The rise of generalists in the age of complexity

Medicine is becoming increasing complicated. New knowledge is being published every year, with research showing that 2.5 million new scientific papers are published every year. The digital revolution has improved access to knowledge immensely, but it has also made things overwhelming. Studying medicine is quite a frightening because it seems never ending, that you will never know enough. It is frightening because how much you know might determine if someone lives or not when you are providing treatment. ‘It is impossible to memorize everything’, is the most common thing I hear from my fellow classmates. From different organ systems, anatomy, biochemistry, and drugs and procedures – in addition the new knowledge that is being published everyday, how can doctors make sense of it all?

The medical field has responded to this explosion of knowledge with the compartmentalization of the human body, the specialist. Each organ system has its own specialist; a cardiologist for the heart, a neurologist for the brain. And specialties are further divided into subspecialties. An orthopaedic surgeon may decide to work solely on the shoulder, and nothing else – a super-specialist. Looking back on this trend, it is only natural to see why this compartmentalization arose. The large volume of information makes it impossible for a single doctor to manage every disease and condition and treatment. The segregation of specialties also ensures that the patient will be taken care of by the expert for his or her particular condition, and will receive the best possible care.

This approach works if symptoms are clear-cut and the condition obvious. However, as our population ages, the medical conditions seen will become more complex and integrated across multiple disciplines. The specialists have its place, but in the face of new challenges, this compartmentalized approach may be contributing to fragmented and disconnected care. It is not helped that in certain countries, the patient may approach the specialist directly, circumventing the generalist altogether. In the age of the internet, patient self-diagnosis and seeking of a super-specialist may help save time – but it could also miss out critical symptoms of a larger, more comprehensive underlying problem.

How should care be coordinated effectively in hospitals and communities, while balancing the need to address the patient’s condition holistically while dealing with the massive amount of information out there? Generalists such as General Practitioners (GPs) and Internists (essentially ‘specialists’ in providing general care), are responsible for performing such a role, and have the virtue of knowing ‘a bit of everything’. Generalists have been essentially side-lined for decades in the era of super-specialists. Among the medical specialties, they are among the least compensated (with orthopaedic and plastic surgeons topping the pay list. But in this age of chronic, complex conditions, continuity of holistic, integrated care may be the way forward. Specialists remain indispensable, but perhaps there is a need for the role of generalists to be strengthened, to be the coordinator of care for the patient.