REVITALIZING GENERALIST PRACTICE: THE MONTREAL STATEMENT ======================================================== * Joanne Reeve * Marie-Dominique Beaulieu * Thomas Freeman * Larry A. Green * Peter Lucassen * Carmel Martin * Tadao Okada * Victoria Palmer * Elizabeth Sturgiss * Joachim Sturmberg * Chris van Weel > “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 Box 1 ### Differentiating Specialist and Generalist Care7 | Medical Specialists and Generalists Ask Fundamentally Different Diagnostic Clinical Questions When Making Decisions About Individual Patients | |:-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | **Specialist** | | | The specialist uses their detailed knowledge of and expertise in a specified area of biological (mal) function to ask, “could we diagnose this individual with condition X ?” | Best diagnostic practice is defined by the correct assessment of whether the individual has a particular disease/condition. It requires the clinician to collect appropriate clinical data and apply hypothetico-deductive logic to ask does this individual meet the diagnostic criteria for this condition? If no, the patient is discharged. If yes, an individual clinician may then explore this condition in the context of this patient’s life and personal circumstances in order to decide between competing treatment options (adopting a person-centered approach to care in the specialist context). | | **Generalist** | | | The generalist uses their expertise in using multiple sources of data to interpret individual illness experiences to ask, “should we diagnose this individual with condition X?” | Best care optimizes an individual’s health-related ability to continue living their daily life: supporting a person to understand their illness (including the pros and cons of medicalization) and enhancing individual capacity to adapt and respond personally to that experience. Choosing diagnoses and treatment options on the basis of their likely impact on daily living, rather than solely their ability to instrumentally improve disease management. | 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 View this table: [Table 1](http://www.annfammed.org/content/16/4/371/T2) Table 1 Defining and Identifying Generalist Best Practice–All Elements Must be Present 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. ## In Order to Deliver the Health Care Needed for 21st Century Challenges We call on health systems, practices, and practitioners around the world to evaluate their current models of care against our stated criteria for best *generalist* care. In so doing, to advocate and implement the changes needed to enhance the delivery of generalist care, *supplemented* by specialist disease management when appropriate for a given individual. We call on the World Health Organization to incorporate recognition of the intellectual task of person-centered care in its 2018 statement on strengthening primary care1 to recognize the delivery of generalist decision making as a quality indicator for primary care practice. ## Footnotes * This statement was developed out of work undertaken at a consensus statement meeting held at the annual North American Primary Care Research Group conference in Montreal in November 2017. * © 2018 Annals of Family Medicine, Inc. ## References 1. World Health Organization. Draft Declaration 2nd International Conference on Primary Health Care: Towards Universal Health Coverage and the Sustainable Development Goals. Geneva, Switzerland: World Health Organization; 2018. [http://www.who.int/primary-health/conference-phc/DRAFT-Declaration--9-April-2018.pdf?ua=1hgf](http://www.who.int/primary-health/conference-phc/DRAFT-Declaration--9-April-2018.pdf?ua=1hgf). Accessed Jun 7, 2018. 2. Lewis S. The two faces of generalism. J Health Serv Res Policy. 2014; 19(1):1–2. [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1177/1355819613511075&link_type=DOI) [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=24231721&link_type=MED&atom=%2Fannalsfm%2F16%2F4%2F371.atom) 3. World Health Organization. The World Health Report - Primary Health Care (Now More Than Ever). Geneva, Switzerland: World Health Organization; 2008. [http://www.who.int/whr/2008/en/](http://www.who.int/whr/2008/en/). Accessed Jun 7, 2018. 4. Duerden M, Avery T, Payne R. Polypharmacy and medicines optimisation. Making it safe and sound. London, UK: Kings Fund; 2014. [https://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation](https://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation). Accessed Jun 7, 2018. 5. Reeve J, Britten N, Byng R, Fleming J, Heaton J, Krska J. Identifying enablers and barriers to individually tailored prescribing: a survey of healthcare professionals in the UK. BMC Fam Pract. 2018;19(1):17. 6. Medical Generalism: Why Expertise in Whole Person Medicine Matters. London, UK: Royal College of General Practitioners; 2012. [http://www.rcgp.org.uk/policy/rcgp-policy-areas/medical-generalism.aspx](http://www.rcgp.org.uk/policy/rcgp-policy-areas/medical-generalism.aspx). Accessed Jun 7, 2018. 7. Heath I. Divided we fail. Clin Med (Lond). 2011;11(6):576–586. [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=22268313&link_type=MED&atom=%2Fannalsfm%2F16%2F4%2F371.atom) 8. Stange KC. The generalist approach. Ann Fam Med. 2009;7(3): 198–203. 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