Being philosophical when it’s complicated

Andrew Papanikitas is deputy editor of the BJGP, and a GP in Oxford.

About 20 years ago Plsek, Greenhalgh and colleagues argued in the BMJ that practice had become more complicated, for both the patient and the practitioner. Recommending the science of complex adaptive systems, they warned against reductive and simplistic approaches to clinical care and service organisation.¹ The articles in this month’s Life and Times (February 2023) not only illustrate the dynamic and complicated nature of primary care but imply some ways to manage complexity; they unpack the promise and perils of medical language, the importance of understanding situated realities, and the dangers of adopting a naive approach to the complexities of medicine in society.

Concepts ideas and language

Concepts and ideas are important. We use language to express and exchange ideas about the world, even to make sense of it for ourselves. Offering healthcare for example, depends on what we mean by health. In 1946, the constitution of the World Health Organization defined health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Richard Armitage shows us how this definition is utopian (who can attain total well-being?), but also un-nuanced. And yet these three domains of health help us think about health, especially when we think about them in a nuanced way.²

Indeed, the term ‘Biopsychosocial’ is a familiar one to any medical student or teacher. How we use words can be as important as what those words mean. Ben Hoban observes that doctors are inordinately fond of nouns. By and large, patients come to us not just with nouns, but with stories which include them and are driven along by verbs, words of action, backed up by adverbs, pronouns, and so on.³ The last century saw the wholesale introduction of computing and machine intelligence into medicine. Computers are even more dependent on precise agreed meanings than humans. Luke Roberts re-introduces SNOMED CT -the world’s most comprehensive clinical terminology. It supports the standardised recording and encoding of patient information, including diagnoses, procedures, and medications. The terminology is designed to be usable in any electronic health record system.⁴

Situated understanding

We cannot hope to directly experience all of medicine and healthcare ourselves and rely on others to extend our gaze and understanding. Cancer and end of life care have become major features of 21st century general practice. We review two books that describe cancer experiences. Roger Jones reviews, ‘The last book I’ll ever write.’ In this final autobiography, a GP approaching retirement is diagnosed with inoperable gastric cancer. He charts the medical, human, oncological, and psychological dramas that take place over the next 3 years.⁵ Karen Chumberley reviews Fiona Mason’s ‘36 Hours’, a reflection on the last 36 hours of Fiona’s husband’s life as he undergoes end-of-life care at home.⁶ Here we see that there (at least) two people with physical, mental and social needs.

Recent data suggest on average 13 600 beds in NHS hospitals across England are occupied every day by patients who are ‘medically fit for discharge’. Peter Levin delves into the complexity of the term ‘medically fit for discharge.’⁷Not only is it critical to see the other aspects of patient that allow them to survive and thrive in the community but to acknowledge that medicine cannot work in isolation from the rest of society. In order to free those 13600 beds, we need to reprioritise the unglamorous work of social services, carers and communities, and help individuals back to (dare I say) a more complete state of physical mental and social well-being. Kemple expands the situated outlook to the world in which we live by bringing social justice and the environment to join financial profit and loss accounting in the economic model of primary care, a triple bottom line. ⁸

Howe and colleagues raise practical and professional issues for consideration by those considering the process of ‘retirement’. Using the question of whether to stay registered with the GMC, they offer some experience to inform others’ thinking, and also to set out issues that bodies such as the RCGP still need to address. Once again language becomes important as registration is bound with identity. Am I a GP, or do I work in general practice?⁹

Ahmed Rashid casts a critical eye at breastmilk expression, mild cognitive impairment, Ramadan, and invisible services, exemplifying the sheer heterogeneity of GP-relevant knowledge.¹⁰

Sleepwalking: The dangers of simplistic naivete

Samar Razaq argues that whilst the media may intend to inform, they can influence panic-behaviour in the public, with the recent Strep A outbreak being a powerful example.¹¹ The concern with news media is that the economic goal to make money, whether through selling papers, advertising revenue, or playing to the prejudices of billionaire sponsors, can eclipse the purpose of sharing information with the public. Quite separately from the moral harms or what is shared as news, there may be direct harmful consequences of a misleading story – in this case a literally overwhelming for GP services when the system is already in crisis. One strange and unhelpful narrative is that corporate profit-based healthcare will ‘save the NHS.’ Nada Khan argues NHS chiefs and policy-makers should be cautious about assuming that diverting patients to the private sector will take pressure off the NHS or reduce NHS waiting times as the evidence to date does not support these views.¹² Tim Senior argues that if GPs are replaced by a more industrial/transactional form of primary care, we systemically remove the part of the health system that has researched and trained in handling relationships and complexity well. We need to be able to describe what health systems stand to lose if general practice goes.¹³ This brings us back to complexity, which is both a challenge for primary care and a unique selling point for general practice.

It’s complicated… So what?

‘Being philosophical’ about something is often interpreted as a defeatist reconciliation with the futility of our actions. I prefer to see being philosophical as the ability to be a critical agent in the world. We can use concepts and language to share ideas help us see things we might overlook. We can use the narratives of others to extend our own experiences of the world. The dangers from being intellectually and morally passive compel us to embrace complexity. More than this, we need to convince the world that ‘It’s complicated,’ and (with time and resources) general practice can help.

References

1. Plsek PE, Greenhalgh, T, The challenge of complexity in healthcare, BMJ 2001; 232: 625–628.
2. Armitage R. The WHO definition of health: a baby to be retrieved from the bathwater? Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731841
3. Hoban B. A tyranny of nouns. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731925
4. Roberts L. SNOMED CT: working smarter, not harder. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731901
5. Jones R. Book review: The Only Book I’ll Ever Write: When The Doctor Becomes The Patient. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731949
6. Chumbley K. Book review: 36 Hours. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731961.
7. Levin P. ‘Medically fit for discharge’: does not mean ‘fit to go somewhere else’. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731889
8. Kemple T. How to be a triple bottom line (TBL) general practice — working for profit, the people, and the planet. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731865
9. Howe A, Aquilina M, Wilkinson M. Do you still need your licence to practice? – some reflections for British GPs. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731877
10. Rashid A. Yonder: Breastmilk expression, mild cognitive impairment, Ramadan, and 111 online — ‘the invisible service.’ Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731937
11. Razaq S. It’s the sun wot won it. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731937
12. Khan N. Sleepwalking into a two-tiered healthcare system. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731853
13. Senior T. A world without general practice. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp23X731973