Sati Heer-Stavert is a GP and Clinical Education Fellow, University of Warwick. He is on Twitter: @SatiHeerStavert

General practice has always been a beacon of introspection within the health service. GPs as gatekeepers, holistic practitioners or even intergenerational guardians of health sit uneasy with the algorithms and architecture that modern medicine defines itself with. Societal expectations along with organisational change, the reach of mis/disinformation, novel pathogens and the health effects of climate change are further opportunities for us to question what it now means to be a GP, let alone a good one.

The difficulty with defining things is not new. Readers of Ancient Greek literature will be aware of how annoying the citizens of Athens found Socrates, occupied as he was with knowing nothing. Today, the relevance of ancient philosophy to medicine is often confined to the ideas of Aristotle’s virtue ethics. The concept of phronesis (practical wisdom) seems particularly relevant to those physicians with a disposition for general practice and its understanding continues to experience a contemporary renaissance.1,2 Renewed interest in the philosophy of general practice lends credibility to re-examine the most simple question that remains frustratingly difficult to answer: What is general practice?

What is general practice?

Plato’s Theory of Forms provides a conceptual framework from which abstract theorists can elucidate a definition of what exactly general practice was, is and will be in the future. It proposes that the physical things around us are not as true as the non-physical essence they reflect. We only see imitations of intellectually grasped Forms that are timeless and unchangeable. Consider a perfect triangle: it must have three sides and the interior angles must summatively equal 180 degrees. There are various types of triangle but they all exhibit this nature of triangleness. Despite knowing this, no person can draw this ideal triangle, the sides could not be perfectly straight since there will always be an imperfection. Our drawings are mere images of the Form.

Now consider the sophisticated nature of a GP and the characteristics a Form would possess to permit GPness? This Ideal GP is the one from which all other GPs are imperfect facsimiles. Of course, GPs are more complex than geometric shapes but like triangles, there are more than one type and they all must share some essential characteristics that both define them and separate them from other things.

From gut feelings through to the transposition, transcription and translation of Korotkoffian whispers into an index of mortality, GPs are adept in the art of interpreting shadows.3,4 Directing this ability into the intellectual exercise of illuminating our own nature is an important one with practical implications. Toon highlights the ‘GP should syndrome’ where GPs are told they should [insert whatever you like here].5 However, a GP cannot do everything, there must be limits. Therefore the opposite but more challenging approach is equally important in delineating ourselves: What shouldn’t a GP do?

A GP cannot do everything, there must be limits… What shouldn’t a GP do?

The refraction of ideas from the past to the present shines a light on our current ontological predicament. With scientific advancement, branches of medicine have budded and grown, as has the question on the value of the tree trunk when compared to the leaf. Through our lens, the physicians of antiquity were more generalist than specialist, yet this very differentiation is to view the past with modern sensibilities. The question of whether GPs are really expert generalists or specialists from the perspective of the Theory of Forms distracts from the notion that all doctors must in some way reflect the Ideal Doctor. This eternal unchanging Doctor is the Form from which all doctors of the past, present and future derive an imperfect image regardless of contrived designation. Artificial distinctions present in modern life only highlight our distorted interpretation of Ideal Health.

We cannot be left with doing everything and nothing.

Plato was critical of his own theory but Russell explains it well when he states ‘any hypothesis, however absurd, may be useful in science, if it enables a discoverer to conceive things in a new way’.6 The nebulous shadow of General Practice looms large on the health service. We cannot be left with doing everything and nothing. Plato empowers general practice to break it’s shackles, escaping toward a sustainable future while not losing sight of what makes us what we are.

References

  1. Svenaeus F. Hermeneutics of medicine in the wake of Gadamer: the issue of phronesis. Theor Med Bioeth. 2003;24(5):407-31. doi: 10.1023/b:meta.0000006935.10835.b2. PMID: 14760869.
  2. Misselbrook D. Medical philosophy? Smart thinking for doctors. Br J Gen Pract. 2013 Jan;63(606):8. doi: 10.3399/bjgp13X660625.
  3. Smith CF, Drew S, Ziebland S, Nicholson BD. Understanding the role of GPs’ gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Pract. 2020 Aug 27;70(698):e612-e621. doi: 10.3399/bjgp20X712301.
  4. QRISK®3 calculator, https://www.qrisk.org/
  5. Toon PD. What is good general practice? A philosophical study of the concept of high quality medical care. Occas Pap R Coll Gen Pract. 1994 Jul;(65):i-viii, 1-55. PMID: 9248307; PMCID: PMC2560367.
  6. Russell, B. (1945). History of Western Philosophy.

 

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