By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer
“What ever happened to the confident generalist?”
– Sachin Jain and Balu Gadhe, Health Affairs, 2021
Sixty years ago, in 1973, the United States passed the Endangered Species Act, creating special protections to prevent the extinction of species of animals and plants. In those days before modern DNA sequencing and cloning technology, the thought was that once a species became extinct, any special attributes and features of that species would be lost from the world forever.
Are generalist physicians and generalist nurses endangered species?
Twenty-five years ago, much of the primary care for Partnership members was provided by small private practices of family physicians, general internists, and pediatricians, who cared for their patients in their offices, saw their patients when they were hospitalized, and took phone calls from patients after closing time to provide guidance and advice. In those days before hospitalists became the norm, they worked hard, and the deep appreciation of their patients helped sustain them through this hard work. Generalists worked across settings consistent with their broad training.
In the past 30 years, Medi-Cal reimbursement has been largely stagnant, and in the last 20 years, Medicare reimbursement for outpatient care has risen far below the rate of inflation. Somewhat protected from this financial pressure were Health Centers, whose prospective payment reimbursement system did a better job of going up over time. The result has been a steady decline in the proportion of Partnership members cared for in private practices and an increase in the number cared for by Health Centers. Primary Care practices have expanded the use of Physician Assistants and Nurse Practitioners to reduce costs and allow increased capacity. The production pressure of many primary care settings compounds the pressure to not take the time to care for the broad range of patient problems.
In the midst of this, hospitalists took over the care of hospitalized patients, and the expectation of many primary care trainees seeking work-life balance is that they will not work in the evening or weekends, and not need to care for complex hospitalized patients. As a result, primary care physicians and non-physician clinicians such as Nurse Practitioners and Physician Assistants are largely caring for patients with similar levels of acuity.
The generalist physician is an endangered species.
Is something similar happening in nursing care?
While nursing school has brief rotations in different clinical settings, these are not enough to competently provide care in these settings without additional training. This extra training may be in rehab nursing, or critical care nursing, or ER nursing, or acute inpatient nursing, or pediatric nursing, or NICU nursing, or SNF nursing. Nurses may occasionally float to other settings due to staffing issues, but with the complexity of expected competencies, they are generally not well trained for these assignments. Training nurses to be generalists to care for several different settings in the hospital, where they have the training and experience to provide excellent nursing care in all these settings, is now rare. The result is that nurses express that they feel unsafe in covering nursing duties outside their narrow area of training.
One consequence of this for rural hospitals: they are likely to narrow their scope of activities over time due to the lack of specialty-trained nurses. This was the key contributory factor behind the closure of maternity units in three rural hospitals in the Partnership region in the past few years.
Well-trained generalist nurses are also an endangered species.
When a species is endangered, and saving the species would require economic sacrifice (not building a dam or a highway, for example), society actively chooses between allowing that species to go extinct in the name of progress, or preserving the species, even if that comes with an economic cost.
If the species becomes extinct, we can read about that species in books and stories, and reminisce about the days when that species existed.
Should we celebrate the endangered species of truly generalist physicians and nurses, and save a few from extinction, so we can learn from them and allow them to thrive in some protected environments?
Alternatively, is this just delaying their inevitable extinction? Should we carefully log what we know now, for future posterity and stop wasting our time training generalists who never actually become generalists?
The answers to these questions will impact how we think about residency training, nursing education, and the scope of care we can accept in rural communities. At a minimum, I think it is worth supporting pockets of excellence in generalist training and practice, particularly to better serve patients living in more rural areas. Not every physician or nurse will want to pursue a robust generalist path, but for those who are willing, we as leaders need to find ways to support them.