John Goldie is a retired GP and medical educator.
Critics argue that ideas like justice or epistemic humility are too abstract for busy surgeries. But GPs use them every day, often without naming them. Making these ways of thinking explicit isn’t academic indulgence — it is part of the method by which GPs work safely when time is short and uncertainty abounds.
The Monday morning surgery is already running late. A man with chronic pain turns up, worn down by trying and failing to get an appointment. A parent is on the phone about a child with a rising fever. A tearful patient arrives asking for “just a quick word.” There is no protocol that tells you exactly what to do next. You decide who to see, who can wait, and who needs something now. We tend to describe this as “managing demand” or “keeping to time.” But something else is happening: you are making a judgement about whose need matters most, right now, under pressure.
That is micro-justice in conditions of scarcity. Not as a slogan or policy principle, but as something you do: distributing attention fairly when everything feels urgent.¹
You could force a diagnosis just to settle the uncertainty. Instead, you pause. You let a few possibilities breathe.
In many consultations, even under the usual time pressure, something quieter happens. A patient describes a dizziness that refuses to slot into any familiar pattern. You could force a diagnosis just to settle the uncertainty. Instead, you pause. You let a few possibilities breathe. You ask one more question, check one more assumption, and resist the urge to quieten the story too quickly.
From the outside, this can look like hesitation. From the inside, it is a method: a disciplined way of not fooling yourself — what philosophers call epistemic humility. The label matters less than the practice. It is a way of staying close enough to uncertainty that the right answer still has a chance to appear.2,3.
Or take a different moment. A child with a fever appears, on examination, to be well. The parent is not reassured. You explain what you think is happening, but you also do something more: you describe what change would look like. You say when to worry, when to come back, what would make this situation different.
If we reduce this to “safety netting,” it sounds like a script or a defensive routine. In practice, it is neither. It is a shared piece of work. You and the parent are constructing a way of understanding what might happen next. You are not just giving instructions. You are shaping a story that can hold uncertainty safely enough for them to go home. It is not contingency planning after the diagnosis, it’s part of the diagnosis itself.
When that labour remains invisible, it is easier for it to be undervalued — by others and, over time, by us.
None of this feels abstract when you are in the room. And yet, when we step outside the consultation — into guidelines, targets, and system metrics — the language often misses this entirely. Care gets described as processes, decisions, or outcomes. The thinking that holds it all together becomes invisible.
Inside the consultation, we are already deciding what matters, staying with uncertainty, and making sense together over time. These are not an exhaustive taxonomy, but examples of forms of thinking already embedded in practice.
What stays unspoken is hard to teach, examine or defend. Experienced GPs may call it “gut feeling,” or “pattern recognition,” but naming these ways of thinking reveals the structure that makes the work sustainable. When that labour remains invisible, it is easier for it to be undervalued — by others and, over time, by us.
These ways of thinking are already shaping what we do. The question is whether we recognise them and can therefore use them deliberately, or whether they remain tacit habits. Unexamined habits are harder to adapt, harder to explain, and more vulnerable to systems that prioritise speed over judgement. Conceptual clarity, in this sense, is not an academic exercise. It is part of working safely in uncertainty. ²
General practice has always depended on this kind of thinking. It is part of the method of the consultation — as real as examination skills or knowledge of pharmacology, but less often named. The question is not whether we have time for it. It is whether we recognise it while we are doing it — in the pressurised moment of who to see, what to hold open, and what to say before a patient walks out of the room. The consultation is not only where theory is applied; it is where practical knowledge is generated.4 Naming that work is how we protect it.
References
- Mol A. The logic of care: health and the problem of patient choice. London: Routledge; 2008.
- Fox RC. Training for uncertainty. In: Merton RK, Reader LG, Kendall PL, editors. The student physician. Cambridge (MA): Harvard University Press; 1957. p. 207–41.
- Montgomery K. How doctors think: clinical judgement and the practice of medicine. Oxford: Oxford University Press; 2006.
- Reeve J. Interpretive medicine: supporting generalism in a changing primary care world. Br J Gen Pract. 2010;60(575):420–5. PMCID: PMC3259801
Featured photo by Annie Spratt on Unsplash.
