Chronic Illness, Comorbidities, and the Need for Medical Generalism

I read Dr. Grumbach’s excellent article, “Chronic Illness, Comorbidities, and the Need for Medical Generalism” and it reminded me of some of the old articles written by Dr. Nicholas Pisacano and colleagues when they were making their case to the American Board of Medical Specialties in the 1960’s that in fact there was a dire need for the generalist physician in a specialist world. What developed from these unyielding efforts was the second largest specialty. Though our environment is much different now than it was 40 years ago the mantra sounds strikingly similar. Technology has advanced tremendously and with it our patients’ expectations. Patients are sicker and we have many more treatment options. The explosion of information is overwhelming at times. As family physicians we are faced with a difficult predicament. There is no doubt a generalist will help a patient navigate through the maze of medical care but we must show objectively that our care improves outcomes. Additionally (and perhaps an even greater challenge) we must change our current model of billing and appointment structure to allow us to spend adequate time with patients and receive appropriate reimbursement that is at very least equal or better than our specialist counterparts. With the average time spent with patients at or near 7-10 minutes per visit it is impossible to adequately address multi-system disease, perform appropriate physical examinations, provide counseling, bill and order tests - not to mention all the associated paperwork and documentation required to provide the best care to our patients. Family physicians are very efficient and capable individuals but we must maintain a realistic view of our capabilities and limitations. We perform a vital service to our patients and the health care system and deserve to have salaries comparable to our specialist counterparts. We must make fundamental changes that allow us more time and better reimbursement for the management of our patients and their increasingly complex problems.

Robert L. Bratton, MD

Assistant Professor

Dept of Family Medicine

Mayo Clinic Jacksonville

Competing interests:   None declared

Generalist models of care persist but their survival is threatened by the predominant graduate education model of Family Medicine that employs a series of segmented sub-specialty, hospital-based rotations as its foundation, and too often leaves continuous, integrated, community-based care as residency "capstone" experiences.

This ordering of Family Medicine education replaces rational generalists with homunculi of sub-specialists that call their limited components to the fore when their discipline's disease is glimpsed. Unfortunately, a preoccupation with isolated disciplines distracts learners from the importance of interrelationships--illness to patient, patient to family, family to doctor, doctor to community, etc. Segmented care also introduces substantial harms: an intolerance of uncertainty that induces anxiety and over-diagnosis; the propensity for profligate resource use; and the dignity-eroding denial of senescence and death as necessary parts of the life cycle.

Dr. Grumbach's call for an integrated model of care that addresses the whole person should be heeded in Family Medicine residencies. "Fundamental redesign of primary care systems" could easily begin by releasing Family Medicine residency education from subservience to sub- specialties and establishing holistic community-based care as the foundation of learning how to be a Family Physician.

Competing interests:   None declared

My father recently died from head injuries sustained in a fall, and had seen multiple specialists in the months preceding his death. He had seen cardiology (no need for a stent on cath; aspirin and Plavix should help his small vessel disease) and urology (his new finasteride should soon allow him to drink without worrying about being able to void) and family practice (his chest pains could be related to his reflux so keep up his omeprazole and stay on his fluoxetine). But he didn't know how to manage his dysequilibrium, so after a half hour on his exercise bike and walking to his bank, when he felt dizzy he fell hard.

As a family doctor, I chastise myself (of course) for not hounding his doctors to consider that although he did not need an acute intervention, he still needed help and explanations. His low blood pressure, poor fluid intake, peripheral neuropathy, and polypharmacy all contributed to his fall and the subsequent bleeding.

Only a thoughtful generalist can take this diverse collection of facts and synthesize it into a coherent discussion for a patient to understand how it affects his life. Now the problem is to find how to encourage the generalists to take the time and effort to think about the "big picture," and to share it with their patients. Most of us want to do this, but the exigencies of reimbursement don't encourage us to do it as well. When it's your father who dies as a result, you stop and contemplate a little longer.

Competing interests: None declared