[Re: https://www.hifa.org/dgroups-rss/what-changes-when-generalists-are-respo... ]
Dear Neil,
Thank you very much for this thoughtful and important response. You raise exactly the right questions, and I appreciate the opportunity to clarify.
You are absolutely correct that routine in-hospital monitoring — including regular observations such as blood pressure, pulse, temperature, and symptom checks — is and has always been a core part of inpatient maternal care, primarily carried out by nursing staff. That did not change. What changed was medical continuity and pattern recognition across shifts.
Before these adjustments, observations were taken appropriately, but medical review was often fragmented. Doctors rotated frequently, and responsibility for synthesizing trends across multiple shifts was diffuse.
Subtle changes — for example, a gradual rise in blood pressure that remained below escalation thresholds, or evolving neurological symptoms reported intermittently — were documented but not always interpreted longitudinally by the same clinician.
The key change was assigning generalist doctors explicit responsibility for continuity across shifts, not replacing nursing vigilance but complementing it. Generalists were present more consistently on the ward than specialists and were tasked with reviewing observation trends over time, re-assessing patients at the bedside, and actively synthesizing information for specialist rounds. In practice, this meant that incremental changes — which might not trigger formal chart alarms and might appear insignificant to a
clinician seeing the patient for the first time — became clinically meaningful when viewed cumulatively.
Specialists remained responsible for complex decision-making and interventions, but generalists acted as clinical anchors: following the patient’s trajectory from admission to discharge, ensuring that patterns were recognized early, and escalating concerns proactively rather than reactively.
Your reference to the NHS debate around the firm system is very apt. I would agree that these incremental changes are most likely to be missed by incoming doctors who have not previously seen the patient. What we observed was that restoring a form of functional continuity — even without recreating a full firm structure — reduced that risk. In effect, the generalist role recreated some of the benefits of the firm system within modern shift-based staffing constraints.
I see this not as a substitute for nursing observation or specialist expertise, but as a way of bridging them, ensuring that data becomes insight and observation becomes action.
Thank you again for engaging so carefully with the piece. Your questions have helped sharpen the argument, and I am very grateful for that.
Best wishes,
Viengchan
HIFA profile: Viengchan Sek is a General Practitioner at Orchid Hospital, Cambodia. Professional interests include improving access to reliable health information in low-resource settings, maternal and newborn health, evidence-based clinical practice, health literacy, digital health innovations, and strengthening healthcare systems through quality improvement and clinical guideline implementation. viengchansek777 AT gmail.com