The move to greater use of a generalist model is a key discussion point in the planning for the new Dunedin Hospital.

 

What is generalism in a hospital?

All hospital doctors, nurses and allied health staff use generalist skills to some degree, but the term generalist applies to teams who work with all patients within their discipline rather than just a specialised sub-group.

In the past few decades there has been a rise in the number of sub-specialities in medicine. This has been driven by factors including advances in medical knowledge and technology and rising patient expectations.

However, this model doesn’t meet the needs of our ageing population who often come to hospital with a wide variety of health needs requiring a broad spectrum of care.

Developing more generalist expertise, particularly in general medicine, means these patients with complex conditions can be cared for by one team instead of moving around a series of sub-specialist teams.

What are the potential benefits of a generalist model?

• Better management of complex health needs, particularly in the elderly.
• More focus on and contribution to community network healthcare delivery
• Shorter length of hospital stays
• Better discharge planning and reduced re-admissions
• Better learning opportunities in broad-based medicine for health professional students

What are the potential disadvantages?

• Inferior outcomes for some acute conditions
• Appropriate referral to some sub-specialist teams might not always happen
• Potential loss of some specialised expertise

Would a generalist model mean the hospital loses expertise?

If a generalist approach is introduced, it will mean a re-balancing of generalist and sub-speciality staff numbers in the hospital as there will be more generalist inpatients and fewer sub-specialist inpatients.

The care of people by generalist teams would be supported by specialists through a rapid and easily accessible consultation service.

However, this will free up sub-specialist teams to have a greater role across the SDHB district.

How would patients be affected?

A new system on how patients are admitted and cared for would have to be agreed to by all parties.

For example, frequently attending patients in a given sub-specialty may be automatically admitted to a sub-specialty bed. Patients who are new to the hospital or are admitted infrequently may be more appropriate for generalist care.

The research on the quality of care from generalists and sub-specialists is mixed.

Overall there is evidence that the outcomes for some acute conditions such as stroke and myocardial infarction are inferior for generalist teams but the management of less acute conditions is similar to sub-specialists. These factors would need to be incorporated into guidelines regarding allocation to generalist or sub-specialist teams.

Are there local examples where the system is already in place?

Some conditions such as infectious diseases have been managed by generalists at Dunedin Hospital for decades with a good back-up ID consultation service.

Aspects of endocrinology such as diabetic ketoacidosis have also been handled by generalists.

The physicians at Southland Hospital provide a comprehensive generalist service and in Dunedin the general internal medicine and Older Persons’ Health services offer a generalist service.

What about elsewhere?

This approach has been implemented to varying degrees in all other main hospitals in New Zealand.

In the United States the demands of the ageing population have led to an evolution in hospitals where generalist doctors are now responsible for much of the in-patient medical care.

Known as ‘hospitalists’, their number rose from 11,000 to 52,000 between 2003 and 2016.

The Royal Australasian College of Physicians has also promoted the need for more general medicine expertise through a position paper, ‘Restoring the Balance’.

The Council of Medical Colleges in New Zealand has released a similar discussion paper although this has a wider focus on all specialties.

 

This Q and A is based on a position paper produced by the New Dunedin Hospital project's Clinical Leadership Group