Re: Generalist skills are vital to serve ageing population, says England’s CMO

I Agree

Dear Editor

The belated clarion call for the optimisation of generalist skills to serve England’s ageing population[1] is best considered in the context of the complex dynamics of workforce planning[2], exclusion of non-EU medical graduates from training posts in specialist branches of medical practice (including general practice)[3], the UK’s subsequent exit from the European Union[4], and the subsequent increase in reliance on physician associates, not only in the context of primary care[5], where generalist skills should be the standard of care, but, also, in highly specialised scenarios such as neurosurgical practice[6].

All these parameters are interrelated.

Exclusion of non-EU medical graduates from the opportunity to embark on specialist training (including training in General Practice) amounted to a missed opportunity to benefit from the generalist skills of those doctors, some of whom would have imparted a much-needed generalist dimension, both to specialist clinical practice and to primary care practice, in the UK. On a more personal level, I had the benefit of 7 years’ experience in General Practice in South Africa[7] before coming to the UK.

As a junior doctor in the UK I rotated through a variety of posts (one characterised as General Medicine with a special interest in Gastroenterology), and another at Senior Registrar level in General Medicine without a special interest, before specialising in Geriatric Medicine, the latter with generalist publications to match[8],[9],[10].

Our exit from the European Union created a huge deficit, not only in the number of potential candidates for specialist posts, but also in the number of potential candidates for posts in General Practice. Reliance on physician associates to fill that workforce gap has been tantamount to recruiting an entire segment of the clinical workforce who do not have specific training in generalist skills. Notwithstanding the caveat that many physician associates have the benefit of 2 years’ university education as well as training on the job, I struggle to recognise that the generalist skills of a physician associate in neurosurgery are equivalent to the generalist skills of a medical graduate who has gone through a 2 year foundation programme[2] before embarking on a neurosurgical training programme. Likewise I struggle to recognise that the generalist skills of a physician associate in primary care are equivalent to the generalist skills of a medical graduate who has gone through a 2 year Foundation programme[2] before embarking on a General Practice training programme. What I do not struggle to recognise is that a neurosurgeon who exercises his clinical skills in the diagnosis and management of the entire range of neurosurgical clinical problems, including those that are perceived to be trivial, might, in due course turn out to be a more mature clinician than the neurosurgeon who is “picky” about what is within his remit. The same logic applies to clinical medicine at primary care level.

An unintended benefit of generalist experience is an enduring intellectual curiosity and fascination with all aspects of the complexity of clinical medicine. That kind of intellectual curiosity is the ultimate antidote to burnout. That is the intellectual curiosity that has sustained me in my post retirement years, hence my regular contributions to Rapid Responses

I have no conflict of interest

[1] Elisabeth Mahase. Generalist skills are vital to serve England’s ageing population. BMJ 2023;383:2640
[2[ House of Commons Health Committee. Modernising Medical careers. Third Report of Session 2007-2008. Volume 1. Published on 8 May 2008
[3] Morris N. Non-EU doctors barred from specialist training in the UK. The Independent 07 February 2008
[4] Martha McCarey. Brexit adds further complexity to the health and care staffing crisis. BMJ 2023;380: 208
[5] Ethan Ennals. GP chiefs call for a crackdown on NHS physician associates following a string of life-threatening blunders. Mail on Line 14th October 2023
[6] Michael Searles. Safety fears as non-medical staff learn neurosurgery on the job. Daily Telegraph 7th October 2023
[7] Jolobe OMP. Tips for young cardiologists or aspiring cardiologists. SA Heart Journal of the South African Heart Association 2021;18:16-18
[8] Jolobe OMP. Evaluation of renal function in elderly heart failure patients on ACE inhibitors. Postgraduate Medical Journal 1999;75:275-277
[9] Jolobe OMP. Does this elderly patient have iron deficiency anaemia, and what is the underlying cause? Postgraduate Medical Journal 2000;76:195-198
[10] Jolobe OMP. Fluctuation in levels of biochemical parameters on choledocholithiasis. JR Coll Physicians Edinb 2003;33:295

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Electronic Publication Date: 
Sunday, November 19, 2023 – 15:43
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Re: Generalist skills are vital to serve ageing population, says England’s CMO

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Oscar M
retired geriatrician
British Medical Association
BMJ: Additional Article Info: 
Rapid response

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