Thoughts of a Generalist

Warning! Gross Generalization Alert!

I read several blogs written by doctors. One of the familiar refrains is the lack of primary care physicians. While lifestyle and income play huge roles in medical students choosing specialties over PC, it occurs to me that part of the problem may be the competitive nature of getting into medical school, and the kind of people who are currently getting accepted.

To be good at Primary Care, and to really like it, requires a generalist; a person who knows a little bit about everything; a person who is comfortable having limits to their knowledge and is humble enough to admit to not knowing something. It requires a person who, even more than a specialist, can see the big picture and draw connections between seemingly unrelated events. A primary care doctor needs to be able to think globally and with a certain humility. In other words, the opposite of a specialist.

IMO, the kind of person who is likely to choose primary care as a specialty is less likely to get into medical school in today's climate. (This is not a "med schools are only admitting driven, socially inept, research geeks" sort of rant. The vast majority medical students I have known have excellent social skills and will make extraordinary physicians.) And I'm certainly not suggesting that generalists, and by extension, PC docs are somehow less intelligent or worse students than specialists. But, IMO, the kind of person who gets the spectacular grades is less likely to be a generalist. The specialist is more likely to be interested in the minutiae of a problem, more likely to enjoy focused work.

A specialist is more likely to enjoy research. For a generalist, research is usually mind-numbing torture. In my own case, my favorite part of a research project is the part when I do the initial literature search. The thrill of the chase, the hunt for information, and the drawing together ideas and conclusions to design the experiment. Actually doing the research drives me mad. So while admissions committees love to see publications in their applicants files, there is a set of applicants who, by their very nature, are less likely to have done enough research to acquire publication credits.

A generalist, on the other hand, is the sort of person who takes that upper level history course on medieval politics, just because it's interesting. And while the B they got in it was great for a non-history major learning about how the world works, a B in an upper level course is death for a med school application. In the past, when medical school was less competitive, it was easier for a few generalists to get in. Now, IMO, it's much more difficult.

I suspect in addition, that generalists are less likely to enjoy jumping through hoops. In the medical blogging world, there is periodic discussion about prerequisite courses for medical school; should courses like Organic Chemistry be scrapped for other more relevant ones? My question is not whether Organic Chemistry should be scrapped, but what kind of person will do well at it. In order to be a good generalist, we have to know how much information is enough. I think that even untrained future PC docs have excellent instincts for discarding deeper layers of knowledge. In the discussion about Organic Chemistry being a course to weed out students, it occurs to me that in addition to weeding out the students who simply won't be able to cut it in medical school some of the students who are being weeded out are being weeded out because they have good instincts for the irrelevant.

In my case, as a confirmed generalist, I did really well in those science courses that required I think globally: Ecology, Biochemistry, Genetics. I did less well in Orgo and Physics. And my instincts for discarding the irrelevant kicked in with a vengeance when I was taking Physics, Organic Chemistry, Biochemistry, and Molecular Genetics all in one semester (don't ask). I got good grades in Biochem and Genetics, and did less well in the other two, in part because I realized their irrelevance. Do I think that Physics and Organic Chemistry are totally irrelevant. Of course not, just largely so.

I think that many specialist types would look at a person like me, who has a variety of interests and has achieved a certain level of competence in a number of areas, and say, "jack of all trades, master of none." Which may very well be true. But isn't that exactly who you want as your PC doc? Some might look at my undergraduate record and simply call me lazy. But the courses I did well in, and the breadth of my undergraduate education tell the story of a confirmed generalist with good instincts for the irrelevant. (And two four year degrees completed in six, both earned with distinction, doesn't really say lazy to me. But I digress...) Isn't that what you want as your PC doc? Someone who has learned enough about everything to be able to do their demanding job, but who knows when they're out of their depth and when to call for help?

I think that in addition to solving the reimbursement problem for PC and the issues related to lifestyle, the profession (and in particular medical schools) will need to pay careful attention to the kind of individuals they are admitting into the profession. And in addition, they will need to pay attention to the kind of individuals they are keeping out.