Medical generalists: connecting the map and the territory

Abstract

Despite enormous advances within medical science over the past 100 years, an under-recognised but inevitable gap remains between the map of medical science and the territory of individual human suffering.1 The task of the medical generalist is to make useful connections across this constantly recurring gap. All doctors carry the medical map, albeit with patchy and varying levels of detail, but only the medical generalist uses it to try and make sense of the whole human person, transcending all the arbitrary divisions of specialist practice. Here we explore the role of the medical generalist and consider how this might be affected by current NHS reforms.

Full text

The NHS revolution: health care in the market place
Medical generalists: connecting the map and the territory
Iona Heath, Kieran Sweeney
The debate on market reforms must not overlook general practitioners’ over-riding responsibility
—
to recognise and relieve patients’ suffering
Despite enormous advances within medical science
over the past 100 years, an under-recognised but inevi-
table gap remains between the map of medical science
and the territory of individual human suffering.1The
task of the medical generalist is to make useful connec-
tions across this constantly recurring gap. All doctors
carry the medical map, albeit with patchy and varying
levels of detail, but only the medical generalist uses it to
try and make sense of the whole human person,
transcending all the arbitrary divisions of specialist
practice. Here we explore the role of the medical
generalist and consider how this might be affected by
current NHS reforms.
Generalist’s role
In the initial consultation with a general practitioner,
doctor and patient work together to explore the
usefulness and the limitations of the medical map in
relation to the territory (or subjective experience) of
the patient’s particular illness. When the patient has an
acute and remediable illness or accident, attention will
be mostly on the map, but when the patient is dying the
attention will revert almost entirely on to the territory.2
In chronic illness, a careful balance must be achieved
and maintained so that neither aspect is neglected.
To work effectively in this context, the medical gen-
eralist must maintain a clear understanding of both
borders of the gap. This requires a thorough, robust,
and continuously updated knowledge of medical
science; an empathic willingness to recognise, acknowl-
edge, and witness the true extent of suffering; and an
appreciation of the details of individual lives, combined
with a respect for the history, aspirations, and values
which have made those lives what they have become.
Centrality of medical diagnosis
General practitioners operate in a low tech environ-
ment, where, until recently, the most sophisticated
instruments available were the stethoscope and sphyg-
momanometer. Yet they are responsible for making the
initial medical diagnosis on which almost all subse-
quent care is based. The accuracy of that initial diagno-
sis is crucial and necessitates a high degree of technical
and experiential competence, combining a robust
appreciation of the range of the normal with a high
index of suspicion for the dangerous. Diverse diagnos-
tic challenges such as reviewing the diabetic retina,
inspecting the cervix, making sense of multiple
non-specific symptoms, assessing the suicide risk in a
depressed young man, and carrying out a developmen-
tal check on a newborn baby are just part of the
normal working day for the medical generalist.
General practitioners encounter diseases at the
earliest stages of their development, long before a clear
and coherent clinical picture forms. Much illness
resolves without reaching the threshold of disease defi-
nition, and fully developed disease is much rarer in pri-
mary care than in secondary care. The general
practitioner must develop the skill of using time to
reveal the natural course of a presenting condition.
The inevitable uncertainty of front-line primary
care medicine is confirmed by the fact that the predic-
tive tests of medical science do not work nearly as
robustly in the low prevalence setting of general prac-
tice.3One of the contributions of generalist practice to
improving health outcomes for populations is medi-
ated by broadly based diagnostic skills that can select,
through the referral process, high prevalence popula-
tions for specialist practice and thereby ensure the
effectiveness of specialists. This skill constitutes a
uniquely valuable healthcare commodity.4Illness is
much more extensive than disease
—
and the disease
which is referred on to specialist colleagues is only just
over a tenth of that seen and treated in general
practice. At each stage, the prevalence of biomedical
abnormality increases and diagnostic tests work more
robustly.
Thus general practitioners must use technical and
experiential evidence from a multiplicity of sources to
formulate both a diagnosis and a response.5This pro-
cess always involves judgment and is always risky. Both
too little and too much caution can be dangerous. It is
surely right that society should place the responsibility
for these risks on those who are most highly trained.
The current proposals to replace doctors with nurses,
pharmacists, and computers can do nothing to reduce
the risks and, in the face of less medical knowledge,
General practitioners operate in a low tech environment
Education and debate
This article is
part of a series
examining the
government’s
planned market
reforms to
healthcare
provision
Caversham Group
Practice, London
NW5 2UP
Iona Heath
general practitioner
Peninsula Medical
School, Royal
Devon and Exeter
Hospital, Exeter
EX2 5DW
Kieran Sweeney
honorary clinical
senior lecturer in
general practice
Correspondence to:
I Heath
iona.heath@
dsl.pipex.com
BMJ 2005;331:1462–4
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may well increase them. To offer this substitution is to
misunderstand the complexity of the generalist’s task.6
Coordination of care
The role of the general practitioner in coordinating
health care across a range of professionals, within and
beyond primary care, is often assumed but has been
subject to little analysis. The role falls to the general
practitioners because of their continuing commitment
to the care of a registered list of patients, and because,
alone across the whole range of health professionals,
the general practitioner is not expected to discharge
the patient from his or her care. Patients and general
practitioners therefore have a tacit understanding that,
if the healthcare system is not working, the general
practitioner is in a position to sort things out and has a
responsibility to do so. Practising within a defined local
area, general practitioners rapidly develop knowledge
and understanding of how the local healthcare system
works and an awareness of which parts of the service
are performing well and which are struggling with, for
example, an excessive workload or a staff shortage.
This knowledge is continually updated by patients, who
return from hospital or from other parts of the service
to give an account of their experience.
The general practitioner’s coordinating role7
becomes absolutely crucial given the increasing
number of patients who have more than one health
problem, each of which affects the course and
management of the others.8Such comorbidity occurs
disproportionately within populations that are socio-
economically disadvantaged or elderly, and particu-
larly within populations which are both.9
Social solidarity
The NHS is an expression of social solidarity by which
citizens, through taxation, provide health care, free at
the time of need, to each other.10 The current emphasis
on rights within health care without a balancing
emphasis on duties threatens the survival of the under-
pinning social solidarity. The right to see a general
practitioner within 48 hours, and at any time of day or
night, with no allowance for the degree of need, mini-
mises the duty of citizens to use the limited provisions
of the NHS in a manner that is proportionate to their
needs.
General practitioners working within a nationally
funded service will always have a role as agents of dis-
tributive justice, if only in the way that they choose to
allocate their time to different patients competing for
this limited resource. This means that general
practitioners and other clinicians must retain both the
ability to allocate their resources on the basis of
perceived need and the responsibility to try to modify
health seeking behaviour. The emphasis on rights at
the expense of duties also makes it more and more
usual for people to demand a level of service for them-
selves and their families while declining to pay the level
of taxes that would be needed to provide that same
level of care for everyone.
Suffering
Much contemporary discussion about general practice
focuses on the profession’s response to the enormous
pressure for change within the NHS.11 How will
general practitioners adapt to new relationships with
other professionals? How will they deal with the
challenges of new technologies and new interventions?
At the heart of general practice however rests the cen-
tral, enduring responsibility of doctors in any society
—
the recognition and relief of suffering.
Paradoxically, the successes of medicine have
enabled an increasing number of people to survive
many previously fatal events and diseases including
heart attacks, strokes, and cancers. As a result, more
people live long enough to experience one, or more
likely several, chronic conditions. These common con-
ditions (such as hypertension, diabetes, ischaemic heart
disease, chronic obstructive pulmonary disease,
and dementia) remain incurable, debilitating, and
progressive.
As general practitioners focus increasingly on the
management of people with multiple and compound-
ing conditions, the balance of technical with compas-
sionate care must be continuously negotiated so that it
makes sense in the context of the patient’s life story
and acknowledges the full diversity of their health and
social problems. In such a situation, the values and pri-
orities of the individual patient must always be allowed
to trump the dictates of medical science and evidence
based guidelines. The ever present, malevolent
potential of illness to destroy an individual’s person-
hood can never be forgotten. Although biomedical
interventions may become more sophisticated, and
service delivery more slick, the responsibility of the
general practitioner to acknowledge and where
possible relieve suffering endures and can never be
abrogated.
Contributors and sources: IH and KS are general practitioners
and the ideas in this article arose from thinking and reading
around the experience of caring for patients in general practice
over many years and from discussions which took place within
the future of general practice group established by the Royal
College of General Practitioners, of which the authors were
members. We thank the convenor of the group, David Haslam,
and the other members, Richard Baker, Bonnie Sibbald, Martin
Roland, David Colin-Thome, Martin Marshall, Maureen Baker,
Tim Wilson, Susannah Graham-Jones, and Hilary De Lyon for
their contributions.
Summary points
General practitioners’ skills encompass both the
principles of science and the experience of
suffering
As more people survive to endure multiple and
compounding chronic illnesses, the need for
generalist skills to integrate care of the whole
person becomes greater
In a system of health care predicated on social
solidarity, the rights of the individuals have to be
balanced against the duties of citizens
The current emphasis on radical transformation
of the NHS demeans the enduring responsibility
of doctors in any society: the relief of suffering
Education and debate
1463BMJ VOLUME 331 17 DECEMBER 2005 bmj.com

Competing interests: IH and KS are general practitioners and
will therefore be directly affected by the government’s planned
changes to healthcare provision.
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Using markets to reform health care
Nigel Edwards
The English healthcare market will be different from conventional markets and may not behave in
the same way. Predicting whether the reforms will produce the intended results is therefore difficult
Many health systems are using market mechanisms,
competition, and incentives as a way of driving reform.
The benefits of this are seen as increased responsiveness
to the needs of patients and payers, the ability to increase
and reduce supply quickly when required, greater
efficiency, innovation, and less unhelpful meddling in
provider management by central authorities. These
advantages are potentially important but come with
some problems and costs. The policy question is at what
point the costs exceed the expected benefits?
Costs of competition
Competition has costs for providers, payers, and
patients. Competition reduces some management
costs but transaction costs such as billing and contract-
ing are likely to be higher than in managed systems
and providers may have large marketing costs. The
reforms proposed for the NHS have avoided one
important transaction cost by setting prices nationally,
although this may be at the cost of removing some of
the power of market mechanisms.The more independ-
ent providers become, the more they will need to
strengthen their governance arrangements and the
greater the need for external regulation. Competition
requires some duplication and redundancy, which car-
ries a potentially high cost. This means that the
evidence on costs is less clear than economic theory
suggests,1particularly as this does not necessarily apply
to systems with fixed prices.
The creation of spare capacity,which is required for
competition, carries an appreciable risk of creating
supplier induced demand because providers need to
make productive use of their assets. This creates an
industry to manage demand, pre-authorise treatment,
review use of services, etc, which adds to costs for a
relatively low marginal benefit. Too much effort may be
put into differentiating products or aspects of quality
that are important for competition but add cost and
deliver little value to patients.
Choosing providers has a substantial costs for
patients in terms of time spent searching and selecting.
This is especially true for patients with long term condi-
tions, and the benefits of switching may be low, particu-
larly if they value continuity of care. Indeed, low benefit
can be inferred from the observation that switching
family doctors is uncommon in settings where patients
have this right and where supply is less constrained than
in the United Kingdom. Patients need to be able to
switch providers if they are dissatisfied but may regard
frequent changes as having limited value.
Effect on quality
The impact of competition and markets on the quality
of care is contested, and it cannot automatically be
assumed that quality will improve without supporting
policies and regulatory machinery.12Several potential
hazards exist.
Competition and market incentives can lead to the
fragmentation of care and threaten continuity and
integration, which are important for patients with
long term conditions.3–6 For example, disconnecting
management of chronic disease from primary care is
Effects of competition in the NHS are unpredictable
Education and debate
This article is
part of a series
examining the
government’s
planned market
reforms to
healthcare
provision
NHS Confederation,
London SW1E 5ER
Nigel Edwards
policy director
nigel.edwards@
nhsconfed.org
BMJ 2005;331:1464–6
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