If you don’t think general practice is hard then you’re probably not doing it properly – or more likely, you are probably not doing it at all. Why is general practice so difficult to define? Why did it take the college many years to define core curriculum and competencies? Why could experienced colleagues not agree on what is meant by ‘core work’ at the time of the 2004 contract? The answer lies at the heart of what our profession attempts to do – balance opposing philosophies.
Reconciling these two fundamentally contrasting philosophies is the challenge of general practice
At secondary school we all remember being in one of two camps – the scientists and the ‘arty’ types. In politics we have the collectivist approach and the individualist approach. Milton Friedman and John Keynes divided economists. There is also the yin and yang of Chinese philosophy and the id and ego from Freudian psychology. When it comes to general practice we have all heard of the phrase ‘art and science of general practice’. Roger Neighbour referred to ‘the two heads’ and the lay person will understand a dilemma that involves both ‘the head and the heart’. What does this actually mean for the jobbing GP?
The science part of our daily work relates to QOF targets, access targets, evidence-based medicine, audits, clinical algorithms, NICE guidelines, Q-risk scores, dementia screening and any other box-ticking exercises that we have learned to love and loath in unequal measure. Its approach is to use maths and science; assume certainties and measure quantity, whilst ignoring quality.
The art side refers to empathy, the biopsychosocial approach, holistic care, a ‘good death’, communication skills, managing uncertainty, continuity, patient-centred care, team working, patient involvement and any other touchy-feely side of general practice that our cardigan-wearing teachers were fond of. It encompasses those aspects of our work that are difficult to quantify but most colleagues believe in their innate value.
Reconciling these two fundamentally contrasting philosophies is the challenge of general practice. This challenge is not unique to our profession. What I believe is unique is the fact that most of us do this 30 times a day with each patient we see. Each consultation has the potential to make us feel that something has been compromised, and with each compromise there is risk. The types of risk broadly follow the risks of failing to follow the two respective philosophies. Risk of failing to investigate, failing to refer, failing to diagnose, failing to treat, failing to monitor, failing to review, failing to follow guidelines, failing to meet access targets or QOF targets are all risks that may occur in a doctor who neglects the science of his/her profession. On the other hand, the risk of poor communication, uncaring attitude, over-medicalising, arrogance in not involving a second opinion, lack of team-working are all risks that occur in a doctor who may be over-reliant in the science and has neglected the art side of his/her profession.
Being a GP in the today’s NHS is a bit like Blondin crossing the Niagara Falls on a tightrope. So remember – don’t lean too much one way, or the other way, but just keep looking straight ahead, and pray.
Dr Nasir Nabi is a GP partner and trainer in Newcastle
