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Medical generalism. Past, present and future
El generalismo médico. Pasado, presente y futuro
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Past, present and future" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "129" "paginaFinal" => "132" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ramon Pujol Farriols, Marina Geli Fabrega" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Ramon" "apellidos" => "Pujol Farriols" "email" => array:1 [ 0 => "ramon.pujol@umedicina.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Marina" "apellidos" => "Geli Fabrega" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Decano de la Facultat de Medicina, Universitat de Vic-Universitat Central de Catalunya, Vic, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Directora General de la Fundació d’Estudis Superiors en Ciències de la Salut (FESS), Universitat de Vic-Universitat Central de Catalunya, Vic, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El generalismo médico. Pasado, presente y futuro" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Well into the <span class="elsevierStyleSmallCaps">21</span>st century, the generalist view of medicine is going through a crisis, and it is therefore imperative to review the evidence, identify its causes and analyse the way forward in the search for the place it should reasonably occupy in the future.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The knowledge and subsequent practice of medicine have undergone major changes in recent decades. These changes are not only inherent to the profession, but are also a consequence of today’s globalised world, which includes societies influenced by socio-demographic, economic, technological and political factors of various kinds. In this context, biomedical research is advancing and the practice of medicine is inevitably becoming more complex. The new reality does not justify the loss of its essence and the practice of medicine, largely carried out by general practitioners, must find a new direction.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">If we had to sum it up in one sentence, as a statement of intent, we would say, quoting Eric Topol in his book <span class="elsevierStyleItalic">Deep Medicine</span>: “Artificial Intelligence Can Make Healthcare Human Again”, a more humanised medicine enabled by machines.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A good scenario for analysing the preferences of the doctors of the future is to see what their specialisation intentions are at the present time. There is much to suggest that the preferences of this new generation will not resemble, and indeed are no longer resembling, previous generations.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Recent data on which medical specialties are preferred by doctors starting their postgraduate training require careful consideration by all the institutions involved (educational, health, political) and by society in general. It is up to all of them to change the current course without hesitation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">With some peculiarities, there is a decline in interest in traditional generalist specialties such as, in the case of Spain, Family and Community Medicine, Internal Medicine or Geriatrics.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Extending this analysis to other countries may be helpful although it is complex given the differences in concepts, grouping of specialties<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and, above all, the diverse organisation of health systems in Europe and even more so in other continents.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Past and present of medical generalism</span><p id="par0040" class="elsevierStylePara elsevierViewall">When we speak of medical generalism, we refer to those generalist specialties of medicine whose members apply their knowledge in a broad and less specific way, as opposed to specialism whose members apply their knowledge in a narrow and more specific field. Both are needed to offer quality medical care. The boundary between where generalist practice begins and ends in relation to specialised practice varies between health institutions, countries, competencies acquired and other variables, so that being a specialist, or a generalist nowadays goes beyond what is dictated by the choice of one or the other specialty obtained through a specialised training entry exam.</p><p id="par0045" class="elsevierStylePara elsevierViewall">There are clear signs that the crisis of generalism in some of the flagship specialties started some years ago. Others, such as Paediatrics or Preventive Medicine and Public Health, have suffered a different type of crisis and will not be the subject of this article due to their own specificities.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The first generalist medical speciality in the history of modern medicine was <span class="elsevierStyleItalic">Internal Medicine</span>,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which had its heyday in the mid-twentieth century as the Western world recovered from the Second World War. Well-trained doctors were grouped together in health centres, preferably in hospital departments, who took care of the patients' medical ailments. It was the time of the great masters of medicine who left their legacy in the universities and in the centres where they practised their profession.</p><p id="par0055" class="elsevierStylePara elsevierViewall">From the second half of the 20th century onwards, starting with Internal Medicine, an unstoppable growth of medical specialties took place thanks to advances in research and the development of new diagnostic and therapeutic techniques. Although unevenly, depending on the country, they moved away from Internal Medicine, became firmly established in hospitals and progressively in medical schools up to the present day. It is the consolidation of specialism that has continued to develop with super-specialisation within the specialties themselves. It was the beginning of the crisis of the founding generalism which, at the beginning of the 21st century, led to a redefinition of its competences both in Europe,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> in some American countries<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and in Spain, where Internal Medicine was very strong.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In recent years there has been a redefinition of the specialty based largely on the specialisation of tasks arising within Internal Medicine itself at the hands of leading internists (in infectious diseases, in autoimmune diseases, in chronicity, in hepatology, in functional units or in hospital emergency departments, among others). This hint of recovery stems also from the assumption of new clinical tasks which, like the American hospitalists,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> the internists themselves perform outside their “comfort” zone (in other departments, in day hospitals, in rapid diagnostic units, etc.). Nevertheless, there is a debate, at different levels according to countries and care settings, on the vision of a specialised Internal Medicine in the manner of the established specialties or as a generalism serving the new care needs of post-modern society.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Another major general medical specialty in the history of modern medicine has been given different names depending on the countries in which it is practised. These are General Medicine, Family and Community Medicine in Spain and Latin America, the practice of the <span class="elsevierStyleItalic">General Practitioners</span> in the United Kingdom or the <span class="elsevierStyleItalic">Family physicians</span> in the USA and other countries or the <span class="elsevierStyleItalic">Medecin traitant</span> in France, to name but a few. It is based on the practice of broad-spectrum medicine, primarily in primary health care rather than in hospitals. The creation of the <span class="elsevierStyleItalic">Family and Community Medicine</span> specialty at the end of the 1970s was a historic event in Spain; it would be the updated version of the classical “general medicine”.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Inspired by the principles of the Alma-Alta conference of 1978, it offers care to citizens near to them, it is their Primary health care and ensures care at the level of families, extending beyond the individuals and the community in which they are embedded. As the specialty training program says: <span class="elsevierStyleItalic">The family doctor cares about each person as a whole and throughout his or her life. His or her professional practice is not limited to clinical cases or treating illnesses; rather, he or she cares for people with specific problems and beliefs, immersed in a family and social context that constitutes an indivisible whole which is also the object of his or her daily work</span>.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The role of family doctors has been, in these decades, decisive in improving the health of citizens and has brought great prestige to primary health care doctors. After a very strong and enthusiastic start, the economic crisis of 2008 had a negative impact on the reforms needed to bring it up to date; it was the beginning of a crisis from which it has not yet recovered.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In contrast to what has happened to Internal Medicine, namely, that technology has progressively taken over with the advent of specialisation; the causes of the crisis in Family Medicine are of a different nature. A thorough analysis of these is considered essential. Certainly, there have already been many such analyses, and some very recent,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which reiterate that, among others, limited time for care, work overload and low pay are among the most important causes, but they are not the only ones. However, it seems that now is the time to look for solutions to the underlying problems that cause these difficulties and, once they have been diagnosed, the most appropriate treatment should be applied. It is somewhat more systemic than the need to look for new leaderships.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">For years now, primary care and its professionals have been considered by many health systems as the basis and the natural entry point to the health system,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> which must necessarily be strengthened so that it can assume this central role. The reality in Spain, aggravated by the COVID-19 pandemic, is that the appeal for young doctors has declined and there is a significant deficit of these specialists. According to recent data, it is the first speciality with a deficit.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Paradoxically, the interest in family medicine continues in some countries, such as the USA, despite the fact that, as in Spain, a significant shortage of these specialists is expected in the coming years.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The third generalist specialty to be mentioned is <span class="elsevierStyleItalic">Geriatrics.</span> The first references to modern Geriatrics date back to 1914<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>; since then it has grown significantly worldwide following a biopsychosocial model imported from the UK.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> It was recognised in Spain as a MIR (resident) specialty in 1978 and by 2003 there were 22 hospitals accredited to teach the specialty. The members of the National Commission of the specialty defined it as: <span class="elsevierStyleItalic">“the branch of medicine devoted to preventive, clinical, therapeutic and social aspects in the elderly”</span>.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Geriatric specialists can currently practice in a variety of settings: hospitals, home care programmes, geriatric centres or specialised clinics. Their role in undergraduate teaching and research has been increasing, often in multidisciplinary teams with other specialists such as internists, oncologists and others. The relationship with the other generalist specialties has proved generally successful, although the boundaries between them are not linear.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The implementation of geriatrics in the different countries has been very diverse according to a study conducted in 22 of them spread over the 5 continents.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The specialty was not even perceived as popular in 55% of them.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Geriatrics has undergone an exceptional development in the USA and exerts a scientific leadership that has resulted in a professional practice that is recognised worldwide.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> As a result of this work, the clinical activities that differentiate its practice from that of other generalist specialties are defined.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Just as it is happening with the other 2 generalist specialties that are the subject of this article, an unavoidable reality in Spain is the preference among eligible MIR (resident) candidates for specialties other than those mentioned above.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> A clear dissociation between the planning of health systems and the preferences of those who should be part of them.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Future of medical generalism</span><p id="par0100" class="elsevierStylePara elsevierViewall">What should be the strategy for good planning and consequent training of medical specialists now and in the future? It is a question without a sound satisfactory answer, or rather, without a successful answer, which, left to natural evolution, risks leading to health and education systems where theory and practice diverge. A very worrying example of the current situation in Spain is that while the health authorities are committed to strengthening primary health care, young doctors are prioritising the choice of hospital specialties where technology plays a leading role or, in other cases, the hope of gaining access to specialties that provide better economic benefits or a better work-life balance.</p><p id="par0105" class="elsevierStylePara elsevierViewall">It is unthinkable that in the remainder of the 21st century, medicine will be provided only by a swarm of non-generalist specialties, no matter how advanced and technologically advanced they may be. It is not foreseeable that in a period of little more than half a century a clinical practice that has more than 20 centuries of history will disappear. As a result, and leaving aside the differences that may exist between continents and countries, which by the way, the poorest always lose out, a globalised world teaches us that diseases are similar in the way they express themselves and that what really changes are the social, demographic, economic and political conditions. In this context, a general practitioner who cares for people’s health from a broad-spectrum perspective will endure into the measurable future. How countries organise themselves to provide this care is up to them. In our case it has to be embedded in the European continent which, although still under endless construction, is our natural environment.</p><p id="par0110" class="elsevierStylePara elsevierViewall">And, above all, it must be planned with a long-term vision of what the health systems and the needs and profile of the professionals (not just doctors) of the future should be like. The inadequacies of this exercise in the past play an important part in the situation we find ourselves in right now.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In our view, those with responsibility, at whatever level, should consider a set of principles that will generate effective strategies. Strategies need to be tailored to each geopolitical environment, although some of them are widely applicable. The following are based primarily on the realities of southern European countries.</p><p id="par0120" class="elsevierStylePara elsevierViewall">A shortage of doctors <span class="elsevierStyleItalic">is expected in the next few years</span>.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Certainly, the balance between retirements and the number of medical school graduates is clearly in favour of the numerator. Yes, let us train more doctors, of course, but we must consider for what purpose and with what foreseeable consequences. Thus, for example: Will joint practice with other health professions or the replacement of tasks currently performed by doctors by these other professions change the health care landscape; what will be the consequences of the free movement of incoming and outgoing doctors in a given country; to what extent will technological advances facilitate, or replace, part of the tasks of professionals; will the increase in the number of graduates go hand in hand with an equitable distribution in the training of specialists? A few questions to discuss… and to decide.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The vicious circle in which <span class="elsevierStyleItalic">the Family and Community Medicine specialty</span> finds itself in Spain, apart from being a clear example of the crisis of generalism, is a situation that requires a profound analysis. It offers the highest number of jobs and has the highest number of vacancies. Substantial changes must be made from outside and from within the specialty. One thing without the other will not change the current situation. There are several components of this vicious circle. Working conditions are negatively conveyed to potential candidates (more often female candidates), who opt to choose other specialisation paths that allow them better working conditions, more possibilities to devote themselves to teaching and research, or to reconcile family life. Doctors who end up choosing it are less able to pursue an academic career, which means that they take longer to enter university educational establishments and are unable to provide a generalist view of the profession, not only in terms of teaching, but also because fewer reach higher academic levels (and they do it late) because their access to research is more difficult in comparison to hospital specialists.</p><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Uniting medical generalism.</span> Generalist specialties must come together to share issues that affect them in common, and the current loss of interest by the new generations provides an opportunity to do so. So far, this collaboration has been ad hoc and on an individual rather than an institutional basis. Some of the misunderstandings that may have arisen at certain times are the result of different visions between tasks belonging to one or another specialty or unempathetic interactions between some professionals in hospital departments or towards primary care centres, or vice versa. These occasional disputes should be turned into strategic alliances where everyone wins,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> starting with active or potential patients. It would also be an indicator that we are beginning to overcome the crisis and a strengthening element for the appeal of the relevant specialties.</p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The decisive role of medical schools.</span> Fifty years have passed since the selection and training of medical specialists in Spain moved from the universities to the government's health and education administration. Over the years, medical schools have made efforts to adapt their curricula to European standards,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> but despite all this, the weight of the students' academic curriculum when they graduate only amounts to 10% and, therefore, the key element in the choice of specialty and centre depends on the MIR (resident) exam. A situation that has been reported by the university deanships,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> which limits the impact of training during the undergraduate period on subsequent specialisation.</p><p id="par0140" class="elsevierStylePara elsevierViewall">However, the will and conviction of most medical schools is to train general practitioners, who will later specialise. Moreover, the inclusion of Family and Community Medicine doctors as university professors and lecturers will contribute to the concept of generalism being more present in the classroom. This is another example that should help break the long-standing vicious circle that access to academic chairs in medical schools has been in the hands of those who had more opportunities for research in the field of health sciences.</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Listening to the new generations of doctors.</span> We are facing an accelerated generational change. The feeling we <span class="elsevierStyleItalic">seniors</span> have is that many of the things we think or pass on to <span class="elsevierStyleItalic">juniors</span> are not part of their life expectations, or perhaps in some cases they are, but they realise this after they have already had some unpleasant experience. The future of generalism needs to take their opinion into consideration once they are at a mature stage of their education, e.g. when they are already at an advanced stage of their university studies. This debate can provide us with useful information in order to modulate all these changes that we believe are necessary at many levels in the training and preferences of future doctors.</p><p id="par0150" class="elsevierStylePara elsevierViewall">If these ideas are shared by people and institutions with the capacity to move in this direction, we will be jointly addressing a transcendental aspect to improve the training of doctors, their professional practice and, consequently, the health of the population.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have no financial support or conflict of interest. This paper has not involved animal testing and does not involve patients or human subjects. It also does not include clinical trials.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interests</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Past and present of medical generalism" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Future of medical generalism" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Protecting generalism: moving on from evidence-based medicine?" 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