Intended for healthcare professionals

Career Focus

Complexity In Primary Care

BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.335.7613.s48 (Published 04 August 2007) Cite this as: BMJ 2007;335:s48
  1. Sabina Dosani, editor
  1. Career Focus sdosani{at}bmj.com
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Complexity in Primary Care

Kieran Sweeney

Radcliffe, 2006

£21.99, 165 pages

ISBN: 1 857 75724 6

Rating:⋆⋆⋆⋆/5

Exeter general practitioner Kieran Sweeney presents an elegant ponderosity: that the explanatory model in contemporary medicine needs to be overhauled to accommodate plurality of world views. This book's strength lies in the way Sweeney analyses thoughts and feelings probably all GPs have grappled with, but never understood. His understanding of the subtleties of what happens between practitioner and patient in consulting rooms is by turns touching, troubling, and thought provoking.

Sweeney graduated in art as well as in medicine. His career has taken him from the Times, where he was medical correspondent, to the Healthcare Commission, from which he resigned to start a doctor-nurse partnership in the NHS. He is a senior lecturer at Peninsular medical school, an honorary fellow of the Royal College of General Practitioners and Royal Society of Arts, and was awarded the Eric Elder medal by the Royal New Zealand College of General Practitioners. He has published prolifically and received a personal commendation from Annette King, minister of health for the government of New Zealand. In short, he's amazing, and so is this book.

Beginning with a patient referred to as “Mrs B,” who mourns “Jack's dead and the boys are gone” during a consultation to reduce her cardiovascular risk, he analyses general practice, dissecting shifts between biomedical and biographical. Continuing with a lively critique of evidence based medicine, he teases concepts out with skill and style. If he's half as good a doctor as he is a philosopher and writer, his patients are a fortunate group. They have a GP who understands concepts of diagnosis are broader in primary care than strictly biomechanical models. Let's face it, many primary care consultations proceed without a diagnostic label. Where, asks Sweeney, is the caseness in hopelessness, despair, or humiliation? What is the appropriate evidence based question for patients presenting like this?

His chapter on the historical overview of the epistemological origins of qualitative research oozes with insights and clarity reminiscent of the late Roy Porter; not a comparison lightly made. He describes the evolution of a second intellectual tradition, quite distinct from the scientific tradition, and compares it with both scientific thought and non-linearity.

The non-linear paradigm is perhaps best explained using analogies from physics. In 1998, Prigogne won the Nobel prize for physics by showing how an open system, far from being in equilibrium, had the capacity to respond to change and disorder, by reorganising itself at a higher level of organisation. Understanding and applying complexity theory to primary care helps not only GPs but also patients and policy makers.

If you're looking for bedtime reading, try Joanna Trollope. If you want one of those rare important and illuminating books that change the way you think and probably your practice, look no further.

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