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