REVITALIZING GENERALIST PRACTICE: THE MONTREAL STATEMENT

“Today, the need for people-centered primary health care is greater than at any time in history”¹

The challenges facing our health systems are immense. International efforts strive to meet the needs of aging populations, the rising prevalence of chronic disease and illness, and the changing impact of complex social factors (including health care) on individuals’ experiences of, and capacity to manage, illness. The international community has pledged to renew its efforts to better align health care to a person-focused, individually tailored, goal-oriented model of health care.¹

To date, primary care reform has focused on improving the integration of health services by strengthening coordinated access to multidisciplinary teams delivering continuous, comprehensive care,² the aim being to reverse the fragmentation of health care resulting from over-specialization.

But integration alone cannot guarantee the delivery of person-centered care: health care that recognizes its goal as optimizing an individual’s health-related capacity for daily living, rather than the “command and control” of disease.³ This tailoring of health care decisions about diagnosis and management to the individual’s context often requires compromise between a biomedical, patient, and professional view of what constitutes “best” care.⁴ Enhancing our capacity to appropriately and safely deliver such balance or compromise within modern medical practice is essential if we are to tackle emerging problems of treatment burden, overdiagnosis, problematic polypharmacy, and other forms of iatrogenic harm.

Research into patient and professional experiences of care demonstrate that delivery of person-centered, individually tailored care is currently challenged by the context of clinical practice.⁵

Whole-person individually tailored clinical decision making is the expertise of the medical generalist.⁶ Medical generalism is a distinct form of clinical practice that is complementary to, but different from, specialist practice. Although both forms of practice are needed in today’s health system,⁷ the majority of patients require comprehensive generalist care (Box 1).^8,9

However, a failure to recognize the differences between the definitions and monitoring of quality of care in primary care systems is contributing to a failure in person-centered care.

We describe the 4 key elements of best quality generalist practice that are needed to enable and ensure quality person-centered care, and suggest how these may be recognized within practice (Table 1). The 4 key elements are:

• The goals of care

• The data used in practice

• The tasks of practice

• Assessment of quality of care

We deliberately do not offer specific ways to measure each element as these will be context sensitive. Our Table, however, does offer a framework by which individual settings can review their own models of practice.

• © 2018 Annals of Family Medicine, Inc.