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Letters to the Editor

In Reply to Volpintesta and to Schwenk et al

Fins, Joseph J. MD, MACP

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doi: 10.1097/ACM.0000000000001124
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I thank my colleagues for their responses regarding my proposal to expand access and provide affordable, quality care to more Americans using an expert–generalist model.1

I was careful to delineate implementation challenges and propose preliminary demonstration projects, and thus was surprised by Dr. Volpintesta’s characterization of the model as “dangerous” and even “disastrous” for primary care physicians because it risked burnout and litigation. I disagree on both counts.

In fact, the expert–generalist model could be an antidote for burnout, providing intellectual growth and career renewal. New skills and competencies would not add to but alter one’s workload, leading to better patient care and professional fulfillment.

With respect to malpractice, as a physician ethicist, when I teach trainees about informed consent, I suggest that it is dangerous to practice medicine with an imaginary lawyer at the bedside. Focusing on risks at the expense of potential benefit to shield against hypothetical litigation can lead to the refusal of proportionate care and constitutes professional abdication.

This is equally true in health policy. The greatest danger to U.S. health care is a lack of imagination. Instead of malpractice fears squelching workforce innovation, we need to delineate scope of practice through board certification, and craft statutes and regulations that articulate community standards for expert–generalists. This process can inform fair and cost-effective reimbursement at intermediate levels between generalists and specialists.

Although much needs to be done, I am delighted to learn that the University of Michigan Department of Family Medicine has been utilizing something akin to the expert–generalist model for decades. Their experience, and that of other academic departments of family medicine, constitutes a proof of principle that could inform future dissemination and demonstration projects. Moreover, their experience points to the added educational value of expert–generalist faculty. As Drs. Schwenk, Green, and Zazove note, this can promote critical thinking and better integrate specialty knowledge within a generalist core. Exposure to such novel pedagogy can improve patient care, prepare generalists to better appreciate the scope and limits of their knowledge, and even prompt trainees to emulate their specialist–generalist teachers. The house of medicine has much to learn about implementing an expert–generalist model from its friends in family medicine.

Joseph J. Fins, MD, MACP

E. William Davis, Jr, MD Professor of Medical Ethics, chief, Division of Medical Ethics, and professor of medicine, medicine in psychiatry, medical ethics in neurology, and health care policy and research, Weill Medical College of Cornell University, New York, New York; [email protected]

Reference

1. Fins JJ.. The expert–generalist: A contradiction whose time has come. Acad Med. 2015;90:1010–1014
© 2016 by the Association of American Medical Colleges