Generalism in Teaching: Key Concepts for MD Undergraduate Program Teachers

• Illustrate patient care in the context of family, social environment, and community.
• Encourage questions and discussions on patients’ lived experiences, lifestyle, routines, stressors or conditions they are going through, and explore the potential impact of social determinants of health.
• Discuss how the patient’s social context (e.g., family dynamics, socioeconomic status, etc.) might influence their treatment plan. Encourage learners to ask questions about the patient’s support system and integrate that into their care plan.
• Include statistics on health disparities and prompt discussion on addressing social barriers in care, such as the cost of medication, gym memberships, physiotherapy, etc.

• Give space and time for the patient experience to emphasize person-centered care, develop patient rapport, build a relationship and see the patient in context.
• Emphasize how a strong relationship with a health care provider can lead to more effective and more streamlined care, especially in complex or chronic cases requiring cross-discipline organization and coordination of care.
• Incorporate local traditions, cultural practices, and community-centered service as they are important to holistic care.

• Prepare learners to handle undifferentiated problems, multimorbidity, and diagnostic uncertainty.
• Provide cases where a patient presents with nonspecific or undifferentiated symptoms that could indicate multiple conditions (such as fatigue, abdominal pain, etc.).
• Ask learners to propose differential diagnoses and discuss the reasoning for prioritizing one over another while highlighting decision points where uncertainty is managed.

• Highlight how generalists coordinate care across teams and disciplines while advocating for patient needs.

• Use public health data to emphasize the role of preventive care, such as vaccinations or screenings.

• Include real-life stories of how early prevention impacted patient outcomes.

• Highlight preventive opportunities during patient care as relevant/appropriate, such as discussing smoking cessation or scheduling cancer screenings. Show how care coordination works by involving learners in discussions with multidisciplinary team members about co-ordinating follow-up care.

• Incorporate diverse perspectives in your teaching to promote understanding and valuing of their roles and how they contribute to comprehensive care e.g., Indigenous perspectives, different health professionals, etc.
• Present diverse patient cases that reflect varied cultural backgrounds, gender identities, and socioeconomic contexts.
• Incorporate insights from patients or community members in your teaching (e.g., guest speakers or quotes).

• Highlight the value of generalism by demonstrating its role in integrating diverse knowledge, managing complex care, and collaborating within multidisciplinary teams.

• Engage learners in care coordination across disciplines (e.g., working with pharmacists, dietitians, or social workers) to address patients’ multifaceted needs.

A slide is presented outlining the patient case of John, a 29-year-old man.

He had chest pain last week and presented at the ER. He had many labs done and an ECG, these were normal. John has been referred to cardiology for a stress test. A history confirms his father died at 55 of a myocardial infarction (MI).

Background

Understanding John’s complete history will better support generating a comprehensive differential to a common presentation. Conducting further inquiry would reveal new events, stresses, and systemic symptoms. For example, students could learn that John is an RCMP officer who, two weeks ago, attended the aftermath of a motor vehicle accident where a small child was killed. He keeps waking up at night and seeing the scene. Last week he started having brief episodes of sharp chest pain. Additional diagnoses to consider would include acute trauma adjustment reaction and significant anxiety. Even if John’s chest pain is due to a primary cardiac pathology (e.g., coronary artery disease), it would be important to ensure ongoing follow-up for his physical and mental health.

Framing the case from a generalism lens:

• Emphasize that by going straight to the cardiac issue with only minor inquest into his history and not exploring whether other contributing factors may be present, a huge piece of context is missing, and John will not receive appropriate, whole person care.
• On the slides, consider adding prompts asking what may be missing in this case. You could also add John’s context to a second slide, allowing students to view all that was missed.
• Discuss the importance of continuity of care for John and sharing that with students. It is not just about this one presentation, but also exploring what happened prior and what will happen with the patient afterwards.
• Since John is seeking care, discuss offering more wholistic care by addressing other patient issues if possible and where appropriate, and not necessarily deferring.

Without a generalism lens:

• The full scope of John’s case is not realized. Students miss out on this key experience of uncovering more about a patient’s experience with a thorough inquiry. The focus is on ruling in/out one particular condition (e.g., coronary artery disease) rather than an approach to undifferentiated clinical presentations. This can be common in the emergency department where the focus is on ruling out acute causes for symptoms.

3rd year medical student in the Emergency Room (ER).

Mr. S presents at the ER and is initially seen by a 3rd year medical student who collects the history. Mr. S has had increasing headaches over the last 6 weeks and has seen their family doctor several times. The student presents Mr. S’s history to the ER doctor as follows.

“This 51-year-old man has had increasing headaches for the last few weeks. His vision feels funny, he has seen his family doctor several times but came here today as his symptoms have gotten worse and nothing is helping.”

The ER doctor does a brief neurological exam without focal signs and sends Mr. S for a CT scan, which shows a large glioma in his brain. The ER doctor reviews the CT with the student and expresses it was lucky that he had come to the ER today to get urgent care, and Mr. S would now see neurology and a neurosurgeon today. The student is left with the impression that something serious was missed in Mr. S’s previous care.

Background

Mr. S saw his family doctor 6 weeks ago as he had off and on headaches for a week. He has a history of migraines. He had a general frontal headache and had been under a lot of stress recently, and had also quit drinking coffee cold turkey recently (4-5 cups per day). His blood pressure and neurological exam was normal, but he did have some tightness of neck muscles and felt stressed. His family doctor advised doing neck stretches, discussed how to manage caffeine withdrawal and organized physiotherapy with a caution to return if nothing improved.

4 days ago, he saw his family doctor again. While he initially had felt better with the treatment outlined at the last appointment, his headaches had started to increase again. Again, normal vital signs and a cranial nerve exam. With the increase in symptoms and knowledge that it was unlike Mr. S to seek care readily, the family doctor was concerned and ordered an urgent CT scan. Without any focal signs and “just headache”, they were told an urgent CT scan was 3-4 weeks away. They referred the patient to the outpatient neurology clinic but were told without an acute event it would be 12 months. They advised Mr. S if there was an increase in severity to come to the office or present to the ER.

Framing the case with a generalism lens:

• This case demonstrates the hidden curriculum of not exploring the actual care that is provided before and after an acute presentation. Clinical teachers can model or ask students to probe the patient’s social context with questioning to uncover the history of care and discuss with students the risks associated with assuming that nothing was done before.
• This case illustrates that undifferentiated symptoms often have multiple explanations early on, and that managing uncertainty is an important component of generalism.
• The case illustrates how having knowledge of the whole patient in context can be helpful to decision making
• The case also illustrates the importance of collaboration with all members of the health care team, and it can be helpful to strategize how to prevent fragmented care.

Without a generalism lens:

• Without the appropriate exploration of Mr. S’s history in this case and the assumption that his family doctor provided inadequate care, the student may move forward in their training with an assumption that other health care providers (family physician, radiologist, neurologists) provide substandard care, and perpetuating an assumption that damages health care team work, and may result in more fragmented care for that patient in the future.
• It could also result in over-investigation because the patient population that presents to specialists versus family physicians is different.
• If the prior history of care is not explored, there can be an assumption that this is the one and only time Mr. S has presented and information obtained will be incomplete.

[1] The quintuple aim for health care improvement: A new imperative to advance health equity — Nundy S, Cooper LA, Mate KS. (2022). JAMA.
[2] 20 Priority Recommendations to Rethink the Final Year of Medical School — The AFMC Final Year Task Force. (2025). AFMC.
[3] Rethinking the Final Year of Medical School — AFMC. (2024). AFMC.

• Assessing undergraduate medical education through a generalist lens — Nutik M, Woods NN, Moaveni A, Owen J, Gleberzon J, Alvi R, Freeman R. (2021). Canadian Family Physician.
• The Craft of Generalism clinical skills and attitudes for whole person care — Lynch JM, van Driel M, Meredith P, Stange KC, Getz L, Reeve J, Miller WL, Dowrick C. (2022). Journal of Evaluation in Clinical Practice.
• Operationalising generalism in medical education: a narrative review of international policy and mission documents— Ramanathan A, Clarke N, Foster M, Pope L, Hart N, Cheung S, Kelly M, Park S. (2024). Education for Primary Care.
• Outside the lines: the added value of a generalist practitioner — Loxterkamp D. (2019). Canadian Family Physician.
• The Generalist Approach — Stange, KC. (2009). The Annals of Family Medicine.
• Characterising generalism in clinical practice: a systematic mixed studies review protocol — Kelly M, Cheung S, Keshavjee M, Stevenson A, Elliott J, Singh S, Foster M, Park S. (2021). BJGP Open.
• Protecting whole person care with generalism in medicine —Lynch, J. (2023). The University of Queensland Medical School.
• Rethinking undergraduate Medical Education: A View from Family Medicine — The College of Family Physicians of Canada. (2007).
• 6C’s of Generalism — Department of Family Medicine. (n.d.). University of Calgary.
• Info-Morsels: The Praxis of Generalism in Family Medicine: Six Concepts (6 C’s) to Inform Teaching — Family Medicine, Faculty Development. (n.d.). McMaster University.