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

doi:10.1370/afm.2280

Article Figures & Data

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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.

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Table 1

Defining and Identifying Generalist Best Practice–All Elements Must be Present

Defining Best Practice: Describing Quality Generalist Practice	Recognizing Best Practice: What You’d Expect to See in a Service Delivering Quality Expert Generalist Care
The goal(s) of care
Best care optimizes an individual’s health-related ability to continue their daily life.	Individually tailored care is ENDORSED by health systems, professionals, and patients. Individuals, practice teams, and organizational systems consistently and actively emphasize the value/importance of individual goal-related care. Individual health-related capacity for daily living is ENHANCED by health services. Contact with health services leaves patients better able to understand and to respond and adapt to their illness experience, resulting in enhanced capacity to manage daily living and health literacy; minimized illness burden.
The data used in practice	Generalist practice is ENABLED by:
Best care is informed by scientific evidence, together with patient accounts of experience, contexts, and preferences; and professional experience of illness and disease in this patient’s particular context.⁹ Scientific evidence is viewed not as “top of an evidence hierarchy” but rather 1 source of a wide range of data, information, and knowledge to be used in interpreting what is wrong and what might need to be done. Contact time with patients is designed to support access to, and use of, an appropriate range of data sources.	Informational continuity: accessible, appropriately completed, updated, and summarized records to provide patient context data Scientific data: readily accessible in formats that are suitable for patients and professionals, eg, guideline summaries, decision aids Patient-centered consultation spaces that enable both parties to exchange patient accounts of experience, context, and preference Professional-centered work spaces that provide opportunities outside of the consultation for the creation, use, and maintenance of locally constructed “mindlines,” a term to describe “collectively reinforced, internalized tacit guidelines” constructed from brief reading, tacit knowledge, and interactions with professionals and patients; so creating “knowledge-in-practice-in-context.”¹⁰
The tasks of clinical practice
Best care recognizes the intellectual task of the clinician to integrate data, information, and knowledge; to construct a unique individual interpretation of illness experience; to safety-net/check that interpretation (including appropriate follow-up); and to empower the patient to own the decision process.	Clinicians are trained in, and confident to use, the skills needed for the intellectual task of using data to construct new context-sensitive knowledge about this individual. Clinicians and patients perceive that they work in an enabling context with adequate resources to support this form of practice (including prioritization of workload). Process of care is described with reference to the context in which clinical decisions are made and not just on the basis of the decision itself.
Assessment of quality of care/practice
Quality of care is described with reference to the context in which clinical decisions are made and not just on the basis of the decision itself; and assesses whether context and care have ideally enhanced— certainly not undermined—health-related capacity for daily living.	Feedback and monitoring processes assess both the context of, and outcomes from, care from a person-centered perspective. Services support longitudinality¹¹ of care—to observe the impact of personalized clinical decision making—is evident. Clinicians and patients are supported to judge the quality of care (decision making) based on the goal/impact of the decision over time rather than any decision itself.