Joanne Reeve is a GP, professor of primary care at Hull York Medical School and leads the @wisegpcouk programme.* She is on X: @joannelreeve
I’m angry…
When I tell you why I am angry, you might wonder why this? Maybe you think I should focus my anger on the urgent practical challenges we face. You might tell me that ‘wisdom’ is too ‘academic’? Let me see if I can explain why I think this is worth being angry about.
In a world of ‘Evidence-based medicine’, it is remarkable how little research has been done on advanced generalist medicine. It’s a core component of modern healthcare, but not one that is prioritised for research funding. So we are excited to be in the final stages of setting up a generalist research study. Our trial will help GPs optimise generalist management for patients with complex healthcare needs and measure the effect. Routine science.
We’ve started recruiting practices to the study. Then, I am told we can’t use “busy” GPs. Instead we should use advanced clinical practitioners – because they “…do the same job as they can de-prescribe…”
Now, I’m angry.
In this short response from a well-meaning research support team, we see the core problem that lies behind so many of the problems in general practice. People just don’t understand what General Practice, as a medical discipline, is. Meaning that people are creating solutions to our capacity issues based on a misunderstanding of what we do.
…people are recognising us by the work we do, and not by the distinct expertise that we use to do that work.
They now know that general practice isn’t just about coughs and colds. ‘Simple’ tasks have been ‘replaced’ with more ‘complex’ ones. Where we used to be given pathways to follow to start ‘simple’ medication regimes (for hypertension perhaps), we now get involved in deprescribing. But, still, people are recognising us by the work we do, and not by the distinct expertise that we use to do that work.
Maybe we ourselves are part of the problem. We regularly talk about our role in terms of what we describe as ‘soft skills’ – relationships with patients, continuity, communication skills. These are all hugely important – but they are not distinct. Other people are doing them now.1,2
So, what do we – the GP community – uniquely bring to general practice? To answer that, I was thinking about the tasks that come to me as a GP because no-one else can manage them. I’m sure many of my examples will be on your list too…
There is the patient with persistent physical symptoms, who has had multiple tests, referrals, trials of interventions, and yet still craves an understanding (not just a diagnosis) of their problems. Then there is the elderly lady helping her husband take his 18 medicines a day (whilst managing her own 6). Both feel overburdened and overwhelmed by the ‘gold-standard’ medical care they receive but which doesn’t help them live their daily lives. What about the person with persistent mental health symptoms despite multiple excursions into stepped-care? Who really isn’t interested in whether this is ‘relapse’ or ‘recurrence’ but just wants to know what they can do differently, today. And don’t get me started on people being sent round in circles with mild abnormal blood tests…
[Advanced generalist medicine] …describes the work we do to critically, creatively and safely create new knowledge-in-context…
The common thread in managing all of these is our wisdom – our ability to work beyond a simple evidence path, a single diagnosis. It is a practical wisdom, but it is more than just a practical action. It describes the work we do to critically, creatively and safely create new knowledge-in-context2 when the (external) evidence doesn’t fit the problem in front of us. This is the essence of advanced generalist medical practice,3 and it is why you can’t replace a generalist physician with either a task-focused role or pathway.
So yes, we need to sort out the funding and contract issues blighting our profession. But if we want to recruit and retain GPs, and so maintain strong primary care, we need also to sort out the job that we are funding them to do. That means recognising the distinct and irreplaceable contribution we make in a multidisciplinary team. That is the wisdom of whole person medicine – of general practice.
*Authors note: Read more on the wisdom of general practice at WiseGP- www.wisegp.co.uk
References
- Westlake D, Wong G, Markham Set al. “She’s Been a Rock”: The Function and Importance of “Holding” by Social Prescribing Link Workers in Primary Care in England—Findings from a Realist Evaluation, Health & Social Care in the Community, 2024, 2479543, 16 pages, 2024. https://doi.org/10.1155/2024/2479543
- Hoban B. One Big Thing. Br J Gen Pract. 2024 Mar 27;74(741):172. doi: 10.3399/bjgp24X736881. PMID: 38538127; PMCID: PMC10962505.
- Gabbay J, le May A. Knowledge transformation in health and social care. Putting mindlines to work. Routledge, Oxon, 2022.
- Reeve J. Medical Generalism, Now! Reclaiming the knowledge work of modern practice. CRC Press, Oxon 2024.
