- David Oliver, consultant in geriatrics and acute general medicine
- davidoliver372{at}googlemail.com
Follow David on Twitter @mancunianmedic
The case for a greater focus on medical “expert generalists” in the NHS has been in the health policy news recently. The NHS England diagnostic review of postgraduate medical training, which I discussed in my last BMJ column,1 was clear on the need for more doctors with good generalist skills, to reflect the reality that our ageing population has a growing number of people with multiple long term conditions. Chris Whitty, lead coauthor of that report and chief medical officer for England, made a similar case in his 2023 report Health in an Ageing Society,2 calling for doctors with the training, skills, and mindset to support a population with those changing needs.
Doctors will increasingly be caring for patients with undifferentiated symptoms or several simultaneous conditions, often compounded by frailty or by age related cognitive or functional impairment. These patients need multiple medicines and have competing management priorities and trade-offs, use multiple services, and are often nearing the end of life. They will benefit from skilled all-rounders who can coordinate and support their care, with the ability to look beyond a narrow single disease, organ system, or intervention and without having to refer to other doctors for every issue outside their specialism.
In October a report by the Re:State policy think tank, Hospital of the Future,3 called for more generalist hospital doctors in adult internal medicine who could look after patients throughout their whole stay in hospital and so help with patient flow, senior decision making, and discharge planning. Looking to the “hospitalist” model in North America, said the authors, could help “end patient gridlock.” They recommend creating a new specialty that focuses explicitly on providing clinical generalism in hospitals. But expert generalists already very much exist in our system.
GPs are trained precisely for this role in primary care settings, and England alone had over 380 million primary care appointments in 2024-25.4 But generalist disciplines exist in acute secondary care too. Specialists in emergency medicine might have their role defined by the acuity of presentations and the locations they work in, but they also see a huge range of pathology, including undifferentiated symptoms. Likewise, doctors in intensive care medicine require high end generalist skills.
Geriatricians are trained and certified both in geriatrics and in adult general internal medicine for all ages. Our job frequently involves looking after patients throughout a hospital episode from acute admission to discharge, including a focus on post-acute rehabilitation, multidisciplinary assessment, and discharge planning. Many of us also work in community healthcare teams outside the hospital walls and bring our generalist training to acute stroke care and surgical liaison.56
Many geriatricians also work in roles in acute internal medicine, which is a specialty in its own right.78 These practitioners have excellent broad experience through emergency, general, and critical care medicine and are skilled in ambulatory care, undifferentiated presentations, patients with multimorbidity, and helping patients return home before requiring follow-up care. If physicians in acute internal medicine don’t hold a certificate of completion of specialist training (CCST) in the specialty, they will otherwise hold specialist certification in general internal medicine alongside another organ based internal medicine discipline. Of those who gain a CCST in specialties such as respiratory medicine, gastroenterology, diabetes, endocrinology, clinical pharmacology, renal medicine, or rheumatology, most will also dually accredit in general internal medicine.9
Engine room of the NHS
General internal medicine training in the UK is already as long, rigorous, and serially assessed as in any country, and doctors gain a huge amount of experience dealing with a very broad range of patients. We don’t need to recreate or rename medical generalism, but we do need to value, support, and expand it. Let us increase the number of geriatricians and acute internal medicine physicians we train and employ, as they are key to getting patient flow and early assessment right. We should also ensure that doctors in other specialties who dually accredit in general internal medicine have enough of their job plans protected—at least in the early part of their consultant careers—to maintain some time for working on ward and acute based general internal medicine so that other responsibilities don’t always take precedence.
Meanwhile, teaching throughout medical school should make it clear that the job for many modern doctors in adult medicine will increasingly be to look after patients with multiple conditions and biopsychosocial complexity, where single disease or organ protocols don’t work. We need to value that aspect of the job more, rather than seeing it as an encumbrance to more narrowly specialised work that people might see as more prestigious. “Expert generalism,” whether in primary or secondary care, is its own specialty, and it needs parity of esteem.
Most importantly, we need to improve recruitment, retention, and working conditions in general practice, the engine room of the NHS. If the government wants to make any headway with its ambitions to move more care out of hospitals or to shift the focus of care from reactive to preventive, it needs to ensure that the GP contract is far better funded and has the flexibility to ensure that the additional GPs we train can actually find work.
