Saturday, May 2, 2015

Despecializing toward a generalist Medical education

One of the best persons to put generalism to practice in India currently in the defunct MBBS scenario (as pointed out by Raman in his email below) is the MD Pediatric physician who is essentially a complete general physician for the child.

Yogesh Jain (a pediatrician practicing in rural Chattisgarh) and Raman Kataria (a Pediatric Surgeon in the same location as Yogesh) have further extended this by practicing what has been termed 'de-specialization' by Dr Priyank Jain in an anecdotal observation shared in this book chapter here: (more about de-specialization in Chapter VI page may take a while to open as the link downloads the entire book).

However the above is just 'generalism' as we used to know it and it may have changed with time. Currently people may want to even specialize in 'Generalism' (although it seems to be a contradiction in terms). Also many primary care physicians 'globally' do have a special skill based focus where they may be practicing 'dermatology' or 'critical care' or 'emergency medicine' (think of any of the MBBS subjects here) in addition to what is/was deemed primary care.

In India i have seen cardio thoracic surgeons practicing 'primary care' treating their staff for fever and not hesitating to take advice from 'primary care physicians.'i have also heard anecdotes of MBBS surgeons performing closed mitral valvotomies in rural primary health centers (however that was probably a few decades back when a fresh MBBS intern performing appendix and hernia operations was not frowned upon but encouraged...currently it just seems like a pipe dream due to educational and legislative regulations). Perhaps it is the team work between knowledgeable and enthusiastic 'patient centered' health professionals that facilitates 'primary-care'  of the patient rather than any primary-care curriculum?

Generalism is an attitude that is innate in any successful practitioner of medicine who requires both 'skill' as well as 'attitude' to reach out to a larger mass of potential beneficiaries. It can be found in many prominent physician role models of present day India who have excelled with their skills in handling the microscope, ET tube, ultrasound probe, EEG, endoscope, scalpel or statistics (tools that shape skillful practice of their tacit knowledge). In India there are clinical physiologists who have the capacity to handle both the microscope as well as ultrasound probe and EEG toward the best interests of their patients (and i am sure there are similar clinicians in clinical anatomy, clinical biochemistry, clinical pathology, clinical microbiology, clinical pharmacology and other clinical MBBS subjects that have been for long labeled as non-clinical).

These role models other than their capacity to handle tacit knowledge requirements have at the same time managed to look after the overall requirements (including social, mental and financial wellness) of their patient beneficiaries.
Sometimes we need not even care for patients as patients (particularly when they are well) but just interact with them as humans as a part of their 'wellness' management (that can do with both explicit and tacit knowledge and this is where Health care IT shows promise).

Explicit knowledge supported by health care IT can make a primary care physician appear like a super/sub specialist in terms of knowledge although the 'primary care physician' would still need tacit skills that a focused competency based residency curriculum currently provides (and a computer cannot yet provide). Can we design a family/general-medicine curriculum that can take care of both these tacit and explicit knowledge requirements of the present-future? Only time will tell.

Meanwhile, we need to promote 'Generalism' in medicine for the primary beneficiaries of medical education (patients) and it is imperative that medical educationists try developing in their students, a patient centered 'primary care' attitude with skill based competency in focused areas and let patient requirements drive the current medical curriculum to produce skillful doctors expert in both tacit and explicit knowledge. 

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