Person-centred Primary Care

Searching for the Self

Christopher Dowrick

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351998260
• Edition: 1
• Topic: Medicina
• Subtopic: Medicina de familia y práctica general

Primary care, grounded in the provision of continuous comprehensive person-centred care, is of paramount importance in the delivery of accessible and effective health care around the world. The central notion of person-centred care, however, relies on often-unexamined concepts of self, or understandings of what it means to be a person and an agent. This cutting-edge book explores contemporary pressures on the sense of self for both patient and health professional within a consultation and argues that building new concepts of the self is essential if we are to reinvigorate the central tenets of person-centred primary care.

Contemporary trends such as shared decision-making between health professionals and patients and promoting self-management assume those involved are able to make their own decisions and take action. In practice, however, medicine often opts for reductionist perspectives of patients as passive mechanical systems and diseases as puzzles. At the same time, huge political and organisational changes mean time and resources are scarce, putting further pressure on consultations. This book discusses how we can start to resolve these tensions. The first part considers problems posed by the increasing bureaucratisation of primary care, the impact of information technology in the consultation, the effects of chronic disease on our sense of self and how an emphasis on biology over biography leads to over-diagnosis. The second part proposes solutions based on a strong ontology of consciousness, concepts of creative capacity, coherence and engagement, and will show how these can enhance the self-esteem of patients and doctors and benefit their therapeutic dialogue.

Combining theoretical perspectives from philosophy, sociology and healthcare research with insights drawn from clinical practice, this edited volume is suitable for those researching and studying primary healthcare, communication and relationships in healthcare and the medical humanities.

1Recovering general practice from epistemic disadvantage

Sally Hull with George Hull

What is the role of the general practitioner?

Though a visit to the GP is a familiar part of life for most of us, the question, ‘What does a GP do?’ can be hard to answer.

In particular, it is harder to answer than the equivalent question asked about – for example – an anaesthetist or a hepatologist. Each of these has a well-defined area of specialist knowledge and core skills. Equally, each has a clear set of hurdles to negotiate in the achievement of specialist status.

By contrast, the GP is a generalist. In spite of evidence of the importance of general practice for population health within health systems, there have been repeated assaults on the value of the generalist’s role (RCGP, 2012; Starfield et al., 2005). So it is worth pausing to consider some distinctive aspects of the work of a GP.

Although generalists may work in many settings the term, particularly in the UK, usually applies to the contemporary GP. A frequent formulation is that GPs work at the interface between illness and disease and between individual health and population health, a place where serious disease has low prevalence, where diagnostic tests are less precise and where a diagnostic formulation involves judgement and is always risky (Heath and Sweeney, 2005). For our purposes, what is important is that the role of the GP is to be at the interface between illness and disease. In other words, the GP must co-ordinate biomedical knowledge and expertise with the subjective experience of the patient in their consulting room. As Heath and Sweeney put it, the GP must bridge the gulf between the ‘map of medical practice’ and the ‘territory of a patient’s suffering’. Iona Heath discusses this dilemma further in her chapter later in this book.

The general practitioner stands in a distinctive type of relation to their patients, not replicated in specialist medicine. This is lucidly captured by Ian McWhinney:

The commitment of a GP is to a person, not to a person with ‘a limited list’ of diseases. If GPs are to fulfil their place it is important that their commitment is unconditional. We cannot say I will be your doctor as long as you are not housebound, dying, or have a complicated condition in which I don’t have much expertise. The unconditional nature of the commitment means that the relationship between GP and patient is open ended.

(McWhinney, 1981)

A number of things can flow from this relationship. It allows intimacy and friendship to grow, based on a mutual interest in the patients’ health, and at its best the relationship is one of trust, which is both precious and very fragile.

The everyday work of co-ordinating biomedical knowledge with the subjective experience of patients is made up of a mass of situated judgements. And it is vital that a GP’s judgement calls be informed by the psychosocial context of the patient as much as they are by biomedical expertise. A GP’s situated judgements are supported by the findings of medical science and are often improved by computer-based decision aids. However, these decisions remain hedged about with uncertainty. Is it right to stick to the hypertension guideline for this elderly lady? How best to incorporate my knowledge about the risks of polypharmacy alongside her expressed desire not to take any more medicines?

The skilled practice of generalist medicine may include knowing a set of abstracted rules and recommendations. But the work of a skilled GP could not be substituted by the mechanical application of a list of rules – however long. This is because it relies crucially on making situated judgements with the patient. Decisions are rooted in the immediacy of patient context. The capacity to make such judgements is continually refined and reinforced as the practice of individual GPs is reviewed in the social context of the professional group.

We should consequently understand a skilled GP not as someone who has learned a set of rules and guidelines and applies them automatically, but primarily as someone who has acquired and maintains a number of settled dispositions of character which give rise to perceptive context-sensitive judgements as they interact with patients. Another way of making this point is to say that the expert GP has acquired and manifests a distinctive set of virtues.

The concept virtue is most familiar from moral theory. In applying it to medical practice it is important to avoid misunderstandings.

Theorists in the field of philosophical ethics disagree about what constitutes a morally good individual. The deontological approach says the morally good individual is the individual who knowingly conforms in their behaviour to rulelike norms including duties and obligations. The consequentialist approach says the morally good individual is the individual whose actions maximise some valued outcome (such as pleasure). Virtue ethics, in contrast, says the morally good individual is the individual who possesses certain settled dispositions of character: the moral virtues, including honesty, courage, generosity, and others. The dispositions of character highlighted by virtue ethics form the basis for characteristic patterns of perception and behaviour.

In claiming that successful medical training to become a general practitioner involves the acquisition of a set of virtues, we are not claiming that becoming a skilled GP is the same thing as becoming a morally good person. Whilst it is plausible that possession of certain moral virtues is a necessary condition of true excellence in general practice – a point we will come back to later in this chapter – possessing the moral virtues alone is clearly not sufficient to make someone an excellent GP.

The claim being made here is about form rather than content. The form of (much of) the expertise possessed by an excellent GP is comparable to the form of the moral expertise possessed by a morally good person.

The content of the virtues which best serve the practice of medicine will vary between its different branches. The development of virtue requires a consciously reflective approach, supported by structures which encourage and ‘envirtue’ participants (Toon, 1999).

Discussing moral virtue, John McDowell writes:

If one attempted to reduce one’s conception of what virtue requires to a set of rules, then, however subtle and thoughtful one was in drawing up the code, cases would inevitably turn up in which a mechanical application of the rules would strike one as wrong – and not necessarily because one had changed one’s mind; rather, one’s mind on the matter was not susceptible of capture in any universal formula.

(McDowell, 1998)

Similarly, David Wiggins argues that acquiring a moral virtue is a matter of acquiring a capacity of ‘moral or practical perception’, which he also describes as ‘a high order of situational appreciation’. Here he is making a point which he takes to extend to practical matters beyond the domain of morality:

From the nature of the case the subject matter of the practical is indefinite and unforeseeable, and any supposed principle would have an indefinite number of exceptions. To understand what such exceptions would be and what makes them exceptions would be to understand something not reducible to rules or principles.

(Wiggins, 1998)

A virtue is an acquired disposition, so a good generalist medical training should develop settled dispositions of character in a GP which enable them to make the right judgements in consultation with their patients. One of the goals of training must be to ensure these distinctive virtues are explicit, and become second nature to GPs.

Of course rules and guidance are useful, but they are not a substitute for ‘the educated improvisations of a virtuous … perceptual sensitivity’ (Fricker, 2007).

In sum, GPs are generalists whose medical expertise consists, to a significant degree, in the possession of a set of virtues. These virtues enable the GP to develop an on-going doctor-patient relationship constructively and make situated medical judgements about a patient informed both by biomedical knowledge and psychosocial information.

This chapter seeks to contribute to an understanding of general practice in medicine, and propose ways in which it can be strengthened. It draws on recent work in critical social theory, which has focused on the importance of how we – as society and as individuals – relate to persons in their capacity as knowers. Philosophical work following this epistemic direction in social theory has emphasised the centrality of developing one’s capacities as a producer and conveyor of knowledge, and how this contributes to the development of a flourishing individual life. It has also drawn attention to types of wrongful harm which individuals can suffer at the hands of society in their capacity as knowers.

Our focus is on the roles of doctors and patients as knowers in a well-functioning health service. It principally considers two aspects of the role of knower:

•the testimonial: the doctor and patient as people who convey knowledge to others;

•the hermeneutical: the doctor and patient as people who are able to make sense of their own experiences and activities, and whose experiences and activities are comprehensible to other salient role-players.

This chapter highlights two forces or trends which, we will argue, have adversely affected general practice – and thereby the good functioning of the UK health service – by providing GPs with deficient or distortive explanatory resources with which to frame their professional activity. These two forces or trends are:

•the specialist paradigm: a privileging of specialist medicine as more skilled, more serious, more worthy of attention and funding, and more deserving of high status than generalist medicine;

•the bureaucratic paradigm: a trend towards managing medical activities at all levels in the health service by seeking to identify and maximise discrete quantifiable unit outputs – whether tonsillectomies, root canal procedures, or ten-minute consultations.

Specifically, the chapter makes three claims. First, both the specialist paradigm and the bureaucratic paradigm have made GPs, and GPs-in-training, less able than other medical practitioners to understand the nature of their medical activities and experiences associated with them, thereby making them less well equipped to perform their role excellently. Relative to the medical community, GPs have suffered a hermeneutical disadvantage. Second, important among the skills or virtues that GPs must acquire and manifest are epistemic virtues, which enable them to build doctor-patient relationships over time, in ways which respond constructively to the communicative efforts of patients. Third, when GPs are put at a hermeneutical disadvantage relative to the medical profession as a whole, this makes them less able to appreciate, and thus develop, the skills – including epistemic virtues – which they need in order to provide an excellent service to patients.

We also argue that GPs in the UK, reflective about their practice, have sought to fill in the gaps in their training, thereby improving the theory and practice of their profession. Such efforts require institutional encouragement if the UK health service is to have a well-functioning generalist service in the long term.

The marginalisation of general practice

Not long after the National Health Service was founded, a trend towards privileging hospital-based medicine within Britain’s public health sector began to emerge.

Although specialist medical practice in the UK had begun to grow from the mid-nineteenth century – spurred on by urbanisation and market competition – it was only after the foundation of the NHS that sub-specialism really took off (Rivett, 1986). This specialism was almost exclusively located in hospital settings and was linked to the rise of the single disease model and the rapid advances in technology which transformed hospital practice. Importantly, increased technology-driven specialism resonated with the public self-image of the times, summed up in the phrase ‘white heat of technology’.

The Britain that is going to be forged in the white heat of this revolution will be no place for restrictive practices or for outdated methods.

(Wilson, 1963)

These various strands contributed to what we can call the specialist paradigm in British medicine from the mid-twentieth century onwards. Generalist medicine was out of tune with the spirit of the time, and in this period the threats to general practice came from a pervasive neglect. This included a material neglect of physical resources such as buildings, staff and equipment. Alongside this general practice was affected by an attitude of disrespect from other branches of medicine. Relatedly, while the specialist paradigm thrived, there was a vacuity of theorising about the discipline of general practice and its potential contributions to population health (Collings, 1950). The pervasive view within medicine and within broader society during this period is summed up in the words of Lord Moran, an influential post-war president of the Royal College of Physicians, who declared that GPs were merely the doctors who ‘fell off the ladder’, lacking the ‘outstanding merit’ to become top hospital specialists. It is important to note that this hostility towards general practice was neither new, nor confined to the UK. Joanna Brooks (2016) used data from the oral history collection in the USA National Library of Medicine to chart the trends in disparagement of primary care in American medical schools between 1936 and 1985. Even before medical school training began the new recruits came across messages at university interviews about what was to be avoided:

Clearly, if you mentioned the word ‘general practitioner,’ you had said something terribly wrong. He asked me, he said, ‘Well, what kind of physician do you want to be?’ And I said, ‘A general practitioner.’ And he spent the next 20 minutes berating me, and telling me that I could go to a GP school if I wanted to, but [school name] produced specialists, and was a cut above that kind of interest.

(Paediatrics, Tufts University School of Medicine 1964)

Alongside the overt cultural hostility to general practice came messages that being intelligent and professional were incompatible with choosing primary care. This builds a powerful conceptual framework, a shorthand of stereotypical ideas, prejudices a...