The demand for healthcare is growing and the NHS is facing the challenge of treating patients with multiple long-term conditions in high-cost settings, with limited resource set aside for prevention.  An ageing population with multiple long-term conditions highlights the need for training tomorrow’s doctors with skills such as Generalism, leadership and an interprofessional approach to patient care.  COVID-19 has further emphasised the significance of public health as a speciality and rekindled wider interest in health inequalities[1].

Generalism is a form of clinical practice that is shaped around the priority health needs of the person rather than the practitioners’ own field of expertise. In addition to disease-based knowledge, practitioners work longitudinally and sustainably with their patients to address the determinants of health. Generalism requires the practitioner to prioritise collaboratively with their patient, to work with both specialists and community care, to leverage the expertise of others as they work, and to safely and efficiently manage infinite diagnostic and management possibilities. This presents challenges within medical curricula which prioritise fixed notions of knowledge, closed book assessments, and single best answer assessment formats[2].

Medical educators express challenges integrating Generalism into medical curricula (both teaching and assessments).  However, there are signs of change in the long term perspective on medical education and training, which should be to the advantage of Generalism – such as the NHS Long Term Plan[3]  and the GMC’s Outcomes for Graduates[4].

“Newly qualified doctors must be able to recognise sociological factors that contribute to illness, the course of the disease and the success of treatment and apply these to the care of patients − including issues relating to health inequalities and the social determinants of health, the links between occupation and health, and the effects of poverty and affluence.”⁴

“Newly qualified doctors must be able to apply the principles, methods and knowledge of population health and the improvement of health and sustainable healthcare to medical practice.” ⁴

We also need to be conscious of recent changes in medical education such as the development of new 4-year undergraduate degree, Medical Doctor Degree Apprenticeships and the Medical Licensing Assessment (MLA).  A compressed curriculum, and “teaching to the test” both risk squeezing out elements which are seen as non-core[5].

To explore this further, the Faculty of Public Health’s special interest group, Public Health Educators in Medical Schools (PHEMS) ran an online workshop with medical educators to explore any challenges and opportunities for integrating Generalism into undergraduate medical curricula. 

Challenges identified were systemic, educational, and cultural: 

• Modern medicine increasingly prioritizes specialization, with many medical schools emphasizing specialized training.
• Medical curricula are already densely packed with a broad range of subjects, and adding comprehensive training in Generalism can strain resources and time. 
• Generalism is too broad for closed book assessments and neither does it lend well to summative assessments.  Creating assessments that effectively measure Generalism competencies requires more than testing factual knowledge or hands-on skills
• Not all medical schools have a strong presence of faculty trained in public health or experienced in generalist practice beyond primary care. This limits students’ exposure to role models who can advocate for and teach the generalist approach. 
• While the new Medical Licencing Assessment aims to ensure competency and safety of all graduates, it can inadvertently hinder the integration of Generalism into medical education.
• Lastly, medical students often adopt a positivist and exam-focused mindset due to a combination of exam pressures and the structure of medical training.

These challenges require systemic reforms in medical education, healthcare infrastructure, and students’ perception to successfully integrate Generalism into the training of future doctors.

Despite the above challenges, some delegates at the workshop identified opportunities and mitigation strategies:

• Exploring a longitudinal approach to teaching Generalism:
  • case-based discussions and simulations where students handle complex, multifactorial cases
  • longitudinal placements that support continuity with patients
  • early exposure to primary care settings
  • rural medicine placements and opportunities to work with underserved populations
• Suggestions were also made for assessing Generalist knowledge and skills, such as
  • using open book assessment
  • workplace-based assessments
  • e-portfolio assessments for complex Generalism
• A flipped classroom approach along with experiential learning can provide medical students with patient-focused learning opportunities
• A holistic curriculum design which can offer interprofessional education opportunities, for medical students to collaborate with other healthcare professionals (eg., nurses, pharmacists, physiotherapists) to appreciate the multidisciplinary nature of patient care.

In summary, medical educators need to take on the role of mentors and role models to create a supportive teaching environment facilitating the application of Generalism in clinical decisions.  This also requires institutional support and investment of resources.

Professor Kevin Fenton
FPH President

Dr Bharathy Kumaravel, Prof Ellie Hothersall-Davies, Dr Kay Leedham-Green
FPH Public Health Educators in Medical Schools Special Interest Group

References

[1] Rodrigues V, Hothersall E, Davies M. Public Health Education in Medical Schools – The Impact of the COVID-19 Pandemic. J Med Educ Res [Internet]. 2021 Sep 2 [cited 2024 Apr 16];1(1). Available from: http://www.ubplj.org/index.php/jmer/article/view/1926

[2] Park, Sophie, and Kay Leedham-Green, eds. Generalism in Clinical Practice and Education. UCL Press, 2024. Available from: https://doi.org/10.2307/jj.9128000.

[3] NHS England. NHS Long Term Workforce PLan [Internet]. 2023. Available from: https://www.england.nhs.uk/long-read/nhs-long-term-workforce-plan-2/

[4] GMC-Outcomes for graduates [Internet]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/outcomes-for-graduates/outcomes-for-graduates

[5] Harden RM. Five myths and the case against a European or national licensing examination. Med Teach. 2009 Jan;31(3):217–20.