If medicine is a social science, then what is general practice?

Andrew Papanikitas is Deputy Editor of the BJGP. He is on X: @gentlemedic

“Medicine is a social science, and politics nothing but medicine at a larger scale,” is a surprising quotation, because it was famously written by one of the ancestral fathers of cellular pathology. Rudolf Virchow saw that inequalities in society were responsible for much of the burden of disease at the time. In 1848, after investigating an epidemic, he argued that disease epidemics could only be eliminated through tackling social inequality.¹ Diagnosis is the broader theme this month in the (April) BJGP, and our Life and Times articles (as ever) highlight the idea that health and illness are bio-psycho-social phenomena.

Biopsychosocial determinants of health

Throughout medical history, there has been a tension between systems that locate health within the patient and those that have it outside. Ben Hoban² finds the determinants of health and illness by looking in (located in the biological systems of the body) and by looking out (at the way in which our health is contingent on our relationships).  Domestic abuse is a tragic example of how toxic relationships result in illness, injury and death.  Hannah Milton cautions against the misinterpretation the prevalence of domestic violence suffered by men and the oversimplification of such statistics.³ Jeremy Howick and colleagues illustrate the ways in which human connection affects health and healthcare by sharing ten evidence-based ways to enhance empathy.⁴ A sense of connection enhances the wellbeing of clinician and patient alike. We also say a fond farewell this issue to Ahmed Rashid in his final (10 years) Yonder column. For 120 consecutive issues he has sampled the diverse riches of academia relevant to primary care for our readers⁵ – thank you!

British medical dissociation

Those who are ill exist in the same social ecosystem as those who dedicate their working lives to addressing health and illness. A sense of professional disconnection among GPs is evident in our opinion pieces about the primary care workforce. Nada Khan reflects on the recent decision to rescind new to practice fellowship schemes. We need to properly evaluate what makes new GPs stay in practice.⁶ It feels as though, as soon as a new support package shows promise, it is withdrawn and the money realocated. Moreover there is an erroneous devaluing of what GPs do. This creates an impression that GPs can largely be replaced rather than assisted.  David Zigmond argues that lower skilled healthcare workers at the ‘diagnostic front door’ of general practice will not save money, resources or professional time and that such schemes talk ‘assistance’, but do ‘replacement.’⁷  Connie Junghans Minton and colleagues by contrast show an innovative kind of community health worker can reconnect the public with general practice.⁸ If we fear that GP jobs will go to less qualified additional roles in healthcare, however,  AI must remain a source of existential threat for all healthcare workers. Richard Armitage suggests that where medical writing is concerned (at least) we needn’t yet worry, but remain responsible for any publication we generate with the use or aid of AI. This is partly because the tools we have respond to human instructions, and partly because they can be fallible.⁹

Bibliotherapy

Our book reviews this issue raise the possibility that books can be both a source of therapy and much more rarely a symptom of pathology. David Jeffrey reviews ‘Portable magic,’ a manual for bibliophiles. On the one hand he is troubled by the idea that we can collect books, unread as treasured objects in great number – this is pathologised as ‘Bibliomania.’ True bibliophiles will assert however that a book must be read the value of a book lies in sharing its contents with the reader.¹⁰ Elke Hausmann reviews The Instinct to Heal: Curing Depression, Anxiety and Stress Without Drugs and Without Talk Therapy. She finds a primer on how to live well, and a guide to the role of emotions in health and illness.¹¹ Richard Armitage reviews ‘Science Fictions,’ an exploration of fraud, bias, negligence and hype in science and find that this has been a tonic for his critical thinking.¹²

Connection comes first

 In the infamous medical novel The House of God, by Samuel Shem, the doctors become disconnected from meaning in their work, from their loved ones and from each-other. The characters survived in the narrative by following a series of often cynical rules-of thumb. Flourishing required a new rule, ‘Connection comes first.’ Shem writes, “I’ve come to believe deeply that the danger in being doctors—and being a person is this: Isolation is deadly, and good connection heals … The disease we share is, yes, suffering.”¹³ Whilst medicine exists as social science on a socio-political level, it also has deep roots in interpersonal relationships. Medicine as social science is public and political, but it is personal too. In general practice this is widely understood and must not be forgotten.

References

1. Riley M, https://bjgplife.com/health-inequality-and-covid-two-centuries-of-social-murder/ (Accessed 28/2/24)
2. Hoban B. Looking in and looking out. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736701.
3. Milton H. Domestic abuse statistics. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736581.
4. Howick J. Just do it! Ten easy ways to enhance empathy in the consultation. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736593.
5. Rashid A. Yonder: Farewell. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736713.
6. Khan N. A failure to retain GP retention schemes. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736617.
7. Zigmund D. Physician associates: dissociated doctors. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736557.
8. Junghans C. Community health and wellbeing workers: an off-the-peg solution for improving health and care in england. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736569.
9. Armitage R. Generative AI in medical writing: co-author or tool? Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736605.
10. Jeffrey D. Books: Portable Magic: A History of Books and their Readers. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736629.
11. Hausmann E. Books: The Instinct to Heal: Curing Depression, Anxiety and Stress Without Drugs and Without Talk Therapy. Br J Gen Pract 2024; DOI:           https://doi.org/10.3399/bjgp24X736653.
12. Armitage R. Books: Science Fictions: Exposing Fraud, Bias, Negligence and Hype in Science. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X736641
13. Ward J, Papanikitas AN, Lee R, Warner N, Mckenzie-Edwards E, Bergman S, Handa AI, ‘The House of God’: reflections 40 years on, in conversation with author Samuel Shem, Postgraduate Medical Journal, Volume 94, Issue 1115, September 2018, Pages 531–534, https://doi.org/10.1136/postgradmedj-2018-135727

Featured photo by Tim Marshall on Unsplash