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GIM Practice

The General Idea: From the Trenches to HQ

Hector M. Baillie*

Dr Baillie is a clinical professor of Medicine at UBC, practicing in Community based GIM in Nanaimo (Vancouver Island).

Corresponding Author: Hector M. Baillie: hbaillie@telus.net

Submitted: 26 December 2020; Accepted: 4 March 2021; Published: 2 January 2022

Doi: http://dx.doi.org/10.22374/cjgim.v16i4.587

All articles published in DPG Open Access journals
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).

Some titles mean different things to different people. The word “general” is a case in point. The online dictionary lists:

Adjective: general (from the Latin genus or generalis)

  1. Affecting or concerning all or most people, places or things: widespread

  2. Not specialized or limited in the range of subject, etc.

  3. True for all or most cases

  4. Normal or usual

  5. Considering or including the main features or elements of something and disregarding exceptions

  6. Chief or principal

Noun: general

  1. A commander of an army or army office of very high rank

  2. The general public: people

I hear the word general in General Store, General Delivery, General MacArthur, and General Electric. In my profession, it tends to mean “undifferentiated, not specialised, pertaining to a wide array of skills and services.” I am a General Internist but not an Internist General.

I guess I come across the word most often in General Practice. For me, general practitioners represent the essence, the mother-hub, the most historic face of our profession. We are trained to be familiar with all aspects of Medicine such as delivering babies, psychiatry, medical emergencies, and common surgical conditions. Some doctors then choose to focus on a single area, moving from a broad associative (horizontal) practice to one that is more specific (vertical) in nature. These two approaches are complementary.

Because the term “general” can be degraded to mean “common” or “nonspecialized,” we run the risk of devaluing the importance of a broad viewpoint and end up siloing patients into the care of narrow subspecialties.

What sort of doctors does a country like ours need in times like these? Well, we know that the population is aging, and with that comes degenerative disease and polypharmacy. Diagnosing and coordinating the care of these patients needs the input of multidisciplinary experts, called full-service family practitioners (in association with caregivers, nurse practitioners, pharmacists, etc.). These doctors are generalists, i.e., they look at all systems, all inputs and measures, and direct patients to whatever care resource is most appropriate (whether it be testing, referral to organ specialists, tracking response to treatment).

Of course, not everyone is old but seldom does a disease comes along in isolation. Diabetes without hypertension. Mental illness without social disruption. Alcoholism without employment consequences. Anxiety without palpitations. Sleep apnea without circulatory disarray. So, a “general” approach aims to cover off the substrates and outcomes of the primary illness.

General review can be done at a high level: general inter-nal medicine, general surgery, general psychiatry, or gen-eral obstetrics and gynecology. Many subspecialists are dual qualified by the nature of their work (e.g., nephrologists are generalists for sure). And all these generalists play a pivotal role in the tapestry of our health care system.

There has, in my career, been a tendency to view sub-specialists as being of “higher rank.” I am not sure why. We all went through the same fundamental training. Some chose to continue on to a wide-reaching practice, some choose a more focused career. The ranking does not make a lot of sense. Without the thoracic surgeon, the interventional cardiologist, and the radiation oncologist, we would be much poorer off. And vice-versa. Weft and weave, one cannot work without the other.

In training, there are—I believe—times when a narrow focus seems attractive. More income, higher status, less uncertainty, and paperwork. That might be true. But we should all be thankful we have a fabric of care based on family practice (FP).

The contraction of FP we are seeing now is of concern. New medical graduates have a high level of tuition debt. They also have a clear understanding of work/life balance, and may now be retracting from full-service FP. Hospitalist work, sports medicine, ER and oncology shifts – all of these are important – but the dearth of FSFPs limits our ability to provide optimal longitudinal and preventive care. Well, who wants to pay increasing amounts of overhead, do substantial administration, deal with onerous paperwork, and have huge demands on time and skill that are mostly undervalued and unpaid? No one.

One could say the same of any of us. Give us the resources to do a good job, pay us according to the impact we have in our community, and recognise the fact that we all need time with family – just like everyone else.

In general terms, it makes sense…