asymmetry is more pronounced in cases of inventions that rely on the genetic resource or traditional knowledge (TK) of indigenous peoples and local communities in their research. A good example is the practice of using traditional medicinal knowledge as research leads to develop modern drugs. Aspirin is one of the drugs developed out of traditional practices. A core question in these situations is whether patent applicants that rely on TK to develop their invention are required to disclose such information to the patent examiner. Reports of multiple instances show that patent applicants usually withhold information about their reliance on TK in their inventive process. As a result, they may claim exclusive property rights over what source communities have been practicing for generations. In reaction to the lack of recognition of their contribution, source communities are adopting a protectionist trend by creating restrictions on access to their resources. This Article argues that the introduction of an explicit requirement in U.S. patent law, compelling patent applicants to disclose their use of TK, can create an efficient patent system and sustainable relationships in the relevant industries. It provides two justifications for the amendment of U.S. patent law. First, the Article makes a normative case for conceiving the disclosure of origin requirement as an information-forcing rule. Imposing an obligation to disclose the source of TK would elicit socially beneficial information about the validity and scope of a claimed application from the low-cost providers—patent applicants—thereby creating a more efficient patent system. Second, the Article argues that an explicit and enforceable disclosure requirement would reverse the inefficient and troubling protectionist trend by facilitating the tracking and enforcement of obligations that researchers may have in contracts with source communities or domestic laws of source countries. The requirement will create confidence in the patent system and encourage source communities to facilitate access to TK. The Article uses efficiency and social-welfare perspectives in contrast to the equity and distributive justice justifications dominating the literature. The focus of this Article on domestic U.S. law is another point of contrast to the focus of the literature on international law.

Chronic obstructive pulmonary disease and comorbidities: a large cross-sectional study in primary care.

Chronic obstructive pulmonary disease (COPD) is common, and a major cause of morbidity and mortality worldwide. Recent studies suggest that comorbidities of COPD increase the risk of hospitalisation, polypharmacy, and mortality, but their estimated prevalence varies widely in the literature. To evaluate the prevalence of 38 physical and mental health comorbidities in people with COPD, and compare findings with those for people without COPD in a large nationally representative dataset. A cross-sectional data analysis on 1 272 685 adults in Scotland from 314 primary care practices. Data on COPD, along with 31 physical and seven mental health comorbidities, were extracted. The prevalence of comorbidities was compared between people who did, and did not, have COPD, standardised by age, sex, and socioeconomic deprivation. From the total sample, 51 928 patients had COPD (4.1%). Of these, 86.0% had at least one comorbidity, compared with 48.9% of people without COPD. Of those with COPD, 22.3% had ≥5 comorbid conditions compared with 4.9% of those who did not have COPD (adjusted odds ratio 2.63, 95% confidence interval = 2.56 to 2.70). In total, 29 of the 31 physical conditions and six of the seven mental health conditions were statistically significantly more prevalent in people who had COPD than those who did not. Patients with COPD have extensive associated comorbidities. There is a real need for guidelines and health care to reflect this complexity, including how to detect those common comorbidities that relate to both physical and mental health, and how best to manage them. Primary care, which is unique in terms of offering expert generalist care, is best placed to provide this integrated approach.

Health promotion and screening for people with an intellectual disability

People with intellectual disability have significantly worse health than those without, and have a higher level of complex health needs. The life expectancy for men and women is 13 and 20 years shorter, respectively, than the general population. The increasing role of general practice in delivering and coordinating care across health and social care settings requires expert generalist skills to implement an integrated approach to care. This article explores how general practice can improve the health of people with intellectual disability, by making reasonable adjustments within health promotion, disease prevention, screening and detection.

From expert generalists to ambiguity masters: using ambiguity tolerance theory to redefine the practice of rural nurses.

To redefine the practice of rural nurses and describe a model that conceptualises the capabilities and characteristics required in the rural environment. The way in which the practice of rural nurses has been conceptualised is problematic. Definitions of rural nursing have been identified primarily through the functional context of rural health service delivery. The expert generalist term has provided a foundation theory for rural nurses with understandings informed by the scope of practice needed to meet service delivery requirements. However, authors exploring intrinsic characteristics of rural nurses have challenged this definition, as it does not adequately address the deeper, intangible complexities of practice required in the rural context. Despite this discourse, an alternative way to articulate the distinctive nature of rural nursing practice has eluded authors in Australia and internationally. A theoretical paper based on primary research. The development of the model was informed by the findings of a study that explored the nursing practice of managing telephone presentations in rural health services in Victoria, Australia. The study involved policy review from State and Federal governments, nursing and medical professional bodies, and five rural health services; semi-structured interviews with eight Directors of Nursing, seven registered nurses and focus group interviews with eight registered nurses. An ambiguity tolerance model drawn from corporate global entrepreneurship theory was adapted to explain the findings of the study. The adapted model presents capabilities and characteristics used by nurses to successfully manage the ambiguity of providing care in the rural context. Redefining the practice of rural nurses, through an adapted theory of ambiguity tolerance, highlights nursing characteristics and capabilities required in the rural context. This perspective offers new ways of thinking about the work of rural nurses, rural nurse policy, education, recruitment, retention and clinical governance. A greater understanding of rural nurse practice will assist in achieving positive care outcomes in an environment with competing stakeholder needs, and limited resources and options for care.

Carlo Catani and Alexandra Avenue: The Making of a European Promenade in Colonial Melbourne

Alexandra Avenue, designed by Florentine immigrant Carlo Catani, was declared open in 1901 in Melbourne by the Duke and Duchess of York, as part of the celebrations marking the Federation of Australia. The ornamental boulevard was an object of wonder. Following the European tradition, counter to English ideas of propriety, it was to be a promenade where people would go to see and be seen. In the mould of American landscape architect Frederick Law Olmsted, Catani was an expert generalist, responsible for a wide range of landscape and engineering projects in Victoria, on whom little scholarship exists. The Avenue greatly influenced street aesthetics in inner Melbourne and was later used as an exemplar of urban streetscape at the inaugural Australian Town Planning Conference in 1918. It provides an insight into how urban landscapes were formed before specialist planners and demonstrates the way in which colonial cities such as Melbourne created an identity through their public spaces. This article enriches current scholarship on Catani – a significant influence on the city of Melbourne at the turn of last century.

An expert generalist.

Although he has never actively pursued any special interest within veterinary practice, Robin Hargreaves explains why he believes ‘expert generalists’ are essential to the animals that are at the heart of the communities they serve

Supporting expert generalist practice: the SAGE consultation model.

Consultation models are core to GP training. Current models provide an excellent basis for sharing the key elements needed for safe and effective consultations in a front-line, first-contact setting: where any problem can walk through the door, and where the consultation is an integral part of a therapeutic relationship. They support an all-rounder view of the generalist. But the ‘expert generalist’ is more than an all-rounder: someone who knows a little bit about a lot of things, and is able to navigate a patient through multiple protocols and disease pathways.1 Rather, the distinct expertise of the generalist is in providing personalised illness care.1 We know from patients that individually-tailored care requires more than just good personal care; it requires good communication skills and empathy.2 It also needs personalised decision making;3 that is, the interpretive practice which goes beyond the application of guideline(s) to this individual, to the co-creation of a new, individualised explanation of illness experience. GPs have told us their training has not developed skills and/or confidence in individually-tailored decision making; in going beyond a protocol.4 Existing consultation models do not pay enough attention to the specific practice of individually-tailored decision making. The School for Advancing Generalist Expertise (SAGE) is an international collaboration that aims to support the development and delivery of generalist solutions to complex problems. The group has previously described the principles underpinning interpretive generalist practice and how it differs from other approaches. We have been working with GPs to understand and address whole-system barriers and enablers to expert generalist practice (EGP).4 GPs have consistently identified extended consultation skills as one area of need.4 Colleagues have highlighted …

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions

ObjectivesProvision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role.DesignQualitative study in General Practice.SettingUK primary care.Main outcome measuresA qualitative study – interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory.Design and settingQualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory.ParticipantsUK based GPs (interview and surveys); European GP trainees (focus groups).ResultsOur findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP.ConclusionsWe describe four areas for change: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role.

Dismantling Lord Moran’s ladder: the primary care expert generalist

> ‘It’s not a choice for me to be a generalist. I would have liked to have done something more.’ (Early career doctor)1 It is over 50 years since Lord Moran suggested that GPs were doctors who have fallen off the specialist ladder.2 Then, two-thirds of early career GPs would have preferred to have been specialists.2 Today Lord Moran’s ladder lives on. General practice is still not a first career choice for many graduates, certainly not enough to sustain the workforce we need.3 Our conversations with early career medics reveal that they value the opportunities for flexible working within general practice. But also that they want ‘something more’ than the GP role: notably, opportunities to develop ‘special interests’. We suggest this represents a failure to recognise, or value, the specific expertise of the GP role itself; and in particular a misunderstanding of the primary care expert generalist approach. We start by considering what we understand by the expert generalist. The role is defined by two elements. First, a principle of personalised decision making which recognises health as a resource for …