Currently specialization divides medical disciplines into sectors, much like slices of a cake. The results are that (i) patients with multiple morbidities are shunted from one doctor to another to another etc., (ii) it is impossible to have all the necessary specialists in one place unless that place is sufficiently large (and wealthy), (iii) emergency cover is unsustainable in all areas unless certain specialists double for others, (iv) the inevitable consequence is that a specialists, even if perfectly trained and competent, cannot deal with a patient with a malady accorded to a different specialty than his own, (v) specialists leave the simpler aspects of their field to their juniors, as they prefer to deal with the complex, "more interesting" issues (except in private practice). (vi) the system is more and more expensive to run, (vii) specialization leads to further "super-specialization" and further fragmentation of medicine, (viii) the model is exported to LMICs with catastrophic results as they cannot afford nor accommodate such a system, (ix) inevitably medical schools will be pushed to limit training of their students pertaining to their final specialty destination, (x) the specialties are themselves not defined and "turf wars" are created in bordering areas of practice, both in terms of departmental control and patient care.
There is no proper definition of the generalist, neither in medicine nor surgery. Yet, on the shoulders of this dying breed rests the burden of most "ordinary" patients' treatment worldwide.
Where therefore are we going? Is it not time to define the "Generalist" as a "Specialist" in his own right, and let him deal with the central part of the cake, leaving the periphery to be divided by the particulate specialists?
After all, everyone knows that the cherry is usually in the middle of the cake.
Ha Ha Ha Ha Ha.
Why is this even a question? The answer is obvious to all except the partialists who believe that knowing more and more about less and less entitles them to earn more than the general specialists, and especially than the general doctors. Lord Moran: then President of the Royal College of Physicians, expressed it in, I think 1948, that it is obvious that generalists have fallen off the ladder of progression, and therefore do not deserve equal consideration.
The Colleges of General Practice/Family Medicine have been fighting back since, but we get fine words from those in charge saying yes, the GP/FP is the backbone of the healthcare system, followed by no action to remedy the situation. When rural doctors make a large enough noise, they get a little extra, but there are too many generalists for it to be convenient to restore a reasonable balance, as it would cost too much. Even though we are the majority in most national medical organizations, many of the committees have a representative from each group of specialists so we are structured into a minority. Besides, the medical politicians from General Practice are too polite to push back. Besides, who makes policy? Usually fit healthy, young to middle-aged bureaucrats and politicians. Their health care needs are largely for acute care: for their fracture while skiing, or their MI, or possibly for their curable cancer. They may have one chronic medical problem, like asthma, and likely go to a private specialist for that too. So they see health care needs as being for more hospital specialists and gadgets. They hear about the dramatic research outcomes: from specialists. The lobbying groups are mainly funded by the wealthy doctors: the specialists, and often they have the funds, and the flexible time to put into supporting political parties, especially those without a social dimension to their policy..
Who needs generalist care? The chronically ill, especially those with multiple diseases, mothers with young children, the elderly. But these have left the stress of policy positions, even if they continue in public service. The other major group are the poor who are unable to seek specialist care, but who have no political weight. So our allies - those who understand the value of generalists - are outsiders too.
It reminds me of the King James Bible: Matthew 13, verse 12.
If anyone can find a way out of this conundrum, please let me know. I have tried in my own small way all my academic life. Please show me I am too pessimistic!!
My apologies for my nuanced take on your question and the accompanying elaboration Michael.
For me there needs to be clarification on various points to be sure that we are on the same page. First, by division of the medical cake do you mean total health spending by sector? Second, by "proper" division do you refer to an agreed upon allocation level bereft of value judgement? Third, by generalist do you mean the general practitioner (GP) or primary care physician or the hospitalist - in the context of the US? Just focusing on the third point, although the GP can be considered one and the same to the primary care physician the competencies between the two can be vary varied between health systems.
Cheers.
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