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Are generalists still needed in a specialised world?

Editor—Turnberg in his article on the survival of the general physician rightly highlights the potential problems posed when an undifferentiated emergency patient is cared for by medical subspecialists.1 Four models of care are proposed as possible solutions, including the development of specialised emergency physicians, calling for a new breed of doctor and a specific training programme, although its success would depend on having enough doctors who are sufficiently motivated to take on this type of work. 
 
The specialty of emergency medicine already exists, but its potential for contributing to a solution to the problem remains unfulfilled because of historical, cultural, and resource factors as well as perhaps the stubborn retention of the UK-specific name “accident and emergency medicine.” 
 
Turnberg alludes to the difficulties medical subspecialists have in maintaining their general skills and knowledge. Accident and emergency physicians now undergo a five year specialist training programme whose exit examination requires the demonstration of knowledge and skills in all aspects of clinical emergency medicine as well as evidence based critical appraisal and management skills. No such objective final assessment exists for trainees in general (internal) medicine. An expansion in the numbers of accident and emergency consultants, combined with a sociopolitical climate in which senior doctors' participation in all aspects of patient care will be demanded, suggests that the time is right to expand the role of accident and emergency doctors. 
 
I therefore propose a fifth model: the undifferentiated emergency patient is cared for on an admissions or observation unit integral to the hospital's emergency department, under the supervision of the accident and emergency consultant on duty. Medical subspecialists provide advice and ongoing care when indicated. Patients no longer acutely ill who require further investigation and diagnostic expertise are referred to the general (internal) medicine specialists. This way acutely ill patients remain under the care of physicians motivated and trained to provide that care. The current system of separate medical assessment units and emergency departments, with its consequent duplication of precious resources, would end, and a single point of hospital entry would exist for emergency patients regardless of whether they dialled 999 or were referred by their general practitioner. 
 
To create a new emergency specialty would perpetuate this duplication and thinning of resources for the patients who most need them. Far better to invest in those specialties we already have, since Turnberg's “new breed” is already breeding.