Generalism and orthopaedics

By Helen Cattermole

Introduction

“…Generalism is an approach to the delivery of health care, be it to individuals, families, groups, or to communities. Its principles apply wherever and whenever people receive care and advice about their health and well-being. The generalist approach applies equally to individuals and to clinical teams. It is one facet of medical professionalism. Those adopting a generalist approach…will need to recognise the limitations of their skills and experience and know when and where to enlist the most appropriate help, support and advice from colleagues – working across inter-professional boundaries and recognising the interdependency of professional skills”¹.

“It is possible and desirable to have both a specialist and a generalist skill set; a specialist without generalist skills will be ill equipped to deal with many of their patients… A holistic professional approach is essential”².

Within orthopaedics, we have increasingly adopted specialist or even super-specialist practice. The definition of a generalist orthopaedic surgeon is still primarily related to a surgical interest in more than one area of the body³, rather than a holistic approach to the patient. Indeed, the ‘holistic orthopaedic surgeon’ is often the butt of jokes and memes.

While specialist working is undoubtedly beneficial for surgical outcomes⁴, if we focus too much on our specialty area without considering the patient as a whole, we run the risk of causing detriment to their overall care. For example, recently a colleague declined to X-ray a patient’s healing femoral fracture because they were treating their fresh humeral fracture; the patient had to return for femur X-rays. This was not a rogue event; it happened twice that week with different surgeons. “Specialisation encourages doctors to look at the parts rather than the whole and this can result in a less person-centred approach to the delivery of care. It can also lead to the medicalisation of complex problems and to increased risks associated with greater interventions.”⁵.

The Shape of Training review⁶ recognised the need for greater generalist skills, and current surgical curricula⁷ incorporate generic professional capabilities to reflect integrated values and behaviours.

The Future Doctor report⁸ recommended that doctors, working within the multi-disciplinary team, needed to become ‘extensivist and generalist’ in addition to developing specialist skills. “Future Doctors will…have a deep and nuanced understanding of the healthcare needs and priorities of…populations...This, coupled with a robust knowledge about the wider healthcare system, will enable [them]… to work collaboratively with other healthcare professionals and disciplines to implement innovative ways to improve the quality of healthcare services…Future Doctors will…foster a culture of innovation…They will…understand the needs of individuals and populations and have a broad range of generalist clinical skills that are applicable across different specialties and healthcare environments”⁸. The Enhancing Generalist Skills (enhance) programme⁹ has therefore been developed to incorporate this training into medical and multi-professional practice.

The COVID-19 pandemic brought into sharp focus the necessity for flexibility, adaptability and rapidity of movement, and also highlighted significant issues brought about by existing health inequalities. During COVID we were not only expected to work differently, adapting our clinical skills to a new, emerging condition, but to train differently, use more digital technology, understand the importance of wellbeing within the workforce, demonstrate leadership even when we were ourselves uncertain, and to reflect on all of this both in the moment and after the event. These are all generalist skills, and those of us who were quickly able to adopt these skills adapted better to the conditions of the pandemic.

If it is acknowledged that trainees need to have better generalist skills, then what is the situation for trained orthopaedic surgeons? Is this a trend they can ignore, and focus on their specialist skills, or is this something that applies to us all? What indeed is generalism as it applies to orthopaedics?

Using the framework of the Enhancing Generalist Skills programme⁹, the following illustrations give some practical examples of generalist clinical and behavioural skills which might be relevant to orthopaedics. This is not an exhaustive list, by any means, but shows areas where we may have lost our way.

Person-centred care

Most orthopaedic surgeons would consider themselves, and their practice, to be ‘person-centred’; indeed, many of us, including me, take pride in our approach. Yet, how many of us can truly say that our patients experience whole-person, coordinated care in a busy fracture clinic, or that patients are involved in decisions about their health and care on the trauma wards? How often do we delegate the management of our frail elderly patients to junior doctors once the proximal femur is fixed? Do we know that the ward team has the skills to function effectively and the resources to effect change? Do we know, or care, how much the patient and their family are involved?

Person-centred care is about putting the patient at the heart of everything we do; not the service, the surgeon or the staffing¹⁰. It is about compassionate care, coordination and communication¹¹. Many of us do this very well in the independent sector, but the pressures of the NHS are such that we are too busy, too under-resourced, stretched and stressed to do this at other times. Yet, for the patient, their encounter with the surgeon and the hospital is a significant life event. Surely this should be treated with the importance it deserves?

Recently, a patient said to me “You doctors forget that you are in your workplace, familiar with your surroundings, understanding the noises, the smells, the jargon. But we are in a strange environment, worried by everything unfamiliar, anxious we are going to forget something, or be told something nasty. You need to walk in our shoes to experience the system as we see it.”

How can we do things differently to put each patient’s individual needs to the forefront? How can we involve patients in their decision-making? How can we approach the problem from a different angle?

Complex multi-morbidity

As orthopaedic surgeons, we do not treat the affected limb or joint in isolation but as part of holistic care for that patient. Yet repeatedly colleagues are overheard to say “I’m an upper/lower limb/left big toe surgeon, I don’t know anything about the heart/kidneys/right big toe”. Many of our patients are frail elderly, or have systemic conditions such as rheumatoid arthritis, cancer, or diabetes.

“Treating each disease in a patient as if it exists in isolation will lead to less good outcomes and complicate and duplicate interactions with the…system.”²

While we are masters of the surgical management of bone and joint disease, and are not required to have expertise in the medical management of complex multi-morbidity, we all qualified as doctors and have a licence to practice. Should we not therefore maintain a basic level of current medical knowledge and skills? Such knowledge allows us to supervise our teams, manage handover, review prescriptions, make appropriate referrals and minimise unnecessary investigations.

In clinic, maintaining an understanding of interacting medical conditions allows person-centred discussions about appropriate surgical interventions, optimisation for theatre and coordination of care¹². Many experienced consultants gain a working knowledge of the conditions they see most often, but others may need to make an active effort to grow their medical skills. In modern medicine, it should no longer be possible to make jokes about orthopaedic surgeons and ECGs.

However, the proportion of patients with two or more simultaneous medical conditions is steadily rising¹³. “The multi-morbidity trend presents challenges to the entire medical profession…Greater specialisation, especially for hospital based doctors, has improved our ability to treat single diseases, but unless we react to the increase in multi-morbidity it will disadvantage the increasing proportion of patients with multiple seemingly unrelated diseases”². We can no longer bury our heads in the sands and delegate the management of our patients to our juniors, but need to develop alternative team-based systems to ensure that patients with multiple health conditions are managed effectively, efficiently and holistically.

System working

Population health and social care needs are changing, and the NHS is changing with it. As system leaders, we need to understand the changes to prevent disjointed and inefficient services, and to ensure that we meet the needs of the population. The complexity of the health service causes challenges for patients and staff, yet many of the changes can have positive benefits. For example, new roles in primary care include health coaches who can help optimise patients for surgery, and social prescribers who can assist patients to access support, or help international doctors relocate. Yet, these roles are poorly understood within primary care, let alone secondary care¹⁴.

There is increasing emphasis on collaboration and cooperation rather than competition within the NHS, particularly with the formation of Integrated Care Systems within England¹⁵. This will involve creation of new networks, cross-organisational working, and patterns of community care. If we are to influence these changes, using our experience of managing patients from cradle to grave through both injury and disability, then we should not only understand them but be involved at strategic and local level. Change fatigue is real, but we are team leaders and, rather than disengaging, we should be using our voice to influence patient care, training and education.

Population health

At first glance, it is not obvious how orthopaedic surgery can reduce the occurrence of ill-health across whole populations, and influence the wider determinants of health. However, particularly in research we have the opportunity to reduce mortality and morbidity with our actions. In developing novel and improved treatments, in basic science research and in epidemiology, we have the chance to change the health of the population.

We also have a daily opportunity to influence population health in our clinical interactions, by using the principles of Making Every Contact Count¹⁶. This is particularly effective within trauma, for example educating patients around smoking in relation to fracture healing, or taking advantage of a hospital admission to instigate alcohol support. Screening of fracture patients for osteoporosis and starting bone protective agents, thus reducing the risk of further fractures, is a potentially life-saving intervention. Increased physical activity after successful joint replacement is likely to contribute towards improved cardiorespiratory health and psychological wellbeing.

Social justice and health equity

As clinical leaders within the health service, orthopaedic surgeons are well-placed to improve social justice within their communities. For example, as supervisors, team members and senior clinicians we can demonstrate allyship and protection against workplace discrimination^17-20. We also have a responsibility to ensure fairness and equity for our patients. It is incumbent upon us to ensure that patients are able to access the care that they require, irrespective of background, and this may entail imaginative and innovative solutions, for example in looking after minority communities, refugees, and victims of torture.

Within teaching we need to ensure that we are fair, removing discriminatory language or biased clinical material from exams, decolonising the curriculum, and undertaking activities such as reverse mentoring to make us more aware of the issues faced by our trainees.

Finally, we need to ensure that our practice is free from the effects of modern slavery, ethically sourcing our instruments, gloves and gowns. Accepting that many of these decisions are made externally, we should lobby executive teams to ensure that our organisations are signed up to ethical procurement frameworks²¹, acting as advocates or activists where necessary.

Environmental sustainability

Given that there has just been an intercollegiate declaration of a climate emergency²², it is appropriate that a major domain of generalism is environmental sustainability. Recent papers confirm that this is a ‘hot topic’ within orthopaedics^23-25, and the surgical Royal Colleges have all produced strategies to help mitigate the effect of surgery on the planet^26-28. Within the NHS there are sustainable healthcare plans²⁹, green procurement plans³⁰ and local health organisation green plans to help the NHS achieve its ambitions to become the first ‘Net Zero’ health system in the world³¹.

The evidence for climate change, its effect on planetary health, and the need for action is irrefutable³². There is a plethora of available information, toolkits, checklists, educational initiatives, and case studies to help us make changes within our professional lives^26,33,34. So why aren’t more of us actively engaged in this, and what can we do to make this as much part of our patient care as, say, scrubbing-up?

One reason for inaction is overwhelm; a colleague said recently that they had decided “The problem lies with governments. I am therefore going to carry on and focus on the individual patient without worrying about the bigger picture.” And yet it is precisely by focusing on one patient at a time that we can make the biggest changes. By reviewing the whole patient journey and making small, incremental changes at each step, working with our theatre, ward, sustainability, and procurement teams, we can have a significant impact with the cumulative effect of these changes. While environmental concerns alone will not alter our surgical decision-making, we can use this knowledge to make better choices³⁵.

We can also use our position as healthcare leaders to advocate and communicate with patients, the public, healthcare managers and politicians, to continue the pressure to make changes at all levels of society³⁶. Orthopaedic trainees and junior doctors are concerned, and in many ways have greater legitimacy than established doctors, so we should be joining forces to take action³⁷.

Generalist skills for orthopaedic teams

In order to maximise an open, flexible, generalist approach for better patient care, there are also areas of staff development that need to be considered.

• Wellbeing

Patient safety depends on doctors’ wellbeing³⁸, and the same has been found for nurses and midwives³⁹. Both studies showed that, in order to thrive at work, people need a sense of autonomy, belonging and competence/contribution. Staff wellbeing is not therefore an optional ‘bolt-on’ to orthopaedic services, but an integral part of providing optimal patient care in a safe environment. As orthopaedic leaders we should advocate for our teams, and ensure, as far as possible, that they are supported at work. For example, it is easy to forget in the rush to complete our own work that the foundation doctor may be feeling unsupported, or that the new registrar lacks the system knowledge to complete the referral they have been asked to make. Ward staff may be battling daily to ring-fence beds and need support to achieve this, or to access training which will benefit the whole service. And we must not forget that wellbeing applies to us too – that we should support each other, take time to ‘smell the roses’ and recharge.

• Leadership

“Health systems across the developed world face a common set of wickedly complex challenges; a rapidly aging population with an associated rise of long term conditions and comorbidity, the need for profound and rapid health system redesign, a relentless drive for increased quality and productivity, and accelerating technological advances, all set against a background of varying degrees of resource constraint. Given this context, health system leadership is no longer an option for clinicians, it is a responsibility”⁹. Looking at our own work, not just with a narrow and short-term focus, but with a broad, generalist view, gives the context for leadership and helps us define our goals, our needs, and how to develop our teams and ourselves towards this end.

• Digital

Amongst the changing healthcare systems and context of healthcare delivery is the inexorable march of digital technology. Orthopaedic teams need to be digital-ready, including being able to evaluate new technology using available evidence⁴⁰. Team members will be at different stages in their digital capability⁴¹, and must be supported to find solutions that free up time for care. Most importantly, we need to include patients in our developments, and to remember that not only does health literacy vary, but digital health literacy varies even more, and reliance on digital solutions may exacerbate health inequalities⁴².

• Transformative reflection

Reflection has a bad press amongst surgeons, and is often seen as ‘fluffy’, a tick-box exercise, or a waste of time. It is however, a professional obligation for all doctors⁴³. There is no right or wrong way to reflect, although trainees are required to produce reflective writing for their portfolio, and consultants need to produce evidence of reflection for revalidation. Guidance on developing the skills of reflection has been produced⁴⁴. Transformative reflection is the next step in reflective practice and is about “embracing the unfamiliar, being able to frame (and reframe) the ways we do things and engaging in the types of thought-experiments that lead to meaningful changes in practice”⁹. It goes beyond learning from experience and into the realms of innovation and extrapolation. Having a flexible and wide-ranging generalist mindset allows us to learn from other disciplines, not just within medicine but from other professions, for example sport, business and education.

Conclusion

A generalist approach in orthopaedics allows individuals, teams and services to remain flexible and build on their strengths. Generalism encourages horizon scanning, looking outwards and learning from others. This gives a survival advantage for rapidly moving situations, such as service reconfigurations, critical personal situations (e.g. ill-health) and changes of direction due to major incidents and political shifts. The openness of thought practised by those who have a generalist mindset has direct benefits for patients.

It is both possible and desirable to have both specialist and generalist skills, and those who have generalist knowledge, skills and attitudes will be better equipped personally and professionally to navigate themselves and their patients through the changing healthcare landscape.

The argument, therefore, is not to make orthopaedic surgeons into general physicians or hospitalists, but to encourage and promote a different way of thinking, to look beyond the bones to the whole patient, their multiple health conditions and social environment, in the context of the changing healthcare system. As healthcare leaders, we need the context in which to lead, and adopting a generalist way of thinking will allow us to flex our services to manage the increasing complexity of our patients, our society, and the systems in which we live and work.

“The pattern of health and disease in our population is changing, and as a profession we must respond.”²

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