End of the specialist era?

The current system of medical education “places disproportionate value on specialism.” These words appear in the foreword to Health Education England’s latest paper on The Future Doctor Programme. And this thought is more than just a throw-away comment. Moving away from over-specialism is central to the proposals HEE have developed through collaboration with other bodies. The fact that our system is predominately staffed by doctors who have gained deep expertise in one area at the expense of breadth is identified as a key reason for its shortcomings. The need to see numerous different specialists, even when conditions are related, “costs patient time and risks fragmented care, duplication and waste.”

So, what’s the proposal?

Step forward The Extensivist and Generalist. I’ve replicated the diagram HEE have used to describe the T-shaped skill-set of this Future Doctor. The idea is that a system where more doctors have both breadth and depth in capability will be genuinely patient-centred rather than disease-centred. Doctors with a T-shaped skill-sets are better equipped to manage multi-morbidity. They are more likely to see the big picture, recognise how and why one thing impacts on another and enable holistic management. So, their attention naturally shifts from treating a disease to patient care. Of course, there are still times when such doctors need help. When this is the case, their cross-discipline competence enables them to collaborate with others in a meaningful way.

And there’s more…

The Future Doctors described in the paper have more than breadth and depth in medical expertise. They are multi-faceted and multi-dimensional. They must be able to apply both the natural sciences and social sciences to clinical practice. Our Future Doctors are independent thinkers who are experts in managing uncertainty and ambiguity. They are confident in “resource stewardship… delivering quality care while balancing economic, environmental and social constraints.” The diversity of our population demands expertise in cultural awareness. They must understand the system they work in if they are to be able to optimise services. Leadership, followership and teamwork with the broad range of health and social care providers is essential. They must acquire knowledge about the general principles of scientific research. Then add expectations of excellent communication and teaching skills to the mix. The list goes on.

Many of these requirements are familiar. They are all present either explicitly or implicitly in Good Medical Practice. Yet, reading the lengthy list of “How Must Education and Training Adapt?” statements which appear in HEE’s document, the skill-set expectation of the Future Doctor sounds more like a multi-pointed star model than a simple T-shape.

Is the Future Doctor a realistic goal?

Going back to The Future Doctor Programme’s foreword, there’s recognition that, “For some, it will not go far enough or fast enough, and for others, it will feel like too much too soon.” The latter group may well include the doctors who have aspired to focus on specialism even before starting medical school. It doesn’t mean there will not be specialists. Just that their training and ways of working will be different than they are today. But there are questions over how to create this cohort of doctors who are Extensivists and Generalists.

Is it, for example, realistic for someone to develop the same depth of capability as the current specialist but also have this new desired breadth? How many doctors have the mental capacity to achieve both? Or is this breadth to be gained, to some extent, at the expense of depth? And, while we often think of steep learning curves, what of the “forgetting curve”? If you don’t regularly use what you’ve learned then you’re likely to lose it. After all, you can do anything, but you can’t do everything. So, there’s a risk that a longer time spent on broad-based training before specialism could be a wasted.

These are big questions with major implications.

What happens elsewhere?

Many employers in other sectors set out to recruit people with T-shaped skill-sets. But they struggled to find them. Such people can be few and far between, often found in the senior reaches of organisations. They have gained their combination of breadth and depth through many, many years in different roles, often across different organisations and industries. And their efforts at “creating” such people are typically doomed as their lengthy and costly development programmes lose direction. There’s always a high-risk point when the current leaders and sponsors of the programme move on.

But, if the idea of the Extensivist and Generalist approach is the key to efficient, effective, quality care, then these questions and challenges must be resolved. The Future Doctor must become reality. But how?

Sometimes it helps to look at things upside down.

Well, sort of. Rather than think about depth of expertise, let’s think about height. Let’s think about building a pyramid of skill rather than the point of the T drilling downwards. If you are building a pyramid, you will spend a lot of time on the foundations. Each time you begin to add height you will revisit the layers below right down to the foundations to ensure they are solid. You simply can’t imagine adding a new step if there’s nothing there to hold it in place. And you realise that a broad base with well-planned execution creates a more stable peak. Contrast that with trying to win the argument to widen the hole when drilling deeper and deeper downward as fast as possible seems to be bringing rewards.

Pyramid builders

Pyramid scene

Building a pyramid of skill is in itself a multi-faceted task. It requires excellent leadership, teamwork and communication. Planning, prioritisation and constant assessment is essential through robust management skills. It requires experts of many types who are capable teachers and mentors. Building multiple pyramids will require the commitment and co-ordination of everyone involved. So, the pyramid builders must optimise their own skills-set in terms of both breadth and height. The results will be spectacular!

What are you doing to develop yourself to play an active part in creating our Future Doctors?

Stephen McGuire – Managing Director