Family Medicine’s Identity: Being Generalists in a Specialist Culture?

Howard Stein’s article, “Family Medicine’s Identity: Being Generalists in a Specialist Culture?”, is a call to consciousness for those of us in primary care. Dr Stein reminds us that we must not push ideology or politics in the evolving development of our identity. We also must not dump our values in our attempt to survive, for ethical reasons and because that may have paradoxical effects. For those of us interested in the effect of relationships on health, we must continue to study what is and isn’t true in this regard. Similarly, we must define and operationalize a pragmatic, biopsychosocial, family-oriented model of care for Family Medicine.

Susan H McDaniel PhD Professor of Psychiatry & Family Medicine Associate Chair, Department of Family Medicine U of Rochester School of Medicine & Dentistry Rochester NY

Competing interests:   None declared

I have a dinosaur of an insurance plan that does not require referrals from my FP. So, if I choose or feel I need to see a specialist, then I go to see the specialist without awaiting a referral. A long time ago I utilized that option for either family members or for me.

That attitude changed when I found my current family practitioner. A generalist or family practitioner is important in many ways. Unless the physician is an idiot or complete incompetent, an individual wants to see the same person when they get sick or have continuing complaints. An individual wants someone who remembers family history and medical history. An FP can act as a gateway in helping to prevent unnecessary or expensive tests. They also have the opportunity to engender trust when sensitivity is required for certain referrals in mental health issues.

Being a generalist should be just as celebrated as the choice to become an opthamalogist. Perhaps more activism on the part of Family Practitioners would help change the attitudes of those who just don't understand the concept of generalization.

Competing interests:   None declared

Dr. Stein's comments about family medicine and its identity crisis are timely and needed. While it is a very difficult time for family medicine educators, who see student and resident interest shifted toward specialties, it is likewise wonderful to witness patients' own loyalties to the concept of generalism that is the core of family medicine. In an academic center, no other specialty can lay claim to the teaching, modeling, and clinical care of ALL members of a family. Often, the contributions of family medicine to the care of underserved populations are notable. But family medicine has struggled in its desire to appear and act like one of the "other" specialties while simultaneously clinging to its origins in generalism. If our political structure, like England's, were to endorse the speciality of generalism as a prerequisite for further training, would family medicine be in a different place, politically and emotionally?

Competing interests:   None declared

Excellent exploration of the tensions inherent in discussions around the future of Family Medicine! It would be a tragedy if we as family physicians abandoned our heritage as generalists, as adaptable lifelong learners (ever the novice), all in pursuit of recognition as experts. I for one heartily embrace generalism and our systemic, integrative function within the house of medicine.

Competing interests:   None declared

Howard Stein's article, "Family Medicine's Identity: Being Generalists in a Specialist Culture?" brings to mind a number of important distinctions for those practicing and teaching family medicine. After exploring conflicting notions of identity in the culture of family medicine, he concludes by advocating a practical approach to identity formation through self-reflective and compassionate day-to-day work. Such a view is sound and likely to lead to serving patients, their families and others in ways that are meaningful and helpful, which seems the point. Trying to categorize the discipline's identity in a more presumptive manner may be a futile endeavor as it does not account for the process of identity formation which is an inductive, experiential, on-going process in which individuals will diverge. This is, however, not to say that it does not matter how character and identity are informed. Thoughtful, reflective practice is as critical for practitioner's identity formation as is compassion for patient and family healing. Stein's article reminds us of the importance of the individual journey to practice identity, as well as the courage one must have to live by one's convictions despite conflicting forces within the environment. Given this perspective, Stein implicitly invites those who mentor students and care for patients and families to consider how our own individual and collective identities have shaped the culture of family medicine.

Competing interests:   None declared