Medical Generalists Research Articles

The tip of the iceberg: Generalism in undergraduate medical education, a systems thinking analysis.

There is a shortage of generalist physicians globally impacting health equity and access to care. An important way in which medical schools can demonstrate social accountability is by graduating learners interested in careers in generalism. While generalism is endorsed as a matter of principle in medical education, how this translates into curricula is less clear. The aim of this study was to identify how generalism is understood and supported by family physician educational leaders in undergraduate medical education (UME) in Canada. We conducted a qualitative study, interviewing 38 family medicine leaders in UME across all 17 Canadian medical schools. We examined the data with template analysis, informed by the iceberg model of systems thinking. Four themes were identified: (1) Teaching and learning strategies in support of generalism-a consistent range existed across UME curricula; (2) Curriculum patterns-changes in leadership and curriculum reform created positive or negative feedback loops that promoted or hindered initiatives to support generalism; (3) Curriculum structures-organ-system-based curricula and availability of generalist faculty presented particular challenges to teaching generalist approaches; (4) Mental models and ways of knowing-the preponderance of biomedical frameworks of thinking in curricula unconsciously undermined generalist approaches to patient care. UME programmes promoted generalism through a range of teaching activities and strategies, but these efforts were countered by curriculum structures and mental models that perpetuate epistemic inequity between biomedical approaches to medical education and generalist models of care. Novel curricular frameworks are needed to align undergraduate programmes' commitment to social accountability with community-based need.

Doctors managing mutual funds: Returns to specialization in asset management

We investigate the returns to specialized knowledge in asset management by comparing the performance of medical specialists versus generalists in managing healthcare sector mutual funds. Specialist alpha is 5% higher on an annualized basis. This result is robust to controlling for other observable characteristics and using different performance measures, subperiods, and variable definitions. The positive effect of a medical education on fund performance and specialists’ ability to time industry-specific events suggest that knowledge-based skills, rather than social connections, are key to specialist outperformance. Our paper provides new evidence on fund manager characteristics that provide a competitive advantage in generating alpha.

A case vignette study to refine the target group of an intermediate care model: the Acute Geriatric Community Hospital

Key summary pointsAimRefining the admission criteria of the Acute Geriatric Community Hospital (AGCH) by defining its target group boundaries with (geriatric) hospital care and other bed-based intermediate care models.FindingsThe integration of medical specialist care (MSC) and medical generalist care (MGC) is unique for the AGCH compared to other intermediate care models and (geriatric) hospital care in the Netherlands. Based on these findings, 13 refined admission criteria were developed. Also, 10 additional consideration themes were identified.MessageBecause care is shifting from hospitals to the community, target group boundaries between (intermediate) care models should be continuously (re)defined; based on our experiences, we recommend using case vignettes as this yields rich and practical input.

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.

Becoming the medical registrar: a qualitative study of a professional transition as a transformative learning event

Background: The medical registrar is a daunting role to take on for the first time. While studies have explored how preparedness can be improved through simulation, less has been written about how doctors learn to be registrars through clinical practice. Method: Doctors working as medical registrars were invited to participate in semi-structured interviews. The qualitative data collected underwent thematic analysis. Results: The clinical environment was considered fertile ground for transformative experiential learning, but opportunities for debriefing and guided reflection were rare. Participants felt they needed additional support from supervisors after difficult experiences and mistakes, but this support was not always forthcoming. Conclusion: Acute physicians involved in supervising new medical registrars must facilitate meaningful independent practice to encourage the next generation of medical generalists.

You Want Me to Treat What?

Introduction:There are only two medical practitioners who are genuinely generalists. The confirmed generalist is the one who has been trained and credentialed to perform prenatal care, deliver babies and perform c-sections, take care of young children, perform simple surgeries, perform palliative care, and hold a patient's hand and hug the family after the death of a loved one. In the human world, that medical provider is a family practice physician. In the animal world, that provider is the veterinarian, who cares for all species that are not human and covers their medical needs, from preventive care to surgical needs, dentistry to dermatology, internal medicine to cardiology. As such, veterinarians are indeed generalist medical providers. In disasters, veterinarians are often pushed aside by their human medical counterparts. In doing so, there are a lot of learning opportunities missed on both sides.Method:A literature review was conducted.Results:n/aConclusion:In learning the skills that are unique and overlapping, physicians and veterinarians will be better able to respond to disasters anywhere and will be positioned to help the displaced and injured get better so they may return to normalcy as quickly as possible. It is time that disaster teams and planning sessions stop being siloed and think about how medical generalists can team up and work together.

Skills from General Practice Applied to Polydisciplinary Medical Assessments

Skills from General Practice Applied to Polydisciplinary Medical Assessments Abstract. In Switzerland, the case leader plays a central role in the polydisciplinary medical assessment performed by disability and accident insurances. Until now, a specialist in general internal medicine has been involved in every polydisciplinary assessment. Medical generalists are well suited to take on the role of case leaders due to their clinical activities in day-to-day care. A separate "case leadership" module in medical assessment training could standardize the heterogeneous facets of case leadership, convey specific responsibilities in the polydisciplinary process, and thus sharpen the task profile. This will enable the case leader to uniformly implement the legal expectations for quality assurance.

Internists or specialists-that is the question!

Over the past few decades the rising burden of chronic disorders and multimorbidity has heavily challenged health systems worldwide. In general terms, the architecture of a healthcare service should be dictated by the needs of the population it serves [ [1] Jenkins P.F. Medical generalists and specialists: time for proportional representation?. Future Hosp. J. 2016; 3: 8-9 Google Scholar ]. Chronic, multimorbid disorders would benefit from a broader and “holistic” approach and management but are individual diseases that nowadays impact health-care resources, medical research, and even medical education, where students are less and less attracted by generalist disciplines [ [2] Cassel C.K. Reuben D.B. Specialization, subspecialization, and subsubspecialization in internal medicine. N Engl J Med. 2011; 364: 1169-1173 Google Scholar ]. The individual, economic and societal price resulting from the collision between the relentless epidemiological switch toward chronicity and multimorbidity and the actual specialty and subspecialty-driven architecture of health-care systems is high [ [3] Barnett K. Mercer S.W. Norbury M. Watt G. Wyke S. Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012; 380: 37-43 Google Scholar ]. Generalist vs specialist acute medical admissions - What is the impact of moving towards acute medical subspecialty admissions on efficacy of care provision?European Journal of Internal MedicineVol. 98PreviewIn an era of increasing hospital admissions and a growing older population with multiple co-morbidities [1], the discussion surrounding generalist versus specialist medical acute admissions continues to stimulate debate. Annually, the demand and volume of hospital admissions are increasing with more patients being treated on trolleys [1]. There remains an onus on hospital clinicians to manage existing resources efficiently. Full-Text PDF

What is Wise GP? The intellectual and scholarly challenge of general practice.

The European definition of family medicine states that ‘general practice/family medicine is an academic and scientific discipline, with its own educational content, research, evidence base and clinical activity, and a clinical specialty orientated to primary care.’ (WONCA, Europe, 2002). We know that as GPs we are expert medical generalists, but do we always feel like experts at heart? The complexity of general practice consultations is well documented but is not always obvious to outsiders.1 Media representation of general practice is often negative, focusing on what GPs haven’t done or occasions when GPs have failed to make an important diagnosis. Many medical students see this, and this causes problems with GP recruitment and retention. Along with perceptions of heavy workload there is also a feeling that general practice is not intellectually challenging.2 This can be shared at times by hospital colleagues, the general public, and even GPs themselves — witness …

Rocketship and the Rural Health Workforce Revolution in the Pacific: Growing Skilled Medical Generalists Across the "Blue Continent".

Dramatic shifts are occurring in the size, shape and skill of rural health workforces in Pacific island countries (PICs) due to an unprecedented convergence of political agreement, policy commitment, donor support and technical assistance. In particular, the impact of “medical internationalism” is being felt across the Pacific region, with new doctors returning home in far greater numbers than ever before, the majority having graduated from medical schools in Cuba, China and other countries outside the region, in addition to the more typical numbers graduating and returning home from the region's main medical schools in Fiji and Papua New Guinea. With an agreed regional vision of “Healthy Islands” across the Pacific, the main objective of expanding overseas training opportunities for Pacific island medical students has been to correct the widespread centralization and maldistribution of the medical workforce in PICs and improve health access and quality of care in rural areas by deploying the new graduates to outer-island facilities. However, the return of these new graduates in several PICs has demonstrated that additional training is required to equip them with the knowledge and skills necessary to practice safely and sustainably in unsupervised settings. Thus, the development of specific postgraduate programmes has been urgently needed to provide pathways to vocational training and specialization in rural medicine appropriate to the Pacific region. Rocketship Pacific Ltd. (Rocketship) is an international health charity, based in Australia, dedicated to improving health in Pacific island countries through stronger primary care. Rocketship's particular focus to date has been on education and capacity-building for doctors and nurses working in rural communities and outer-island facilities. Since 2015, Rocketship has been working in partnership with the Ministries of Health and other key partners in Solomon Islands, Timor-Leste, Tonga and Vanuatu to design and deliver postgraduate training programmes in the core generalist disciplines family, community and rural hospital medicine. To date, this has resulted in new postgraduate Family Medicine courses being established in Timor-Leste and Tonga; a rural medical workforce support programme being delivered in Vanuatu; and a new Postgraduate Diploma in Rural Generalist Medicine being designed in Solomon Islands. These new programmes, as well as other notable initiatives elsewhere in the Pacific such as the Master of Medicine (Rural) programme in Papua New Guinea, the Diploma and Master of Family Medicine programme in Fiji and the Cook Islands Fellowship in General Practice, are transforming the health workforce in PICs with the potential to benefit island people across the “Blue Continent.” This paper describes the establishment of new postgraduate training programmes in family, community and rural hospital medicine in Timor-Leste, Tonga, Solomon Islands and Vanuatu from the perspective of Rocketship, the non-profit organization engaged by each country's Ministry of Health (or equivalent) to provide expert technical assistance with their initiative.

Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study

BackgroundThe increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.ObjectiveTo investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.MethodsThe design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.ResultsIn total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant atp < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.LimitationsSmaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.ConclusionsThe case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.Future workThe exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.Study registrationThis study is registered as Integrated Research Application System project ID 191393.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

Challenges and opportunities in pragmatic implementation of a holistic hospital care model in Singapore: A mixed-method case study

IntroductionHospital-based practices today remain predominantly disease-oriented, focusing on individual clinical specialties with less visibility on a comprehensive picture of each patient’s health needs. To tackle the challenge of growing multimorbidity worldwide, practices without disease-specific focus have shown better integration of services. However, as we move away from the familiar disease-specific approaches of care delivery, many of us are still learning how to implement generalist care in a cost-effective manner.MethodsThis mixed-method case study, which centred on a specialist-led General Medicine model implemented at an acute hospital in Singapore, aimed to (1) quantitatively summarise its clinical outcomes, and (2) qualitatively describe the challenges and lessons gathered from the pragmatic implementation of the care model. Quantitative hospital data were extracted from databases and summarised. Qualitative staff-reported experiences and insights were gathered through semi-structured interviews and analysed using thematic analysis.ResultsQuantitative findings revealed that the generalist care model was implemented with high fidelity, where more than 75% of patients admitted were placed under General Medicine’s or General Surgery’s care. The mean length of stay was 2.6 days, and the 30-day post-discharge readmission rate was 15%. Inpatient mortality rate was found to be 2.8%, and the average gross hospitalisation bill amounted to SGD3,085.30. For qualitative findings, themes concerning feasibility and operational aspects of the implementation were grouped into categories- (1) Feasibility of ‘One Care Team’ approach, (2) Enablers required for meaningful generalist care, (3) Challenges surrounding information sharing, (4) Lack of integration with the community to facilitate care transition, and (5) Evolving roles of self-management. The findings were rich, with some being identified as barriers that could benefit from system-level de-constraining.DiscussionThis case study was an illustration of our pursuit for an integrated solution to rising prevalence of multimorbidity. While quantitative findings indicated that a pivot towards General Medicine might be possible, data also revealed gaps in clinical outcomes, especially in readmission rates. These findings corroborated with much of the lessons and challenges gathered from qualitative interviews, specifically surrounding the lack of receptacles in the community to facilitate care transition, training, and competency of generalists in holistic management of complex multimorbid cases, as well as inadequate infrastructure to allow information sharing between providers. Thus, a multi-pronged approach might be required to develop a new and sustainable care model for patients with multimorbidity in the long run. In the short to medium transitional period, nonetheless, the specialist-led General Medicine care model demonstrated might be a viable interim approach, especially in circumstances where trained medical generalists remained limited.

Revealing the reality of undergraduate GP teaching in UK medical curricula: a cross-sectional questionnaire study.

Time in general practice offers medical students opportunities to learn a breadth of clinical knowledge and skills relevant to their future clinical practice. Undergraduate experiences shape career decisions and current recommendations are that 25% of undergraduate curriculum time should be focused on general practice. However, previous work demonstrated that GP teaching had plateaued or reduced in UK medical schools. Therefore, an up-to-date description of undergraduate GP teaching is timely. To describe the current picture of UK undergraduate GP teaching, including the amount of time and resources allocated to GP teaching. A cross-sectional questionnaire study across 36 UK medical schools. The questionnaire was designed based on a previous survey performed in 2011-2013, with additional questions on human and financial support allocated to GP teaching. The questionnaire was piloted and revised prior to distribution to leads of undergraduate GP teaching in UK medical schools. The questionnaire response rate was 100%. GP teaching constituted an average of 9.2% of medical curricula; this was lower than previous figures, though the actual number of GP sessions has remained static. The majority (n = 23) describe plans to increase GP teaching in their local curricula over the next 5 years. UK-wide average payment was 55.60 GBP/student/session of in-practice teaching, falling well below estimated costs to practices. Allocation of human resources was varied. Undergraduate GP teaching provision has plateaued since 2000 and falls short of national recommendations. Chronic underinvestment in GP teaching persists at a time when teaching is expected to increase. Both aspects need to be addressed to facilitate high-quality undergraduate GP teaching and promotion of the expert medical generalist role.

Investing in Queensland's rural medical leaders: Lessons from the Queensland Rural Generalist Program.

To improve the leadership capacity of existing Queensland Rural Generalists and support the emerging leaders needed to assume future leadership roles. A customised leadership program for medical Rural Generalists, embedded in professional standards, was developed and delivered during 2016-2018. Pre and post-program and individual module evaluations from two Program cohorts were analysed. Qualitative, semi-structured phone interviews (n=30) discussing participant views on leadership in a rural context and their Program experience were also conducted. The Rural Generalist Leadership for Clinicians Training Program runs over twelve months and includes three residential modules as well as online learning sets. Forty-four participants completed the Program and obtained Associate Fellowship of the Royal Australasian College of Medical Administrators. Development and delivery of the Rural Generalist Leadership for Clinicians Training Program. Participant's ability to apply Program learning in a rural leadership context. Participant views on leadership in a rural context. Participants indicated they benefited most from the 'understanding self' and management aspects of the Program such as finance, budgeting, and understanding and navigating broader health system governance. They greatly valued the opportunity to enhance their professional networks and relationships and have since developed a regular forum to assist in the transition from individual leadership development to the development of the broader workforce and organisation. The results of this study suggest that further attention and investment in medical leadership is warranted to support and enable the Rural Generalist workforce to continue to meet the complex, context-specific needs of the communities within which they deliver vital health services.

Sharing Is Caring-Data Sharing Initiatives in Healthcare.

In recent years, more and more health data are being generated. These data come not only from professional health systems, but also from wearable devices. All these ‘big data’ put together can be utilized to optimize treatments for each unique patient (‘precision medicine’). For this to be possible, it is necessary that hospitals, academia and industry work together to bridge the ‘valley of death’ of translational medicine. However, hospitals and academia often are reluctant to share their data with other parties, even though the patient is actually the owner of his/her own health data. Academic hospitals usually invest a lot of time in setting up clinical trials and collecting data, and want to be the first ones to publish papers on this data. There are some publicly available datasets, but these are usually only shared after study (and publication) completion, which means a severe delay of months or even years before others can analyse the data. One solution is to incentivize the hospitals to share their data with (other) academic institutes and the industry. Here, we show an analysis of the current literature around data sharing, and we discuss five aspects of data sharing in the medical domain: publisher requirements, data ownership, growing support for data sharing, data sharing initiatives and how the use of federated data might be a solution. We also discuss some potential future developments around data sharing, such as medical crowdsourcing and data generalists.

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 …

How well do public sector primary care providers function as medical generalists in Cape Town: a descriptive survey

BackgroundEffective primary health care requires a workforce of competent medical generalists. In South Africa nurses are the main primary care providers, supported by doctors. Medical generalists should practice person-centred care for patients of all ages, with a wide variety of undifferentiated conditions and should support continuity and co-ordination of care. The aim of this study was to assess the ability of primary care providers to function as medical generalists in the Tygerberg sub-district of the Cape Town Metropole.MethodsA randomly selected adult consultation was audio-recorded from each primary care provider in the sub-district. A validated local assessment tool based on the Calgary-Cambridge guide was used to score 16 skills from each consultation. Consultations were also coded for reasons for encounter, diagnoses and complexity. The coders inter- and intra-rater reliability was evaluated. Analysis described the consultation skills and compared doctors with nurses.Results45 practitioners participated (response rate 85%) with 20 nurses and 25 doctors. Nurses were older and more experienced than the doctors. Doctors saw more complicated patients. Good inter- and intra-rater reliability was shown for the coder with an intra-class correlation coefficient of 0.84 (95% CI 0.045–0.996) and 0.99 (95% CI 0.984–0.998) respectively. The overall median consultation score was 25.0% (IQR 18.8–34.4). The median consultation score for nurses was 21.6% (95% CL 16.7–28.1) and for doctors was 26.7% (95% CL 23.3–34.4) (p = 0.17). There was no difference in score with the complexity of the consultation. Ten of the 16 skills were not performed in more than half of the consultations. Six of the 16 skills were partly or fully performed in more than half of the consultations and these included the more biomedical skills.ConclusionPractitioners did not demonstrate a person-centred approach to the consultation and lacked many of the skills required of a medical generalist. Doctors and nurses were not significantly different. Improving medical generalism may require attention to how access to care is organised as well as to training programmes.

Self-efficacy reduces the impact of social isolation on medical student\u2019s rural career intent

BackgroundSocial isolation in medical students is a subjective experience that may influence medical career decision making. Rural self-efficacy has been shown to influence rural career intentions following a rural clinical placement, however its impact on social isolation during a rural clinical placement has not been previously modeled. The objective of this study is to explore whether self-perception of social isolation is associated with rural career intent in rural medical students. Secondly, to determine whether self-efficacy influences the association between social isolation and rural career intent.Methods2015 data, from a cross-sectional survey of the National Federation of Rural Australian Medical Educators (FRAME) study. Among 619 medical students attending rural clinical schools (RCS), rural career intent was assessed. This included intended rural location for either postgraduate medical specialist or generalist training or completion of that training. Self-efficacy beliefs in rural medical practice were based on a validated scale consisting of six questions. Social isolation was measured asking students whether they felt socially isolated during their RCS placement.Results31.3% of surveyed students self-reported feeling socially isolated during their rural placement. Social isolation was associated with reduced rural career intent after controlling for gender, rural background, RCS preference, RCS support and wellbeing. In step-wise logistic regression the association between social isolation and rural intent disappeared with the inclusion of rural self-efficacy.ConclusionsSocial isolation during a rural clinical placement is commonly reported and is shown to reduce rural career intent. High levels of rural clinical self-efficacy reduce the effects of social isolation on future rural workforce intentions.

Reimagining the diagnostic pathway for gastrointestinal cancer.

A crisis is looming for the diagnosis of gastrointestinal cancers, one grounded only partly in the steady increase in their overall incidence. Public demand for diagnostic tests to be undertaken early and at lower levels of risk is reflected in early diagnosis being a widely held policy objective for reasons of both clinical outcome and patient experience. In the UK, urgent referrals for suspected lower gastrointestinal cancer have increased by 78% in the past 6 years, with parallel increases in endoscopy and imaging activity. Such growth in demand is unsustainable with current models of care. If gastrointestinal cancer diagnosis is to be affordable, the roles of professionals and their interactions with each other will need to be reframed while retaining public confidence in the process. In this Perspective, we consider how the relationship between medical specialists and generalists could be redefined to make better use of the skills of each while delivering optimal clinical outcomes and a good patient experience.

Primary care redesign for person-centred care: delivering an international generalist revolution.

Person-centred primary care is a priority for patients, healthcare practitioners and health policy. Despite this, data suggest person-centred care is still not consistently achieved - and indeed, that in some areas, care may be worsening. Whole-person care is the expertise of the medical generalist - an area of clinical practice that has been neglected by health policy for some time. It is internationally recognised that there is a need to rebalance specialist and generalist primary care. Drawing on 15 years of scholarship within the science of medical generalism (the expertise of whole-person medical care), this discussion paper outlines a three-tiered approach to primary care redesign; describing changes needed at the level of the consultation, practice set up and strategic planning. The changing needs of patients living with complex chronic illness has already started a revolution in our understanding of healthcare systems. This paper outlines work to support that paradigm shift from disease-focused to person-focused primary healthcare.