Being philosophical when it’s complicated

CONCEPTS, IDEAS, AND LANGUAGE

Concepts and ideas are important. We use language to express and exchange ideas about the world, even to make sense of it for ourselves. Offering health care, for example, depends on what we mean by health. In 1946, the WHO defined health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.

Richard Armitage shows us how this definition is not only utopian (who can attain total wellbeing?), but also un-nuanced. And yet these three domains of health help us to think about health, especially when we think about them in a nuanced way. How we use words can be as important as what those words mean. Ben Hoban observes that doctors are inordinately fond of nouns. By and large, patients come to us not just with nouns, but also with stories that include them and are driven along by verbs, words of action, backed up by adverbs, pronouns, and so on.

The last century saw the wholesale introduction of computing and machine intelligence into medicine. Computers are even more dependent on precisely agreed meanings than humans. Luke Roberts re-introduces SNOMED CT — the world’s most comprehensive clinical terminology. It supports the standardised recording and encoding of patient information, including diagnoses, procedures, and medications. The terminology is designed to be usable in any electronic health record system.

SITUATED UNDERSTANDING

We cannot hope to directly experience all of medicine and health care ourselves, and rely on others to extend our gaze and understanding. Cancer and end-of-life care have become major features of 21st-century general practice. We review two books that describe cancer experiences. Roger Jones reviews The Only Book I’ll Ever Write. In this final autobiography, a GP approaching retirement is diagnosed with inoperable gastric cancer. He charts the medical, human, oncological, and psychological dramas that take place over the next 3 years. Karen Chumbley reviews 36 Hours, a reflection on the last 36 hours of Fiona’s husband’s life as he undergoes end-of-life care at home. Here we see that there are (at least) two people with physical, mental, and social needs.

Recent data suggest that on average 13 600 beds in NHS hospitals across England are occupied every day by patients who are ‘medically fit for discharge’. Peter Levin delves into the complexity of the term ‘medically fit for discharge’. Not only is it critical to see the other aspects of patient care that allow them to survive and thrive in the community but also to acknowledge that medicine cannot work in isolation. In order to free those beds, we need to reprioritise the unglamorous work of social services, carers, and communities, and help individuals back to (dare I say) a more complete state of physical, mental, and social wellbeing. Terry Kemple expands the situated outlook to the world in which we live by bringing social justice and the environment to join financial profit-and-loss accounting in the economic model of primary care, a triple bottom line.

Amanda Howe and colleagues raise practical and professional issues for consideration by those considering the process of ‘retirement’. Using the question of whether to stay registered with the GMC, they offer some experience to inform others’ thinking, and also to set out issues that bodies such as the RCGP still need to address. Once again language becomes important as registration is bound with identity. Am I a GP, or do I work in general practice?

Ahmed Rashid casts a critical eye at breastmilk expression, mild cognitive impairment, Ramadan, and 111 online as an ‘invisible service’, exemplifying the sheer heterogeneity of GP-relevant knowledge.

SLEEPWALKING: THE DANGERS OF SIMPLISTIC NAIVETY

Samar Razaq argues that, while the media may intend to inform, they can influence panic behaviour in the public, with the recent strep A outbreak being a powerful example. The concern with news media is that the economic goal to make money, whether through selling papers, advertising revenue, or playing to the prejudices of billionaire sponsors, can eclipse the purpose of sharing information with the public. Quite separately from the moral harms or what is shared as news, there may be direct harmful consequences of a misleading story — in this case, a literal overwhelming for GP services when the system is already in crisis. One strange and unhelpful narrative is that corporate, profit-based health care will ‘save the NHS’.

Nada Khan argues that NHS chiefs and policymakers should be cautious about assuming that diverting patients to the private sector will take pressure off the NHS or reduce NHS waiting times as the evidence to date does not support these views.

Tim Senior argues that, if GPs are replaced by a more industrial/transactional form of primary care, we systemically remove the part of the health system that has researched and trained in handling relationships and complexity well. We need to be able to describe what health systems stand to lose if general practice goes. This brings us back to complexity, which is both a challenge for primary care and a unique selling point for general practice.

IT’S COMPLICATED … SO WHAT?

‘Being philosophical’ about something is often interpreted as a defeatist reconciliation with the futility of our actions. I prefer to see being philosophical as the ability to be a critical agent in the world. We can use concepts and language to share ideas and help us see things we might overlook. We can use the narratives of others to extend our own experiences of the world. The dangers from being intellectually and morally passive compel us to embrace complexity. More than this, we need to convince the world that ‘It’s complicated’, and (with time and resources) general practice can help.