General practice—time for a new definition

Olesen et al. [1] present an interesting analysis of the contents of
General Practice and discuss the grounds for its claim of equal status
with other specialties. While agreeing with most of the premises
presented, we believe it is useful to examine some of the assumptions
made.

To start by considering "the ideal content of the discipline" is only
feasible by choosing a specific view point through which to look at it.
The authors acknowledge this by adopting as principal aim the definition
of "the academic agenda for universities or professional bodies when
training young doctors to become general practitioners." In doing this,
they become attached to a specific academic view of General Practice.
Furthermore, they explicitly favour one specific political positioning of
General Practice within the medical profession, namely that its role "is
best achieved in systems that offer controlled access to specialists."
They also explicitly favour a political definition of General
Practitioners within society which assumes their main role as "responsible
members of the healthcare system", from there discussing a population
based practice (thus the reference to "equity" and "resources") as opposed
to an individual based practice. Their "suggested new definition"
definitively situates General Practice within an organised healthcare
system. Finally, their concern with humanistic approaches to medical
practice is subordinated to the endeavour of maintaining science to be
"the basis of clinical work in General Practice." We want to discuss each
of these assumptions.

1.The educational point of view

To locate the grounds for definition of General Practice within the
educational institutions is to avoid a more profound discussion of 'what
kind of General Practice is desirable, either from the deliverer point of
view, or from the receiver point of view.' The discussion they present is
immediately subordinated to the rules of discourse of the institutions
which one aims to influence. It may be politically expedient, but the
success it may achieve may well turn out to be a Pyrrhic victory. The
current scientific discourse of medical teaching divorces the patient from
its individuality. We see a redefinition of General Practice as aiming to
assert its role in minimising this divorce by addressing the paradox of
applying a science of collectives to individualised persons. To adopt the
discourse that promotes this depersonalisation of the patient is not the
way to achieve it, and it must be present in our minds that universities
and professional bodies are the source of this discourse.

2. The medical politics

To assume the definition of the role of the General Practitioner
around its role as 'gatekeeper'is to choose a subordinated positioning for
General Practice. From a doctor the patient chooses to see, its role is to
be defined as the doctor the patient cannot avoid to present itself to.
Any patient centred rhetoric becomes empty when we define the role of the
General Practice through a medico-political system and not through patient
choice. Thus, the opportunity for effective intervention is compromised
from the outset, as the patient does not present itself to the General
Practitioner out of an autonomous act, but as an imposition for access to
medical care. To impose as a central role of General Practice the care of
patients that would rather be seen by someone else is demeaning for
General Practice, for the General Practitioner, and only understandable
from a need to manage resources seen as primordial, with the patient's
aims placed on a secondary level. If General Practice cannot invoke a
better organising principle for its political relations with the other
specialties, if General Practice cannot invoke the will of the patient to
see its General Practitioner, then General Practice cannot but be a second
rate field of medical practice.

3. The healthcare politics

No medical specialty should be defined through its positioning within
an healthcare system. A medical specialty may only be defined through the
needs created within the interaction of patients and medical knowledge and
practice. A specialty which depends for its existence on an organised
healthcare system, defines itself as not desired by patients: if not
imposed by the internal logic of the system, there would be no place for
it. Again, it is the positioning of General Practice towards the
individual which is at stake: either we understand the General
Practitioner as a medical practitioner to whom certain patients want to
relate, and thus define General Practice around the needs which generated
the relation between General Practitioner and patient, or we find the role
of the General Practitioner to be imposed on the patient, as an area of
enforcement of governmental political choices regarding the medical care
of anonym social entities (and not the medical care of autonomous
individuals).

4. The role of science

Science is the study of collectives, and the knowledge it generates
is thus probabilistic and adequate for interventions upon collectives. The
paradox of medicine is the endeavour of applying a science of collectives
to individual patients, while presenting itself as valuing the uniqueness
of the individual. If patient centered care, patient autonomy, and the
respect for individual uniqueness is something more than an empty
rhetoric, its foundations cannot be scientific. Whatever science of
individuals may be created, it must necessarily be a science of
collectives and always inappropriate for the affirmation of individual
uniqueness. The recognition that the individual is the sole interpreter of
its uniqueness is explicit in the acceptance, within patient centered
discourses, that whatever is produced by the medical encounter has to be
translated, by the individual, into a personal narrative of events from
which that individual will construe the meaning of the encounter. What the
medical practitioner does is not a final act, but an act to be subjected
to the patient's reinterpretation, outside medical control.

Within this
understanding, the final outcomes of medical interventions, in their
personal significance, are outside the realm of science. To acknowledge
this is to acknowledge a polarity for the definition of our aims as
medical practitioners: either the professionally agreed outcome - the
physiological evidence of the changes attributed to a certain medical act
- or the report by the individual of the fulfilment or otherwise of the
aims which brought that particular individual into the medical relation.

At the bottom, here lies the distinction between doctor centred practice
and patient centred practice. If we choose the later, science is just a
tool to be applied within an humanistically defined scenario. In the
education of this practitioner the knowledge of its tools cannot take
primacy over the knowledge of the object of its acts. The incapacity of
medical discourse to overcome effectively the shortcomings of a scientific
approach have produced a medical education preparing doctors to be in
conflict with their patients, as expressed by the finding that the more
qualified doctors are sued more often [2]. The title of this paper asks:
"Are the best doctors sued more?" How is the definition of best doctor
construed to allow this question?

General Practice (as medicine in general) is permanently defining
itself by the discourses it produces. If it is to live up to the
definition of patient centred practice, holistic view of the individual,
and respect for the autonomy of unique individuals, as experienced by
those same individuals, General Practice has entered an area of
fundamental differences regarding hospital medicine. From the outset,
while the General Practitioner is a member of the community, the
specialist is only visible within the ritualised spaces of medical
institutions. This has implications on the submission of the would-be
patient to the ritualised social role he or she is supposed to enact -
within the institutional medical space, the patient is made anonymous
through the rituals performed, reducing individuals to a boring repetition
of the same acts, the same words repeated countless times, disabling the
expression of who the patient is, because the patient is to busy repeating
those words and acts. Anyone who wants to know another individual should
visit that individual on its own space. One of the most important losses
of General Practice is the increased ritualisation of the space of its
practice. Through this, what is affirmed is the primacy of the anonymity
of collectives, making spaces and practices uniform in the name of the
best use of resources.

Another loss is generated by its striving for
recognition. The recognition General Practice seems to seek is
institutional, and expressed as a need of General Practice itself. What
this implies is that General Practice takes the initiative of seeking
recognition through the expression of its conformity with the discourse of
the institutions it sees as 'givers of recognition'. From this it follows
that General Practice is not trying to define itself by the affirmation of
what it is, but through its reinvention according to the rules of the
'recognition givers' - hence the political options expressed, focusing on
the established powers.

Also, the opening of Heath et al. editorial [3]
defines General Practice with the expression of its observance of those
rules: "an academic discipline with its own curriculum, research base and
peer reviewed journals but also the cornerstone of most national
healthcare systems in Europe." Our impression is that such an aim is a
battle lost from the outset, a self-defeating move, as one cannot win by
reinventing itself as it seems expedient, but only by affirming what one
is. The ostensive presentation of 'markers of eligibility for recognition'
is not enough: General Practice has to define itself according to its
practice in the field, not according to an institutionalised discourse
divorced (by adopting a different model) of its daily reality. We
certainly hope that more and more 'good doctors' being sued will make us
see that what makes a doctor 'good' regarding the "universities and
professional bodies" does not necessarily equate with the patient's
definition. Once that polarity becomes accepted, General Practice will
have to decide if it aims to be recognised as 'good practice' by the
institutions or by the patients, and will discuss its definition
accordingly. So far, it seems one of the terms of the equation is missing.

But we must recognise that the aim of medical practice is to serve the
patient, not to reinvent patients according to a medical model. If General
Practice must be the keeper of something, may it be the keeper of an
individualised relation with individuals who present themselves as
patients because they want to do so, a keeper of the difficulties which
lie in looking at science from the perspective of its utility regarding
the individual patient's aims, and not a Godess to be worshipped.

General Practitioner is the name of a trusted medical practitioner
you consult when you want to sort some medical matter that transcends the
narrow technical expertise of a specialist.

References

1 Olesen F, Dickinson J, Hjortdahl P. General Practice: time for a new
definition. BMJ 2000:320:354-357

2 Ely JW, Dawson JD, Young PR, et al. Malpractice claims against family
physicians. Are the best doctors sued more? J Fam Pract 1999;48:23-30

3 Heath I, Evans P, van Weel C. The specialist of the discipline of
general practice. BMJ 2000;320:326-327