What too few people appreciate is that complexity is the rule and not the exception in general practice consultations. Few symptoms that patients present with fit with any diagnosis and few problems can be solved by following a protocol or treatment pathway.
Professor of Medicine and Sociology David Armstrong has studied the history of diagnosis and nosology (the classification of disease) “When it [Diagnostic classifications] came to be applied to primary care in the middle of the 20th century, however, it encountered major problems as general practice struggled to marry a classification of disease to the rawness of undifferentiated human illness and distress. Eventually a classification based on the reason the patient consulted emerged to replace that based on pathology defined disease.”
GP records have a ‘Problem list’ on the front page of each patient record, rather than a list of diagnoses. It can include things like, ‘Patient is a carer’ or ‘housebound’ or ‘at risk of diabetes’ as well as symptoms like ‘chronic low back pain’ or ‘fatigue’ alongside diagnostic labels like ‘hypertension’. In the list of past problems might be ‘bereavement, son aged 15, stabbing’, ‘homeless’ (1999-2014), ‘rape’ (2016) – and other significant life events. Problem lists need to be curated by the GP and are a record that depends on what is disclosed and documented. They are always incomplete but are usually better when the patient is cared for by the same clinicians for many years. For psychiatrist Linda Gask who has written memoirs about her near-lifelong depression, her GP was a ‘keeper of her stories’, someone who remembered how she could be, even as they cared for her when she was profoundly unwell.
Epistemologies of General Practice
Epistemologies are types of knowledge and GPs make use of the theory and practice of narrative medicine. In her role as psychiatrist Linda Gask wrote, “For me as a doctor it was the power of those stories and my ability over time to make a difference in how they ended that fulfilled me.” Knowledge of stories is tied up with chronological knowledge of a patient over time. A concept of time, Kairos, not as something linear but as a series of significant moments or episodes is another form of knowledge that comes with continuity of care. The significance of Kairos is that there arise critical moments when a patient may be able to engage with a diagnosis or treatment plan and others when all they need (and can cope with) is caring, kindness and validation. There may be episodes of serious illness when they see a lot of their GP, among occasional brief encounters of little significance.
Other epistemologies are shared by all medical specialties. Knowledge of clinical science (facts), technical and procedural knowledge (how to do things) and administrative /cultural knowledge (how to get things done) need to be integrated with a greater emphasis on technical aspects for surgeons and interventional radiologists for example.
Academic GP Joanna Reeve describes ‘interpretive knowledge and skills’ as being critical for so many of the problems that GPs face. Interpretive skills enable professionals to integrate biomedical, psychosocial, patient and professional accounts of illness in order to make sense of, and so take an active part in managing, their own health problems. They are particularly useful when dealing with chronic mental health problems which is a large part of most GPs work.
Epistemic hierarchies mean that specialist knowledge is valued above generalist knowledge. The specialist opinion trumps that of the generalist, no matter the problem. Generalism and generalist knowledge is low status. Ian McGilchrist has written about how over the last 200 years modern societies have rewarded and promoted specialist – single issue ways of thinking and people with specialist, rather than generalist ways of thinking. The generalist is concerned with the relationships between things while the specialist is more concerned with things themselves (the relata).
In his book about the process of becoming an expert, Professor Roger Kneebone describes a journey from apprentice, via journeyman to expert. The expert can improvise with other people, recover when things go wrong, and act safely and confidently where there are no guidelines to follow. They can only do this because they have been learned as apprentice and journeyman to work on their own, to do predictable work, and to use guidelines. So much general practice demands the attributes of the expert because it is steeped in complexity. New GPs who are used to hospital medicine and may still be getting to grips with routine and predictable clinical work, can find the sudden exposure to problems without diagnoses, overwhelming.
Often quoted, Donald Schon advocated for knowledge and skills in reflection practices, so that professionals can appraise the many possible right courses of action that are a hallmark of complex problems.
“In the varied topography of professional practice, there is a high, hard ground where practitioners can make effective use of research-based theory and technique, and there is a swampy lowland where situations are confusing “messes” incapable of technical solution. The difficulty is that the problems of the high ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, while in the swamp are the problems of greatest human concern.”
Education or disposition for complexity.
The rapid introduction of new roles in general practice, in particular Physician Associates (PAs) has raised the question of whether 3 years of training is long enough to develop the attributes of Roger Kneebone’s conception of ‘Expert’ and manage the complexity that typifies general practice. It typically takes 10 years to train a GP; 5 years as an undergraduate, and 5 years postgraduate training. In defending the length of time required to become expert, Kneebone says that “you cannot bake a cake any quicker by turning up the temperature”. The Royal College of GPs which is responsible for postgraduate GP training thinks that it should be longer. The apprentice junior doctor must do repetitive tasks until they can do them in their sleep while being immersed in and becoming a member of the culture of the community they are joining. The journeyman must learn to find their own voice and then learn when to listen to others while embodying the skills they learned as an apprentice until more of their work comes naturally. Some GP trainees never seem to get very far towards his conception of the expert who is comfortable with uncertainty and complexity, while some seem to take to it naturally very quickly, as do some PAs. You may not be able to bake a cake quicker, but some ingredients are better suited to cakes than others. Education may be necessary, but is, at least in its present form, not sufficient for some people to become an Expert Generalist. For one thing, medicine is taught as though every symptom conceals a diagnosis and the job of the doctor is to diagnose the disease and prescribe the correct treatment. The failure to acknowledge that most symptoms are unrelated to any disease and may yet persist for life, is a clinical and moral failure of medical education. It is a major reason for dissatisfaction among patients and professionals. Clearly doctors need to know when their patients’ symptoms do signify a disease that needs treating. But its far from the only skill they need and especially so in General Practice. Education could be better, but even as it is, some people are much better at handling the ‘swampy lowlands’ of general practice than others.
Selecting for disposition
We hope that people with the right attitudes and attributes will find their way into the professions to which they are suited. There is some evidence that a low tolerance of uncertainty is more prevalent among orthopaedic and urological surgeons than among psychiatrists and GPs but we do no more than hope that people able to deal with complexity and uncertainty will find their way to general practice. You cannot be a generalist without being an expert, but expert generalists need disposition at least as much as education. They also need a community of practice, and organisations that recognise their expertise, with high levels of trust in which they are valued and can experiment and learn, in which relationships are encouraged and facilitated. This way they can work effectively with patients and the ‘rawness of undifferentiated illness and distress’.