Overcoming barriers to generalism in medicine: the residents' perspective

At a 1993 conference sponsored by the U.S. Bureau of Health Professions, a group of residents in several disciplines discussed barriers to generalism in medicine and ways to overcome them. In medical school, the barriers have to do with the lack of strong generalist mentors and lack of appropriate training in ambulatory generalist practice. In residency programs, the system does not support continuity of care and contains too few generalists as preceptors in clinical settings. The ambulatory clinic's inefficiency reinforces residents' frustrations and disillusionment with primary care practice. Further, the culture of medicine denigrates generalism and gives prestige and respect to subspecialists. In academic medicine, the dichotomy between scientist-physicians and clinician-physicians is a barrier. The public has adopted the perception promulgated by the medical leadership that generalists are less skilled and have less to offer than subspecialists. The residents offered recommendations for medical schools (changes in faculty and administration, curriculum, and financial support), for residency programs (changes in curriculum and structure), for the culture of medicine, and for public awareness. To increase the role of the generalist physicians, academic medicine institutions must pursue systematic, broad-based approaches to overcome barriers to generalist education and practice.