Recovering the self: a manifesto for primary care

The hidden work of general practitioners: An ethnography

High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity.

Hospital physicians' and older patients' agreement with individualised STOPP/START-based medication optimisation recommendations in a clinical trial setting

Aim

To evaluate the agreement of hospital physicians and older patients with individualised STOPP/START based medication optimisation recommendations from a pharmacotherapy team.

Findings

In total, 371 recommendations were discussed with patients and physicians, overall agreement was 61.6% for STOPP and 60.7% for START recommendations. Highest agreement (74%) was found for initiation of osteoporosis agents and discontinuation of proton pump inhibitors.

Message

Better patient and physician education regarding the benefit/risk balance of pharmacotherapy, in addition to more precise and up-to-date medical records to avoid irrelevant recommendations, will likely result in higher adherence with future pharmacotherapy optimisation recommendations.

Objective

To evaluate the agreement of hospital physicians and older patients with individualised STOPP/START-based medication optimisation recommendations from a pharmacotherapy team.

Methods

This study was embedded within a large European, multicentre, cluster randomised controlled trial examining the effect of a structured medication review on drug-related hospital admissions in multimorbid (≥ 3 chronic conditions) older people (≥ 70 years) with polypharmacy (≥ 5 chronic medications), called OPERAM. Data from the Dutch intervention arm of this trial were used for this study. Medication review was performed jointly by a physician and pharmacist (i.e. pharmacotherapy team) supported by a Clinical Decision Support System with integrated STOPP/START criteria. Individualised STOPP/START-based medication optimisation recommendations were discussed with patients and attending hospital physicians.

Results

139 patients were included, mean (SD) age 78.3 (5.1) years, 47% male and median (IQR) number of medications at admission 11 (9–14). In total, 371 recommendations were discussed with patients and physicians, overall agreement was 61.6% for STOPP and 60.7% for START recommendations. Highest agreement was found for initiation of osteoporosis agents and discontinuation of proton pump inhibitors (both 74%). Factors associated with higher agreement in multivariate analysis were: female gender (+ 17.1% [3.7; 30.4]), ≥ 1 falls in the past year (+ 15.0% [1.5; 28.5]) and renal impairment i.e. eGFR 30–50 ml/min/1.73 m²; (+ 18.0% [2.0; 34.0]). The main reason for disagreement (40%) was patients’ reluctance to discontinue or initiate medication.

Conclusion

Better patient and physician education regarding the benefit/risk balance of pharmacotherapy, in addition to more precise and up-to-date medical records to avoid irrelevant recommendations, will likely result in higher adherence with future pharmacotherapy optimisation recommendations.

Clinical trial registration

Trial Registration Number NCT02986425.

General practice - a fertile lagoon in the ocean of medical knowledge

General practitioners (GPs) often find that linear, deductive knowledge does not provide a sufficient map for clinical management. But experience, accompanied by enduring familiarity with individual patients, may offer unique complementary skills to interpret a patient's symptoms and navigate skilfully through diagnosis, treatment, follow-up and prevention.In this article, we draw attention to the nature of this tacit knowing that is executed by many GPs every day. We argue that the nonlinear, unpredictable complexity of this domain nurtures a particular logic of clinical knowing. This kind of knowledge is not intuition and can to some extent be intersubjectively accessible. We substantiate and discuss how and why general practice research can contribute to knowledge development by transforming reflection-in-action to reflection-on-action.We briefly present some concepts for reflection-on-action of clinical knowing in general practice. The VUCA model (volatility, uncertainty, complexity, ambiguity) embraces dynamic and confusing situations in which agile work (adaptive, flexible and responsive behaviour and cognitive creativity) is assumed to be an appropriate response. Using such perspectives, we may sharpen our gaze and apply reflexivity and analytic elaboration to interpret unique incidents and experiences and appreciate the complexity of general practice. In this way, exploratory research can fertilize general practice and offer innovation to the entire domain of clinical knowledge.

Keeping in balance on the multimorbidity tightrope: A narrative analysis of older patients' experiences of living with and managing multimorbidity

Primary care management of patients with multimorbidity in the UK is underpinned by clinical guidelines, quality standards and measurable targets which govern practices of risk management and disease control. There is concern that standardised approaches may not always be appropriate for older patients living with multimorbidity. Using a narrative approach, we elicited the voices of older people living with multiple conditions in order to rethink chronicity, and consider what their accounts might mean for reconfiguring care practices. Within an ethnographic study of multimorbidity and polypharmacy, we conducted in-depth interviews, based on the Biographical Narrative Interpretive Method, with 24 participants aged 65 to 94. Participants were recruited from three general practices in England. All had two or more chronic conditions and were prescribed ten or more medicines. Our analysis draws on Bakhtinian theory, tracing the multiple ways in which participants voiced living with multimorbidity. In this paper, we focus on 'keeping in balance' which emerged as a key meta-conceptualisation across our dataset. Adopting the metaphor of the 'multimorbidity tightrope' we explore the precarity of patients' experiences and show their struggle to create coherence from within a deeply ambiguous living situation. We consider how and to what extent participants' narrative constructions co-opt or resist normative biomedical framings of multimorbidity. Our analysis foregrounds the complex ways in which patients' voices and values may sometimes be at odds with those promoted within professional guidelines. Narrative approaches may offer significant potential for reorienting healthcare towards enabling patients to live a flourishing life, even when facing significant adversity.

Transdisciplinary Generalism: Naming the epistemology and philosophy of the generalist

BACKGROUND

Transdisciplinary research and generalist practice both face the task of integrating and discerning the value of knowledge across disciplinary and sectoral knowledge cultures. Transdisciplinarity and generalism also both offer philosophical and practical insights into the epistemology, ontology, axiology, and logic of seeing the 'whole'. Although generalism is a skill that can be used in many settings from industry to education, the focus of this paper is the literature of the primary care setting (i.e., general practice or family medicine). Generalist philosophy and practice in the family medicine setting highly values whole person care that uses integrative and interpretive wisdom to include both biomedical and biographical forms of knowledge. Generalist researchers are often caught between reductionist (positivist) biomedical measures and social science (post-positivist) constructivist theories of knowing. Neither of these approaches, even when juxtaposed in mixed-methods research, approximate the complexity of the generalist clinical encounter. A theoretically robust research methodology is needed that acknowledges the complexity of interpreting these ways of knowing in research and clinical practice.

METHODS

A conceptual review of literature to define the alignment between (a) the philosophy and practice of generalism in primary care and (b) both the practical (Zurich) and philosophical or methodological (Nicolescuian) schools of transdisciplinarity.

RESULTS

The alignment between generalism and transdisciplinarity included their broad scope, relational process, complex knowledge management, humble attitude to knowing, and real-world outcome focus.

CONCLUSION

The concurrence between these approaches to knowing is offered here as Transdisciplinary Generalism - a coherent epistemology for both primary care researchers and generalist clinicians to understand, enact, and research their own sophisticated craft of managing diverse forms of knowledge.

Which difficulties do GPs experience in consultations with patients with unexplained symptoms: a qualitative study

BACKGROUND

Many general practitioners (GPs) struggle with the communication with patients with medically unexplained symptoms (MUS). This study aims to identify GPs' difficulties in communication during MUS consultations.

METHODS

We video-recorded consultations and asked GPs immediately after the consultation whether MUS were presented. GPs and patients were then asked to reflect separately on the consultation in a semi-structured interview while watching the consultation. We selected the comments where GPs experienced difficulties or indicated they should have done something else and analysed these qualitatively according to the principles of constant comparative analysis. Next, we selected those video-recorded transcripts in which the patient also experienced difficulties; we analysed these to identify problems in the physician-patient communication.

RESULTS

Twenty GPs participated, of whom two did not identify any MUS consultations. Eighteen GPs commented on 39 MUS consultations. In 11 consultations, GPs did not experience any difficulties. In the remaining 28 consultations, GPs provided 84 comments on 60 fragments where they experienced difficulties. We identified three issues for improvement in the GPs' communication: psychosocial exploration, structure of the consultation (more attention to summaries, shared agenda setting) and person-centredness (more attention to the reason for the appointment, the patient's story, the quality of the contact and sharing decisions). Analysis of the patients' views on the fragments where the GP experienced difficulties showed that in the majority of these fragments (n = 42) the patients' comments were positive. The video-recorded transcripts (n = 9) where the patient experienced problems too were characterised by the absence of a dialogue (the GP being engaged in exploring his/her own concepts, asking closed questions and interrupting the patient).

CONCLUSION

GPs were aware of the importance of good communication. According to them, they could improve their communication further by paying more attention to psychosocial exploration, the structure of the consultation and communicating in a more person-centred way. The transcripts where the patient experienced problems too, were characterised by an absence of dialogue (focussing on his/her own concept, asking closed questions and frequently interrupting the patient).

Job strain and retirement decisions in UK general practice

Background

Falling retention in UK general practice is a well-described problem but there has been little previous research into its underlying causes. Poor psychosocial work conditions may help explain falling workforce morale and early retirement from the profession.

Aims

To explore the impact upon morale and retirement decisions of changes in psychosocial aspects of UK general practice over the course of a career.

Methods

Biographical narrative interviewing method (BNIM) was used to obtain and analyse career narratives of 12 London general practitioners (GPs), aged 55–65, half of whom had retired. Findings were theorized using the Job Demands-Control-Support (JDCS) model.

Results

A spontaneous, consistent theme was evident across all 12 interviews: changes in the psychosocial work environment had contributed to a steady decline in morale. Sequential, multilayered reductions in autonomy were the most commonly cited causes for reduced enthusiasm. Increasing demands in the form of both a rising workload as well as a complaints culture drained energy and morale. The GPs described increasingly fragmented teams and therefore reduced social support for the role. Nonetheless, retirement decisions were not straightforward, provoking complex emotions.

Conclusions

The combination of increasing demands with reduced autonomy puts practitioners under intense strain, diminishing the satisfaction they derive from their work and affecting retirement decisions. The Job Demands-Control-Support (JDCS) model is an empirically tested model that could be used to inform improved work design in general practice.