Developing the modern generalist for the community setting

Kay Mohanna

Principal lecturer in medical education Staffordshire UniversityAssociate Dean for GP assessment West Midlands Deanery

The nature of generalism

• What is a generalist?

• ‘Holism’ in medicine

• How does the new GP curriculum support training for generalists?

Generalism

The ability to care for undifferentiated patients

Maybe with vague, multiple or hidden diagnoses

• 65% of over 65 year olds have two or more conditions

• 60% GP presentations ‘MUS’Not unreal, or unimportant, or insensitive to medical intervention.They are simply ‘diseases withoutname.’

Franz Kafka. A Country Doctor

“…To write prescriptions is easy, but to come to an understanding with people is hard…”

A ‘high tech’ world

Often uses algorithms

Imagined diagrams of how the doctor might think, and how the doctor might make choices.

They are interesting abstractions.

But they do not truly reflect the complex pathways of clinical reasoning required in general practice

Hospital Practice

General practice

Increasing likelihood of pathology

Breadth of focus of investigation

Competence

GPs need expertise in excluding the presence of serious disease

Specialists need expertise in confirming its presence

Balancing risk

“…Specialists aim to reduce uncertainty, explore possibility and marginalise error, [the generalist aims] to accept uncertainty, explore probability and marginalise danger…”

Marshall Marinker. Bayliss Lecture.

RCP, 1994

Co-ordinator of care.

Specialists: Increasingly expert in ever-diminishing areas of expertise - care can become fragmented.

Barriers between sub-specialties grow, healthcare systems can become more inflexible.

Generalists: increase communication between and within specialities bringing their wider perspective to the discussion of patient care

So what does society want from doctors?

“Medicine is not only a science; it is also a healing art. It deals with the very processes of life, which must be understood before they may be guided.”

Paracelcus

Born 1493 inEinsiedeln, Switzerland

- alchemist, physician,astrologer,and occultist

Tomorrow’s Doctors…

Should show respect for patients and colleagues that encompasses without prejudice, diversity of background and opportunity,language, culture and way of life

GMC 1993

Tomorrow’s Doctors…

Must have a recognition that a blend of scientific and humanitarian approaches is required, involving a critical approach to learning, open-mindedness, compassion and concern for the dignity of the patient

GMC 1993

In addition…..

The thing is…

….medicine is a difficult job

“For my entire career I have been convinced that general practice is the hardest specialty to do well, and probably the easiest to do badly. GPs deal in uncertainty all the time—the next patient could have schizophrenia or piles, unhappiness or cardiac arrest, anything and everything, and in no particular order.

So the question of which specialty needs the best training … is something of a no-brainer, as our neurology colleagues might say”

David Haslam BMJ Career Focus 2005;331:151-152

Education….

Facilitates a change in an individual so that she or he may function fully

Rogers 1983

“Healthcare professionals exercise their judgment based on skills and training,

but they are also whole personalities, and quality as perceived by patients is determined by their whole approach.

Holism is a two way street - the whole practitioner deals with the whole patient.”

Jenkins 1999

Domains of learning

• Cognitive

• Psychomotor

• Affective

Back to Paracelsus

“The universities do not teach all things, so a doctor must seek out old wives, gypsies, sorcerers, wandering tribes, old robbers, and such outlaws and take lessons from them. A doctor must be a traveller...

knowledge is experience.”

“To be a good doctor you have to be a compassionate chameleon, a shape shifter - a shaman. Even if your adaptation to your patients' world happens at an unconscious level you should always work within their system of ideas, never against it...”

Cecil Helman

…So how do we reach beyond the ordinary?

It's when we create or laugh or are inspired.”

Joanna Shipley http://www.shaman.org.uk

Poetry has the power to remind us that we are hunters and gatherers of values.

That our very solitude and distresses are creditable, in so far as they, too, are an earnest of our veritable human being.

Seamus Heaney 1995

“It is at the point where medicine and art collide, that doctors can re-attach themselves to the human race and re-feel those emotions which motivate or terrify our patients….Every contact with patients has an ethical and artistic side as well as a technical one.”

Fairle J. www.bmj.com rapid response,November 1999

The art of medicine is unique in that it alone seems to occupy a middle place. Medicine has to deal with human personality and human hopes, human fears and human failings, in conjunction with the material body which is liable to so many disasters in the physical environment of our existence….. so that a purely scientific education is inadequate for a profession which deals with so close a relationship between mind and matter’

’

1945 Dr Clarke-Kennedy ‘The Art of Medicine in relation to the progress of human thought’

Pennsylvania State University

College of Medicine

“There is continuing concern that medical technology, and the need to keep abreast of current scientific developments, threatens to pre-empt medicine’s traditional concern for human values.”

1967

This concern extends to assessments of learning in medicine too.

‘In our over-eager embrace of the rational, scientific and technological our concept of the learning process itself has been distorted.’

Kolb, D. A. (1984). Experiential learning: experience as the source of learning and development.

Cited by David Sales former nMRCGP Convener

“Video assessment in GP training risks leading to a gross distortion in learning the consultation process”

Mike Deighan

Former RCGP Curriculum Fellow

Patient – “I’m bordering on serious violence”

Doctor – “Are you still taking the hormone tablets?”

Doctor – “How are things at home?”

Patient – “Okay - We went away for a last ditch attempt to sort things out.”

Doctor – “So you’re quite relaxed?”

Patient (with headaches)

“My husband says I should come up – just in case it’s something different”

Doctor – “ What’s your job?”

Doctor - “Any problem?”

Patient – “Just, Dad died”

Doctor – “Any symptoms?”

Patient – “I’m going to be redundant in June”

Doctor – “Are you all catarrhal?”

The most basic skill is the ability to have comfort with uncertainty, to recognise it with humility, to be open to the ever-present possibility of the surprising and the mysterious and even the holy, and meet people there

Rachel Reman, oncologist(in Suburban Shaman. Oscar London.)

The search for meaning

“Living with chronic illness is not simply a physical affair .. it is our ontology, a condition of our being in the world.”

R.F. Murphy, The Body Silent. (New York: Henry Holt, 1987.)

John McCann University of Windsor, CanadaLiving with chronic illness: subjective contributions toward a

patient- centered ethic 1999

“Nothing so concentrates experience and clarifies the central conditions of living as serious illness. The study of the process by which meaning is created in illness brings us into the everyday reality of individuals like ourselves, who must deal with the exigent life circumstances created by suffering, disability, difficult loss, and the threat of death. Yes, chronic illness teaches us about death; but the process of mourning for losses is also central to healing”

Personal loss

Medical Humanities

We define the term "medical humanities" broadly to include an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, personal narrative, psychology, sociology), and the arts (literature, theatre, film, and visual arts) and their application to medical education and practice.

Literature, Arts & Medicine Database http://

medhum.med.nyu.edu

The healing arts centre

Pennsylvania State University

college of Medicine

The Healing Arts Centre

www.hmc.psu.edu/humanities

Blooming Soul: Lynda Hoffman-Snodgrass

www.ravenhousearts.com

The MAP Foundation

Using the creative arts to express and communicate complex and painful issues relating to serious illness and dying

Picture10.jpg

http://www.mapfoundation.org

Michele Petrone

“The illness stole a place and a time that should have been destined for better things.”

This illness has invaded my life, knocked me off balance and made me feel out of control. I no longer feel the strength and direction I once had, I'm just a passive passenger, being carried whichever way these arms take me. But I still feel a need to direct my life, to feel this life of mine is still mine, so please: "carry me this way". 

“I need to know that this body is my body. And I need to know everything that is happening to my body.

But most of all I need to know that you know that within my body there is me.”

“The physical illness is visible and life threatening.

The emotional feelings, the electrical impulses of my soul, cannot be seen. As they are invisible it is easy to pretend that they are not really there. They don't at first seem to be as important as the cancer on the microscope slide. Yet they can be just as life threatening as the visible cancer itself.”

The GP Curriculum

The six domains of core competences

1. Primary care management2. Person-centred care3. Specific problem-solving skills4. A comprehensive approach5. Community orientation6. A holistic approach.

The three essential features

Contextual using the context of the person, the family, the community and their culture

Attitudinal based on the doctor’s professional capabilities, values and ethics

Scientific adopting a critical and research-based approach to practice, and maintaining this through continuing learning and quality improvement

The GP Curriculum

Architect: Shake SeigelClerk of works: Kay Mohanna

Scientific

Attitudinal

Contextual

A holistic approach

Community orientation

Primary care management

Person-centred careSpecific problem-solving skills

Comprehensive approach

Workplace Based Assessment

“Addresses the majority of the curriculum, assessing those parts that are best tested in the workplace.” 

Twelve areas of professional competence have been extracted from the core curriculum statement ‘Being a General Practitioner’

12 domains of professional

competence • Communication and

consultation skills• Practising holistically• Data gathering and

interpretation• Making a

diagnosis/decisions• Clinical management• Managing medical

complexity

• Primary care admin and IMT

• Working with colleagues and in teams

• Community orientation• Maintaining performance,

learning and teaching • Maintaining an ethical

approach• Fitness to practise

Competency Area MSF PSQ COT CBD

Communication and consultation skills   Practising holistically Data gathering and interpretation Making a diagnosis/decision Clinical management Managing medical complexity  Primary care admin and IMT   Working with colleagues and in teams Community orientation Maintaining performance    Maintaining an ethical approach Fitness to practise        

• “Read this patient narrative and come prepared to discuss what you can hear”

Tutorial Topics

“The disbelief, the grief, the doubt, the flung out, the anger, the banter, the bargaining, the accepting, the clenching of teeth, the sick to the teeth, the pain, the no-gain. Why me? Why me now? I'm living, I'm dying. I want to live and escape it, I want to die to escape it. I'm trapped and that's that. Get me out of it. I hate it. I hate it. I hate this illness, what it's done to me. It took away my love - my love of life, my freedom - freedom to love. It threatened my life. I want my life back. This is not me.”

12 domains of professional

competence Communication and consultation skills

(Active listening, interpreting language)Practising holistically

(understanding the person inside the illness)

Managing medical complexity

(Illness is more than just pathology)

Community orientation

(Isolation, social networks, ‘flung out’)

Maintaining an ethical approach

(First do no harm)

Tutorial Topics

“Look at this painting and tell me what you see….”

12 domains of professional

competence • Communication and consultation skills• Practising holistically • Making diagnosis/decisions• Clinical management• Managing medical complexity • Working with colleagues and in teams• Community orientation• Maintaining an ethical approach• Fitness to practise

Tutorial Topics

“There are 1,200 recent studies on the health and religion/spirituality relationship. How do you feel about the prospect of modern medicine prescribing prayer?

Consider the following papers and come prepared to discuss them…”

• A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Arch Int Med 1999;159: 2273-8

• The efficacy of "distant healing": a systematic review of randomized trials Ann Intern Med. 2000;132:903-10.

• Retroactive prayer: a preposterous hypothesis? BMJ  2003;327:1465-468 

12 domains of professional

competence

• Practising holistically • Data gathering and interpreting• Making diagnosis/decisions• Managing medical complexity • Maintaining performance, learning and teaching • Maintaining an ethical approach

Generalism

• Technical competence; medical knowledge, advocacy and communication skills, critical appraisal skills

• Patient-centred disease-centric, recognising the diversity and vagaries of patient experience and expectation.

• Negotiation: distinguishing between absolute and relative risk, patients’ need and wants, balancing individual and society

• Personal growth: reflective practice, life-work balance and understanding of human nature.

Marinker

Professionalism comes from the quality of our education, not from the quantity of our training.

Training simply prepares us to solve clinical puzzles in a predicted and approved way.

Education prepares us to tackle problems which the learner cannot foresee, by means which the teacher himself cannot imagine.

kaymohanna@aol.com