The ‘law of curriculum drift from generalism to specialism’: addressing the ‘generalist deficit’ in undergraduate teaching

This article explores how undergraduate curricula in medicine become dominated by specialist facts at the expense of general practice (family medicine). This 'generalist deficit' arises largely from assessment focused upon diagnoses and a need for clinical certainty. The law of curriculum drift from generalism to specialism states that 'effort expended upon improving the quality of assessment in medical education incrementally transforms learning from overarching generalist principles ("time as a tool", incremental management, trial of treatment etc) to detailed specialist facts (diagnoses, tests and interventions)'. In their evaluation and expectations of curriculum content, students demand expansion of specialist factual teaching to help pass these assessments. Curriculum reform towards specialism is further driven by school performance in national assessments and by 'metrics-based' quality assurance of curricular content. Specialist content incrementally supplants important learning about the wide range of 'normal' presentations in healthy people, clinical restraint and compassionate patient-centred care. Alongside increasing financial cost, administrative workload and student stress, the processes above leave graduates unprepared for the real-world challenges of practising medicine and being a doctor. This reflective piece also considers wider factors like 'tariff' funding, challenges in defining general practice and a failure to recognise that general practice is an 'approach of practical problem-solving'. The author calls for assessment and teaching throughout undergraduate medical education to embrace clinical uncertainty. This is essential for preparing tomorrow's doctors to work in the National Health Service in both primary and secondary care.