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People do not understand general practice – and that’s a major problem


Karen Price


9/09/2022 3:59:56 PM

There is a need to move on from ‘production line clicks’ favoured by health managers and embrace the complexity of general practice, writes Adjunct Professor Karen Price.

Adjunct Professor Karen Price with patient
Adjunct Professor Karen Price says it is not simple to perform high-quality, patient-centred lifetime care.

General practice is falling victim to the reification fallacy – the increasingly common idea that you can take an abstract concept and assign it a concrete, ‘real’ existence.
 
This fatal intellectual error, in essence, is what people are doing to the patient–GP relationship. And they expect you and me, the GPs, to make the lie work.
 
The existential danger we are faced with is the mercantile, commoditisation and digitisation of medicine – the inverse power law colliding with professionalism.
 
There is thought that general practice is a linear process from symptoms, to diagnosis, to treatment. When it appears to be this simple, then it’s a very small leap to thinking that it can be done by artificial intelligence (AI) and should be done by cheaper health professionals.
 
Meanwhile, general practice is being audited by Medicare into ever smaller specific tasks, and GPs are leaving in droves to simple tasks like skin clinics, with no foreseeable pipeline for replacement.
 
We have seen this same thinking applied in other complex environments, with similarly disastrous results.
  
Robert McNamara, a former 1920s Ford Motors process line industrialist, heavily influenced business and economic thinking throughout the 1950s as the business schools emerged. Then John Kennedy put him in charge of the Vietnam War. Things didn’t go well.
 
Culturally, we need to move on from this industrialised complex of the ‘production line clicks’ so favoured by health managers. The high-speed digitised commodification of data has given us another inverse law we may pair with that of inverse care.
 
The inverse power law oppresses us as follows: those persons least able to manage complexity within systems of power are now those most likely to manage that power.
 
It is not surprising. It is to be expected. For instance, ‘interoperability’ can mean for us that we’re expected to describe our GP–patient relationships in a way that big data metrics will understand.
    
Like some pestilential hybrid of the Dunning-Kruger effect and the Peter principle, if somebody’s the type who loves to collect and curate simplistic and distorted data in a world which is drowning in it, then they are also most likely to stay afloat and flourish, especially if they are wilfully ignorant of anything which can’t be liquified in their idiocy blender.
 
Unfortunately, unlike the Peter principle, there is no built-in cap on how much power they’ll accrue.
 
Also, unlike the Dunning-Kruger effect, these individuals are often fully aware of their own limitations and will quickly learn how to keep themselves safe.
 
I hate being used to make their lies work, and fear for my beloved specialty.
 
Yet, GPs are pragmatists. They use whichever method is to hand to work with their patients.
 
For example:  

  • A systematic review to inform the best treatment for their heart disease? Certainly
  • Motivational interviewing to stop smoking? Definitely
  • History, sociology to understand their reluctance to engage with other health services, given the way they and their ancestors have been treated in the past? Essential
  • Psychodynamic theory to judge our interactions and the way we are stuck on certain problems
  • Narrative theory to reframe the story of multiple failures into one of cannot-be-beaten resilience
What of this is measured or measurable? Who even knows what just happened? Maybe only the GP.   It is not a simple process to perform high-quality, patient-centred lifetime care.
 
Similarly, ‘guidelines’ are reified to the point of almost possessing independent agency.
 
It can sometimes feel like a lost battle now to reiterate the late great evidence guru, Professor David Sacket, and more recently, Professor Trish Greenhalgh, who warn against the tyranny of guidelines, but we must continue to fight against rigid reified ideologies.  
 
Dunning-Kruger-article.jpgGPs are being asked to convert the complex essence of general practice into arbitrary boxes to satisfy an increasingly digitised and mercantile system.

General practice is the medical world where complexity flourishes and multimorbidity is the most common chronic disease. Where the qualitative experience of patient and of physician were always included in the evidence beyond a simple linear guideline.  
 
A health system oriented towards general practice makes people healthier, and is cheaper and fairer
 
GPs tend to follow the guidelines less than non-GP specialists, but we also often get better outcomes for our patients. It’s a paradox for those who don’t know or understand what we do.
 
Making notes for this op-ed I thought of the post-positivist work I have admired in Karl Popper, his friends – and rivals – whose hits and misses over time have brought additional strength and rigor to medicine as a part of the sciences.
 
Yet while those who write our rules would consider themselves heirs to this tradition solely because they like to misuse a vocabulary lifted from AI and economics, they only bring about a debasement of it.
 
It is the ‘Peter-Dunning-Kruger’ who debases general practice and would lose Australia one of the best health systems in the world. The area where complexity, pragmatism and humanism meet, is exactly where our GP expertise is unique.
 
It is the pernicious reification fallacy. The abstract forced into concreteness is not possible.
 
There is no easy answer to this.
 
We do, however, possess some defences, such as a set of ethics stretching back for thousands of years. And a common-sensical agreement is developing on what we need to do – or part of what we need to do, and also need to not do – if we wish to try to keep our profession from becoming unrecognisable.
 
We need to stick together and to support each other. We need to stay up to date with the evidence-based research into our structures and methods of practice.
 
We need, when possible, to make it clear to our self-appointed betters that you cannot (sanely) square the GP–patient circle and that we will never surrender our oaths, or our mottos.
 
Finally, we need to not be afraid to add love and care to the scientific and economic curriculum. Love is the highest and hardest intellectual clinical objective and will resist measurement. 
 
Care in all its complexity remains the ghost in the general practice machine.
 
Cum Scientia Caritas, the motto of the RACGP, must help us find our way back. ‘With skill and tender loving care’ we must defeat those who dumb it down or dismiss the lived experience of GPs and the patient relationship as mere abstractions or stories.   
 
It is not self-serving to point to the outcomes of general practice, to the methods by which we go about achieving those outcomes and the motto which encapsulates that skilled care. 
 
In a complex world, the skills of GPs must attract the best and brightest minds and the greatest resources, to bear on the noble calling of healing with both empathy and intellectual strength.
 
Professor Price would like to acknowledge the contribution Dr Tim Senior made to the development of this article.
 
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Dr Danene Hopkins   9/09/2022 4:57:29 PM

Fabulous article - should be front page of The Australian


Dr Thanjon Michniewicz   9/09/2022 8:01:35 PM

A bold analysis on current failings and a crucial direction for the future of our profession; An excellent article


Dr Joseph Dinesh Rodriguge Fernando   10/09/2022 6:06:10 AM

People do not understand the General practice
Then it is the duty of RACGP to educate people
How much money RACGP spend to educate People ?
Then the pressure will come from people to the government to adequately fund General practices


Dr Scott David Arnold   10/09/2022 6:42:31 AM

Thankyou. Your article brought tears to my eyes. I am a GP who chose the simple life and now work full time in skin cancer. I left GP broken and depressed in 2007. You have clearly articulated the reasons I was never able to return.


Dr Gihan Ruchira De Mel   10/09/2022 6:51:41 AM

This is a brilliantly written article. A well articulated, clear, incisive analysis. Thank you!


Dr Ann Elizabeth Parker   10/09/2022 7:06:36 AM

Thank you, Karen for an article expressing everything I have felt was wrong but was unable to express. You have really understood the pickle we are in. You have been a passionate, insightful and determined advocate for the true value of General Practice. The data collectors never understand that a relationship is at the heart of our profession.


Dr Megan Elisabeth Barrett   10/09/2022 7:27:34 AM

I agree wholeheartedly with this article. There have been many times when a patient sees me to discuss the treatment suggested by their specialist before deciding whether or not to accept it. The specialist had given them all the facts but the patient wanted an opinion from the doctor who knows them wholistically and who they trust. It is that relationship which enables the patient to be treated. Not the production line of knowledge and power


Dr Carl Radford George Jansz   10/09/2022 7:27:49 AM

Very well put, Karen. You have nailed the essence of our problem.
The trouble is that this essence just does not compute to non-GPs at the coalface.


Dr Adele Frances Stewart   10/09/2022 8:26:00 AM

So incredibly important. A good GP / patient relationship is a great example of an emergent complex system. Treating it as linear is a problem on so many levels


Dr Patricia Ann Ingram   10/09/2022 8:38:59 AM

Thank you for this amazing article.


Dr Edward Charles Herman   10/09/2022 9:12:19 AM

Brilliant piece Karen and Tim.,


Dr Mary Alice Emeleus   10/09/2022 9:14:41 AM

Excellent article. I agree with Dr Hopkins, everybody should read this.


Dr Anna Lindsey Glue   10/09/2022 9:35:36 AM

Fantastic article- this is what I love about my profession - although over recent times with all the government pressures and misguided information it has been hard to see it. Should be front and centre of all mainstream media. Thanks Karen for advocating for us and our wonderful profession.


Dr Veronika Marie Kirchner   10/09/2022 10:25:04 AM

Agree with Dr Hopkins. And with Adjunct Professor Price when she refers to love and care. (Beautifully written.) I don’t know if these can be taught. I hope it’s possible. Because without love and care, the GP-patient relationship will always be incomplete and suboptimal. You HAVE to care.


Dr Matthew Laurence Byrne   10/09/2022 10:40:37 AM

An excellent article re the complexity of general practice . Well done Karen you have articulated what many of us have known for years but did not have the language to identify.


GP Alycia   10/09/2022 10:56:28 AM

Brilliant article for GPs to form a metacognitive perspective on our work. The concepts presented are vital for our regulators to grasp. Medicare rulemakers, health economists, lawyers, defense organisations and Medical Board ("25 hours of outcome measurements per year to replace previous CPD learning for GPs") should be required to demonstrate that they have understood and engaged with the points made by Dr Price. Not sure that the article as it stands has enough concrete examples for the general reader (eg of The Australian) to understand - slightly different audience -but could easily be modified.


Dr Linda Suzanne Dayan   10/09/2022 11:33:30 AM

Great article ! Please publish in the wider media....


Dr Suresh Gareth Khirwadkar   10/09/2022 11:35:10 AM

A beautiful article on the complexity and privilege of general practice, and simultaneously a seminal piece on exactly why general practice is on its knees and why applications are down, retiring/resignations are up, why GP remuneration is amongst the lowest of all the medical specialties and we are the whipping boys of everyone, particularly those with no insight into what we do, or how we do it, and most importantly WHY we do it.

Sadly this really just reflects why general practice is dying and will continue to die in todays world.


Dr Dhruva Ramachandran   10/09/2022 11:54:56 AM

This is a fabulous article, over years GP’s have been made to look like cough and cold doctors with the believe that our training was simplified to do the basic of tasks, given the responsibility of the Family Physician in Primary care , we are are the first line of defence doing complex tasks and early diagnosis which are important to planning, investigating and treating multiple diseases including future prevention of the complexities of various illnesses. The public, specialist colleagues and the politicians should be re-educated on the important role the GP does in daily management of diseases and the importance of ongoing contributions we do tge society.


Dr Susan Furphy   10/09/2022 12:09:41 PM

Thank you for this wonderful uplifting article Karen and Tim.
Your words give shape to the richness and complexity of the work we practice. We know the value of General Practice and have all felt much frustration that it is so under recognised. Your article articulates the work of General Practice well - lets push this article forward!


Dr Edward Thomas Wu   10/09/2022 12:16:34 PM

Karen's comment has completed the Definition of Primary Care Medicine (definition of General Practice/Family Medicine -if you like). For ages, I have felt there is a serious imperfection in the published definition. Imagine a society without a clearly identifiable "caring profession' and I must say, under the weight of our "health managers" we are losing this group of people - General Practitioners in Australia. We talk a lot of health "care" but we are merely rambling about health "service" which does not differ from supermarket check outs are doing and are now being replaced by machines. If our health managers gets their ways, what kind f society we are gong to have in the very near future. I have personally witnessed this overseas and have tried to demonstrate how "caring" medicine can be practiced until Covid put this to rest.
Karen knows real General Practice and a very deserving President.


Dr Edward Thomas Wu   10/09/2022 12:21:48 PM

Cum Scientia Caritas that is the RACGP ...


Dr Keren Lee Witcombe   10/09/2022 12:30:00 PM

thank you Karen


Dr Linh Tam Doan   10/09/2022 1:12:49 PM

Thank you Dr Price for voicing the sentiments of our profession. Undervalued, betrayed, slandered and used yet trusted to care for others. Only love can do that.


Dr Catherine Andronis   10/09/2022 1:44:24 PM

Excellent article, you nailed it Karen. GPs have been beaten down for decades and are exhausted. Hopelessness and helplessness are easy to give in to. Consider this a rallying call to empowering our profession. Send this article to your family and friends and local MP. I already have. Perhaps we might start to be heard and supported. It’s not too late.


Dr Catherine Andronis   10/09/2022 3:29:20 PM

Excellent article, you nailed it Karen. GPs have been beaten down for decades and are exhausted. Hopelessness and helplessness are easy to give in to. Consider this a rallying call to empowering our profession. Send this article to your family and friends and local MP. I already have. Perhaps we might start to be heard and supported. It’s not too late.


Dr Cathryn Ann Milligan   10/09/2022 4:27:52 PM

Hi Karen and Tim,
Fabulous comment ! We are a skilled specialty that fights to have our expertise acknowledged. We are beginning to fight back. I applaud the erudite arguments that underpin this article and so brilliantly describe the limitations in our system that purports to support the health of the nation but is enabled by an underperforming bureaucracy.


Dr Robert William Hosking   10/09/2022 6:59:58 PM

Simply brilliant! This should be read by GPs with pride, and by bureaucrats who try to dumb down our worth, with shame.


Dr Geir Woldsnes   10/09/2022 9:24:51 PM

Very well written, excellent article. Thank you.


Dr Susan Margaret McDonald   10/09/2022 10:55:46 PM

Thank you, Karen for expressing it so well!
I had hoped to work until I was 75 as I once loved general practice.
I can't work under the current system and am exhausted and beaten down as Dr Catherine Adonis says. I am 73 and will retire on 31st December.
There will be no-one to take over my patients and I am very sad about this.
A very depressing end to my 43 year career!


Dr Christopher Francis Boyle   10/09/2022 11:15:12 PM

Excellent article. Because what we do is not easily counted and codified, it is not valued by the "bean counters" . Despite all the evidence that GP provided care is cheaper and provides better health outcomes, I fear we will disappear unless there is significant investment in primary care.


Dr Sarah Adil   11/09/2022 12:48:12 AM

General Practice is very much misunderstood, by the public at large and even by our colleagues in other specialities at times . Thank you Adjunct Professor Dr. Price for voicing the reasons so eloquently. GP’s feel undervalued, unheard and increasingly frustrated in the current age . General practice needs a powerful voice/ advocate and a major overhaul to shift from “production line clicks” , like you aptly called them , to the more patient-centered and holistic medicine that we are trained for . We also need to monitor and counter the encroachments from other allied health practitioners into our domain . Better funding and remuneration for our time and efforts , public education & building a positive image for General Practice is the need of the hour .


Dr Elaine Sung   11/09/2022 12:53:31 PM

This article is so beautifully written. Speaks to my heart as a gp.
Unfortunately I fear general media is not interested in such complex topics. The rule makers would rather not know about it.


Dr Delfin Mark Sansom   11/09/2022 7:21:14 PM

I take exception to your statement: "Meanwhile, general practice is being audited by Medicare into ever smaller specific tasks, and GPs are leaving in droves to simple tasks like skin clinics, with no foreseeable pipeline for replacement.".
Skin cancer medicine and surgery is not a "... simple task".
I take pride in my FRACGP and the ability it gives me to provide quality skin cancer care, and have obtained multiple other qualifications to be able to offer high quality patient care: MM (skin cancer) ProfDipSkinSurg ACCSCMS ACCD CertDerm CertSCMS. I personally complete around 1000 operations a year treating skin cancer and diagnose around 20-30 melanoms a year. Is this a "... simple task"?
Your article states that general practitioners should be sticking together at this time of crisis in our profession. I would state that your description of one of the major sub-specialities of general practice is creating division.
Embrace and ecourage sub-speciality practice.


Dr Alison Ennos   11/09/2022 7:26:38 PM

Thank you! At last someone is articulating what many of us fear- that we are just simple cough and cold doctors replaceable by nurses and flow charts. I have seen the result of this thinking on my return to the UK and it just does not work : a waste of money. We must stand up as professionals against “ health managers” who have no idea about the work we do and no commitment to individual patients, and to whom funding is being increasingly channelled. No other profession would put up with this sort of thing. The RACGP must realise we are not compelled to make such a system work, but must support GPS in following our excellent and ethically based training to serve our patients.


Dr Allan Michael Fasher   11/09/2022 10:09:38 PM

Thanks to Karen Price and Tim Senior for the conversations that led to this article. An excellent piece of rhetoric; it does what good rhetoric should - it makes the audience feel good. And it made me feel good on my first reading late one night. Celebrating high quality general practice in Australia is close to my heart, as it is to all the respondents above.
However, the tsunami of delight expressed above moves me to flag concerns that I will flag now but work out later.
It is appropriate to highlight the complexity at the heart of quality general practice; it is a mistake to neglect recent progress in the science of complexity to which our very own Achim Sturmberg is recognised as an international contributor.
Caritas is crucial; it can be measured.
Outcome data is essential, but not sufficient, to drive continuous quality improvement
Cum Scientia Caritas
My regards
Michael


Dr Sharmila Biswas   12/09/2022 7:58:24 AM

Every word is gold, thank you Karen and Tim
You are saying what many of us know and feel and have felt for the last 10 years
It's not just the world of neo-liberalism that has done this, and many of our colleagues have been drawn into the lie
This needs to be on the front page of every health journal and newspaper.
We heard in London that not much is changing for the better overall even though some things can be done more easily. You need the GP to pull it altogether and the name is not Dr Google


Dr Karen Linda Price   12/09/2022 5:18:53 PM

Thank you Dr Delfin Mark Sansom. I take your point but sometimes people leave Generalism and not because they want to. Many do manage, due to the gifts of our exemplary training, to combine a specific skill with Generalism.
The concepts were abstract and so needed a concrete example. In no way does this diminish the skill but it is a different skill to that of Generalism. Just as it is skilled to insert a stent into a coronary artery, it is also skilled to journey with a patient on smoking cessation or adolescent suicide prevention. The thing is there should not be a hierarchy of skills when we are talking about the whole. Nor an either or. I will try to exemplify this point in future. Thank you for your careful work.

To (the wonderful ) Prof Michael Fasher, I have had many conversations with A/Prof Joachim Sturmberg and he was on my Presidential task force. He is indeed an intellectual contributor to Generalism and it’s deployment. Thank you. Well acknowledged.


Dr Timothy Ray Lipscombe   12/09/2022 6:40:22 PM

Exquisitely written article. Clearly defining the problem but how do we get the health bureaucrats, other specialists and politicians to understand . Let alone the general population.
Prof Barbara Starfield [dec] was a tireless warrior for Primary Care and her body of research categorically shows the benefits of the GP/patient longitudinal relationship . This is from both a health outcome and economic point of view. We would do well to repeatedly quote her research to the decisionmakers.
Having been a frontline GP for 35 years and out of clinical work for 6 months I am planning to return.


Dr Bryan Sean Connor   13/09/2022 9:09:39 AM

Thank you Karen. That is one of the best explanations of the real issues facing us that I have ever read. It's a pity that so few of our politicians are likely to read it, and much less understand it.


Dr Abdul Ahad Khan   13/09/2022 7:32:15 PM

Very well worded Karen.
This Article most definitely should be published in major Newspapers.
The Australian Populace needs to be demanding from the Politicians a much better Medicare Rebate & much better RESPECT for GPs .

Ah ! by the way, do send it to Professor Ian Hickie by Certified Registered Post - we need to wake him up from his Slumber in his cosy Bed in Ivory Towers - he needs to know as to exactly what GPs do day-in & day-out.


Dr Susan Maree Davis   17/09/2022 3:45:17 PM

Excellent article Karen. I hope that it is circulated more widely to the community .
I believe in the RACGP motto “cum scientia caritas”and agree with Dr Timothy Lipscombe .I also have been a frontline GP for 30 plus years and ceased clinical practice last 6 months but planning to reconnect .I have cared for 5 generations of one family and 4 generations of many families and believe in longitudinal care benefits and hope the decision makers take heed.


Dr David Alan Wallace   23/09/2022 9:30:23 AM

“It is the ‘Peter-Dunning-Kruger’ who debases general practice and would lose Australia one of the best health systems in the world. The area where complexity, pragmatism and humanism meet, is exactly where our GP expertise is unique.”
“ We need, when possible, to make it clear to our self-appointed betters that you cannot (sanely) square the GP–patient circle and that we will never surrender our oaths, or our mottos.”
“ Finally, we need to not be afraid to add love and care to the scientific and economic curriculum. Love is the highest and hardest intellectual clinical objective and will resist measurement.”
Was it ever said so well?


Dr Megan Elisabeth Barrett   13/10/2022 3:24:02 PM

Thankyou Karen for saying so well what I think every day. I am grieving for our lost profession.


Dr Louisa Marguerite Ennis   22/11/2022 7:09:35 AM

Captures the crisis for general practice more than anything I have read before but makes me feel sad for the losses we are experiencing. Most GPs are good people motivated by care for individuals and community and who devote themselves to the concepts of skill and care. Thanks for mentioning the word love. What a radical statement in todays world.
Not sure how we move forward as a profession but thanks to those with energy and creativity who are fighting to improve the health of the community