obstacles to medical generalism
The virtues of a given profession are those qualities that enable members of that profession to fulfil their professional role, achieve the goals of their profession, and meet their professional challenges. Having identified ten professional virtues of generalist medicine something also needs to be said about the range of factors that get in the way of medical generalism, that is, the range of factors that make it harder for medical generalists to fulfil their professional role.
For each professional virtue, there is a corresponding professional vice. For example, if attentiveness is a virtue then inattentiveness is a vice. If humility is a virtue then arrogance is a vice. And so on. The point of classifying inattentiveness as a professional vice of generalism is not to suggest that generalists are especially prone to it. The point is rather to suggest that if one is inattentive then one is less well placed to fulfil the professional role of a generalist than if one is attentive. It is worth noting, however, that inattentiveness and other such failings can simply be the result of overwork, lack of time and fatigue. In these circumstances, it is unfair and inappropriate to censure clinicians for being inattentive.
Are there any vices to which generalists are especially prone? Trish Greenhalgh identifies a tendency to close ranks and an unwillingness to own up to mistakes as two professional vices of clinical practice. These are professional rather than personal vices, to the extent that they affect a clinician’s professional conduct rather than their conduct in their private lives. It is an open question, however, whether generalists are especially prone to these vices in their professional lives. A tendency to close ranks and an unwillingness to own up to mistakes sound like professional vices of virtually every profession.
Vices are generally understood as personal failings for which the person whose vices they are can fairly be blamed or criticized. Yet many of the most significant obstacles to medical generalism are institutional rather than personal. According to Stefán Hjörleifsson and Kjersti Lea, for example, ‘disease-focused clinical guidelines, public health agenda focusing on single diseases and individuals, structured and interventionist electronic records, and expanding medical technologies leave little room for personal interaction between general practitioners and their patients’ (p.28).
There is nothing personal about these obstacles to person-centred care, if that is what they are. They are, if anything, systemic obstacles to generalism. If one insists on employing the terminology of virtues and vices one would have to think in terms of institutional rather than personal virtues and vices. That is not as far-fetched as it sounds. Institutions can be more or less bureaucratic, more or less responsive, more or less adaptable. There is no reason not to think of these as institutional virtues or vices.
What are the institutional obstacles to medical generalism? Do they include the factors listed by Hjörleifsson and Lea? In what sense, and to what extent, do disease-focused clinical guidelines, electronic patient records, and expanding medical technologies prevent generalists from fulfilling their professional role? Joanne Reeve notes that while many clinicians welcome a shift from disease-focused to person-centred clinical care ‘they also describe clear barriers to delivering this way of working within the constraints of modern healthcare systems and practice' (p. 160). As described by Reeve, these barriers include the following:
Current models of service delivery require diagnostic labels to legitimize access to medical care.
Clinicians lack the time and head space required for the practice of self-focused care.
There is a lack of training in person-centred care and a fear of working beyond guidelines.
There is an absence of appropriate systems of learning from self-focused care.
These barriers are not insuperable. However, as Reeve notes, ‘to strengthen the generalist, self-focused, approach will need changes in the way we train clinicians and organize healthcare’ (p. 162). In other words, overcoming the institutional obstacles to medical generalism requires systemic change.
the role of technology
In a recent paper, Deborah Swinglehurst focuses on electronic patient records (EPRs) and their role in UK general practice. She argues that ‘the EPR profoundly changes the dynamics of the clinical consultation and shapes working arrangements and relationships in significant (and sometimes unintended) ways’ (p. 55). For example, GPs spend about 40 per cent of their time in consultations interacting with their computer. It is arguable that there are several professional virtues whose exercise is hindered by the growing role of technology in general practice.
One such virtue is attentiveness. Spending nearly half of every consultation staring at a computer screen and updating the patient’s electronic record is hardly conducive to giving one’s undivided attention to each patient and engaging with their subjective reality. As Swinglehurst puts it, ‘the EPR encourages a certain direction of travel – tending to shift towards a privileging of the “institutional” version of the patient over the patient as “individual” or sharpening the tension between institution-centred care (bringing with it additional surveillance and accountability) over patient-centred care’ (p. 72).
Moreover, the computer is a third voice in every consultation, telling the generalist what to do. The EPR, Swinglehurst notes, ‘is awash with prompts, alerts and reminders’ (p. 70). According to Greenhalgh, currently when someone visits their GP ‘quite a bit of the encounter will typically be taken up by the doctor working through a structured computer template that directs the questions to be asked, the parts of the body to be examined, and the recommended medication’. She adds that ‘if patients knew how much of the consultation was driven by box ticking they would be hopping mad’.
It is easy to see how these trends might both discourage the exercise of the GP’s situational judgement and, in the long run, also diminish levels of professional self-trust and self-confidence. A piece in the BMJ notes that:
‘Inexperienced clinicians may (partly through fear of litigation) engage mechanically and defensively with decision support technologies, stifling the development of a more nuanced clinical expertise that embraces accumulated practical experience, tolerance or uncertainty, and the ability to apply practical and ethical judgment in a unique case’.
Generalist health care is supposed to be a collaboration between doctor and patient but over-reliance on following algorithmic rules is not conducive to collaborative consultations.
the guideline culture and overdiagnosis
The benefits of guidelines are huge. They have been said to improve the quality of care received by patients, improve health outcomes and improve the quality of clinical decisions. However, according to Greenhalgh and her colleagues, heavy reliance on guidelines can also ‘crowd out the local, individualized and patient initiated elements of the clinical consultation’. The heavier the reliance on general guidelines the harder it is for the clinician to engage with the fine-grained particularity of each individual patient.
The guideline culture and technology have also been blamed for the growth and institutionalization of overdiagnosis and overtreatment. In the words of Julian Treadwell and Margaret McCartney:
‘Advancing technology allows detection of disease at earlier stages or “pre-disease’ states. Well-intentioned enthusiasm and vested interests combine to lower treatment thresholds and intervention thresholds so that ever larger sections of the asymptomatic population acquire diagnoses, risk factors, or disease labels. This process is supported by medicolegal fear, and by payment and performance indicators that reward over-activity. It has led to a guideline culture that has unintentionally evolved to squeeze out nuanced, person-centred decision-making’ (p. 116).
These are illustrations of just some of the institutional and technological obstacles to generalist medicine. There are, no doubt, many others. Much could be also said in this connection about the increasingly managerial culture of institutions such as the NHS. The payment and performance-indicators referred to by Treadwell and McCartney are integral to this culture. They are a powerful illustration of the tension between managerialism and the distinctive methods, orientation and objectives of medical generalism.
These obstacles are by no means insuperable. For example, there is nothing wrong with an evidence-based approach as long as it prioritizes the care of individual patients and is not allowed to obstruct real shared decision-making. The deeper point, however, is that many of the most serious challenges to medical generalism are institutional rather than personal. The remedies are therefore also, to a large extent, institutional rather than personal. Of course it is desirable for medical generalists to cultivate the virtues of generalist medicine, but the systems in which they work must also allow for the unhindered exercise of these virtues.
references and further reading
The reference to a tendency to close ranks and an unwillingness to own up to mistakes is from here: https://www.cebm.net/2016/01/5395-2/
The article by Hjörleifsson and Lea is ‘Mismanagement in general practice’, in Christopher Dowrick (ed.) Person-centred Primary Care: Searching for the Self.
The article by Deborah Swinglehurst is ‘Challenges to the “self” in IT-mediated healthcare’, also in the Dowrick volume.
The benefits of clinical guidelines are summarized here:
Greenhalgh’s comments about what happens when someone visits their GP are from this report in the BMJ: https://www.bmj.com/content/349/bmj.g4443
The quotation about the use of decision support technologies by inexperienced clinicians is from this article by Greenhalgh, Howick & Maskrey: https://www.bmj.com/content/348/bmj.g3725
The account of the causes and consequences of overdiagnosis is from this article by Treadwell & McCartney: https://bjgp.org/content/66/644/116/tab-article-info