Cultural boundaries of general practice

Andrew Papanikitas is Deputy Editor of the BJGP.

What do GPs have in common with 18th-century anatomists, 19th-century physicists, or 20th-century nuclear scientists? ‘Boundary work’ is an idea that sociologists have used to discuss the social nature of science and scientists, capturing the idea that scientists create and defend a line between what they are and what they aren’t. That defence is more than a description of who is included as a scientist and what scientists do. It also encompasses the worthiness of science and scientific disciplines and their relative importance compared to less worthy groups (in the argument of those scientists at least), such as amateurs and tradespeople. It is a concept readily applicable to the body of scholars and community of practice that is general practice. Thomas F Gieryn, who coined the term ‘boundary work’, argued that social boundaries could sometimes shift or even be incongruous:¹ nuclear scientists during the Cold War, for example, argued that their work was vital to the Western military-industrial complex, but at the same time presented papers at the same conferences as their Russian or Chinese colleagues. To justify this they suggested they were unlikely to give away any critical secrets but needed to learn what their colleagues were doing. The idea embodies that of a professional group having an interest in status and advantage, but also having to labour to justify this; for example, through the knowledge, skills, and attitudes that a GP embodies.

The intellectual and ethical boundaries of practice

I have previously suggested that medicine claims a privileged status while offering a commitment to service orientation.² These commitments also simultaneously serve as conditions for professional membership, a notion sometimes referred to as ‘ethicality’. Professional scholarship is uncontroversially tied into professional identity, begging the question of what knowledge should be admitted to the professional canon. Mohammad Sharif Razai argues that both the profession and the wider public have an interest in the rigour of academic publishing.³ After all, medical practice needs to be based on good knowledge. This then implies standards for those engaged in safeguarding that rigour. Standards by themselves are not enough to maintain this largely voluntary professional activity, it needs to be suitably supported with resources and incentives. Ethical standards of practice are also a broader feature of public trust — Saud Jukaku and colleagues offer an international perspective on the issue of treating doctor–patients and work colleagues.⁴ To be regarded as unprofessional is to simultaneously risk both livelihood and identity. Nada Khan takes a hard look at the appropriateness of blame when things go wrong, especially when GPs are expected to manage uncertainty and risk on patients’ behalf, taking inspiration from the British intelligence services.⁵ A bad outcome should not necessarily attract blame, though poor decision making might well do. Terry Kemple reflects on a book about our duties to strangers.⁶ He finds that it’s a struggle to reconcile what we do with those inner thoughts that we should be doing more and doing it better. Those inner thoughts, our moral sense or conscience of right and wrong, guide our behaviour and should make us reflect.

The physical boundaries of practice

General practice is embodied in practice and Alex Burrell offers a smorgasbord of studies that unpack this idea. Yonder this issue examines the benefits of scale, deficiencies in shared care at the boundary between GP and specialist, the inferiority of GP’s notes compared with AI scribes, and trust in supervision of medical students.⁷ Annie Farrell reviews an exhibition of a GP surgery created by the artist, Charlotte Mann.⁸ For a few short weeks, before the house was sold, Mann offered a glimpse into a time when general practice was practiced out of a GP’s home. We go from the physical geography of practice to a piece of medical equipment that is emblematic of clinical medicine. Emer Forde offers a poetic perspective on the stethoscope: ‘Listen … Through me, you’ll hear the lub-dub of a beating heart, the heave of a heavy spirit, whisperings and murmurs of a broken life.’ ⁹ The purpose and work of general practice are a constant negotiation between medicine, the state, and civil society.¹⁰ Tim Senior invites an honest dialogue between policymakers, policy workers, and policy targets: ‘It’s become a health system response to decide that GPs are ideally placed to do whatever activity the recommender is enthusiastic about, and decide that GPs just lack the special bit of knowledge and skills that would unlock this potential. All that’s required is a series of webinars. Never mind that there may be funding constraints, a lack of capacity, other priorities for the patients we are seeing, or even that the activity doesn’t really need doing at all.’ ¹¹

So is our commitment to professional knowledge, skills, and attitudes an anthropological mirage? Is the essence of general practice just a recipe for a social status and decent salary? I would like to think not, in a similar way that coming to understand the rules of an unfamiliar sport ought not to compromise participation as a player or spectator. For me, such reflections serve as a reminder that general practice and GPs are part of society, as human as our patients, and dare I say our politicians too.

References

1. Gieryn TF. Boundary-work and the demarcation of science from non-science: strains
   and interests in professional ideologies of scientists. American Sociological Review 1983; 48(6):
   781–795.
2. Papanikitas A. Ethicality and confidentiality: is there an inverse-care issue in general
   practice ethics? Clinical Ethics 2011; 6(4): 186–190.
3. Razai MS. Tackling the problem of quality in peer review. Br J Gen Pract 2026; DOI: https://doi.org/10.3399/bjgp26X744165.
4. Jukaku S, Ahmed FW, Almutairi A, Butt T. Treating doctor–patients and work colleagues: a need for some international principles. Br J Gen Pract 2026; DOI: https://doi.org/10.3399/bjgp26X744201.
5. Khan N. Culpable in the face of uncertainty? A perspective from military intelligence. Br J Gen Pract 2026; DOI: https://doi.org/10.3399/bjgp26X744189.
6. Kemple T. Book: Death in a Shallow Pond: a Philosopher, a Drowning Child, and Strangers in Need. Br J Gen Pract 2026; DOI: https://doi.org/10.3399/bjgp26X744225.
7. Burrell A. Yonder: Scale, shared care, AI scribes, and trust in supervision. Br J Gen Pract 2026; DOI: https://doi.org/10.3399/bjgp26X744213.
8. Farrell A. General Practice 179: a doctor, a lawyer, and an artist. Br J Gen Pract 2026; DOI: https://doi.org/10.3399/bjgp26X744177.
9. Forde E. Poem: How to Use a Stethoscope. Br J Gen Pract 2026; DOI: https://doi.org/10.3399/bjgp26X744153.
10. Salter B. Who rules? The new politics of medical regulation. Soc Sci Med 2001; 52(6): 871–883.
11. Senior T. Every gap is an educational gap. Br J Gen Pract 2026; DOI: https://doi.org/10.3399/bjgp26X744237.

Featured photo by Aleš Čerin on Unsplash.