Are changes needed in the content of general practice?

The content of general practice (GP) is changing. The concepts of polypharmacy and multimorbidity, particularly among older patients, are becoming common in our practice as well as being the focus of research among our GP colleagues.[1–5] Furthermore, calls for screening and diagnosing that do not actually help our patients are increasingly an issue brought up in our clinical work. Words like medicalization, overdiagnosing and overdetection are hot topics in GP. So, once again it is time to pause and reflect on the content of GP, what needs to be changed and what components in our work are still strong and robust, and hence can be used without modification.

The Wonca Europe conference 2016 was held in Copenhagen last June. Among the keynote speakers who gave presentations was Professor Martin Marshall, from University College London, UK. In his presentation, he talked about how GP needs to change as well as about the ways in which it does not need to change. In his opinion, providing continuity of care, providing personal care and care that patients want and expect from GP do not need to change. However, he said: “In order to provide these general aspects of GP, we are going to need to change, with general practitioners (GPs) needing to take greater responsibility for the way the system runs”. He stated three important areas that need to be addressed and changed so that GPs would continue to provide the general aspects of GP.

Firstly, he pointed out that GPs focus strongly on individual patient needs, though they are indeed also very good at keeping abreast of the whole health system. Thus, the conclusion must be that GPs should participate more in discussions and decision-making on how the health system in which they work should operate.

Secondly, Professor Marshall spoke about uncertainty in our work. “Although we often think we know exactly what we are doing, for example what blood pressure value to aim for and what diabetes control to aim for, the reality is that much of what GPs do is uncertain. Our job as GPs is to manage this uncertainty. We must be more explicit in that role and much better in making that part a central part of our function”. This topic of uncertainty in GPs work is very interesting and the question arises as to how many medical doctors have chosen not to work as GPs because of this uncertainty. Managing this uncertainty should therefore be one of the most important aspects of teaching trainees in family medicine.

The third element that Professor Marshall thought should be changed is the way we look at social determinants of ill health. He pointed out that 70% of ill health is not dependent on medical or biomedical problems, but is dependent on social factors like employment, education, income, etc. More evidence on the role of social determinants in patient well-being is being uncovered, for example, that parents’ socioeconomic factors are related to higher antibiotic prescribing for children.[6] However, despite the fact that western countries are spending more money on their health system, inequality still exists and is even increasing. People on low incomes and immigrants are accepting different health care service than those who have higher incomes and less social problems.

Too much testing of well people and not enough care for the sick worsens health inequalities and drains professionalism, harming both those who need treatment and those who do not (Margaret McCartney, GP in Glasgow).

Consequently GPs need to have a critical approach to all those calls for screening and investigations. Nevertheless, we should always remind ourselves of the importance of keeping an open mind and the need to take pause now and then to reassess the content of our practice and to consider what needs to be changed for the good of our patients, while bearing in mind one of the oldest bioethical principles, primum non nocere.