The past 40 years have brought changes that have transformed general practice as we used to understand it. Despite this, as a profession, we like to imagine that the clinician–patient interaction remains centre stage, played out in time and space as close as possible to the communities where individuals live, influenced by their social contexts. However, this archetypal description of general practice is challenged by fundamental uncertainties about our role and purpose, which we explore below. These uncertainties test our conception of relational care and our ability to enter into the therapeutic alliances that we know benefit patients.
THE NATURE OF THE UNCERTAINTY
As far back as 2004, Ronald Barnett described a conflict in the identity of universities whereby it isn’t clear whether they serve to ‘consume and produce resources’ or to act as ‘centres for the promotion of critical thinking and transformatory engagement’.1 It is our assertion that a similar paradox exists in general practice, where we are faced with the dilemma of whether our role is to ensure patient safety by following guidelines, in such a way as to minimise risk; or whether it is to co-create meaning with our patients, to help them navigate a path through their illness and to accept that this can be a risky undertaking, both for them and for us. These two views of the profession are fundamentally misaligned.
WHAT ARE THE SOURCES OF THE UNCERTAINTY?
An important contributory factor to the uncertainty about purpose in general practice has been the rise of positivist and performative paradigms in health care over the last 30 years, whereby particular, defined outcomes are described and incentivised — the Quality and Outcomes Framework being an example. Their introduction has helped to improve population health outcomes, but there have been inadvertent harms — one of which has been to overwhelm clinicians with guidelines, to exclude non-linear strategies and solutions, and to privilege distilled and decontextualised knowledge over the more local, transient, and contingent knowledge commonly emergent from general practice consultations. The presence of alerts on patient records which indicate that particular actions are needed in order to attract payment (for example, checking blood pressure) disrupts the narrative and how it is listened to.2
The increased prominence of protocol-driven medicine has coincided with general practice moving towards larger multiprofessional teams incorporating many clinicians who may work from different locations and who may not know one another personally. Technology is being used to ever greater effect, consultations are now often remote, and continuity of care with the same doctor has become less common. This has changed the nature of relationships within teams and with patients, inadvertently creating fertile ground for a ‘collusion of anonymity’,3 where nobody takes ultimate responsibility for clinical decisions.
Alongside this emphasis towards outcome and the setting out of permissible ways to practise, there have been changes implemented to safeguard patients4 after high-profile cases such as Harold Shipman. These have had the effect of creating boundaries between doctor and patient, which feed into our normative ethical frameworks and that we are careful to maintain in order to avoid disciplinary proceedings.
Many of the changes were needed and went some way towards redressing unacceptable practices that existed previously. However, an unintended consequence of establishing boundaries is to encourage a generic approach in which clinicians are reluctant to take emotional risks and therefore do not deviate from guidelines and protocols, even when to do so would be in the best interests of the patient. This generates a tension between the desire to provide individualised care and the reluctance to ‘break rules’; and creates a paradox whereby the notion of ‘patient-centred’ care, to which we all subscribe, is far from the lived experience of many of our patients.
WHAT ARE THE FEATURES OF A THERAPEUTIC ALLIANCE AND WHY IS IT IMPORTANT?
It is no surprise that there is an abundance of proof that relationship-centred continuity of care is associated with greater patient satisfaction, improved clinical outcomes, and more efficient use of clinical services.5 Evidence exists from clinical psychology that it is the quality of the therapeutic alliance that underpins positive outcomes achieved, irrespective of the nature of the intervention.6 In a similar manner, it is likely that the therapeutic alliance between patient and practitioner is an important explanatory factor for the positive health outcomes associated with primary care.7
It has been proposed that, in order to understand the effect of illness on their patients, clinicians must integrate different bodies of knowledge.8,9 This coming together of the biological and biographic enables GPs to assume an ‘interpretive’ role. We propose that relational care is effective because it involves clinicians being attuned to discontinuity,10 being aware of the contextual, and eliciting a narrative that finds meaning for the patient.11
Co-creating meaning is an ambiguous, slippery process that is open to multiple interpretations, as narratives are formed and re-formed, some being privileged and others ignored. It inevitably involves the willingness and ability to manage risk and uncertainty, which we see as fundamental to our existing conception of general practice, but which is curtailed by the systemic features we have described above.
WHERE DO WE GO FROM HERE?
The proliferation of ideologies, perspectives, and value propositions over recent decades has generated uncertainty of a different nature from that perceived in previous times1 — not only about the nature of knowledge, but also a sense of personal instability. Therefore, what does it mean to be a GP in the 21st century? The tension arising from the different concepts of the role can be destabilising, especially if it is never made explicit.
An honest conversation about the messy nature of uncertainty and its implications for the profession is now needed. If we decide we want future medical expert generalists who are willing and able to manage clinical uncertainty and complexity, we should first acknowledge and accept that there is inherent risk in individualised, relational care. Local, transient, partial, and contingent co-constructed knowledge does not have the reassuring appeal of decontextualised knowledge, with its reliance on numbers.12
As part of this conversation we propose that GPs should explicitly analyse their decision-making processes through the different lenses we describe — the performative, the ethical, and the relational. Through professional dialogue and in training programmes we need to become aware of their influences on our actions. We are not advocating that performativity and protocol-driven care are abandoned; but that their effect on relational care is explicitly considered so that we become more attuned to the effect of these different value systems in which we are immersed.
Finally, and most importantly, we should seek out the views of our patients about which approach they wish us to take and which conception of general practice they most value; and be guided by this.
CONCLUSION
The uncertainty of purpose we describe calls into question the very nature of what the role of a GP is and of what is needed in order to occupy it. We should first define and then address the discord generated by the competing and incompatible discourses that surround us if we are to preserve or re-imagine the therapeutic alliance that has historically been the most powerful tool in the general practice armoury.
Notes
Provenance
Commissioned; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2021
