Generalism

Generalism includes an appreciation of undifferentiated presentations, managing uncertainty and complexity, multimorbidity, shared decision making and continuity of care. We describe these concepts below as well as inviting you to engage with further reading at the bottom of this page. If you are particularly interested in any of the concepts, you will find many interesting articles just through google searches. 

COVID-19 has also significantly changed general practice - here is a leader for a series on general practice after COVID-19 drawing upon the ideas of a transactional or relational encounter with the patient. Another older article on generalism calls for balancing 'technical with compassionate care ... so that it makes sense in the context of the patient’s life story and acknowledges the full diversity of their health and social problems

Patients come to the GP early in the disease process often before a clear clinical picture forms. The GP needs to use time as part of their tool kit as many illness presentations may resolve with time, for others it may become evident they need urgent referral. Safety netting, letting the patients know what we expect may happen and when to seek medical attention again if this is not the case, can be helpful in managing this uncertainty.

There are many consultations where there are no straight answers, no clear diagnosis and no obvious treatment, where guidelines and decision-making protocols do not lead to a satisfactory outcome. Without strategies to address uncertainty (such as safety-netting, use of time and discussing with peers) it can become a source of stress to GPs.

This is defined by NICE as the presence of two or more long-term conditions (LTCs). It is associated with decreased quality of life, fragmented and poorly coordinated increased usage of healthcare, polypharmacy and psychological distress. In UK General Practice, 1 in 6 of all patients have two or more LTCs, including 65% of patients over 65 years and 80% of those over 85%. The most common pair of conditions are osteoarthritis and a cardiometabolic condition (e.g. hypertension or diabetes). A common triad is a cardiometabolic condition, a painful condition (e.g. arthritis) and a mental health condition (e.g. anxiety or depression).

You will hear patients being described as ‘complex’ in Primary Care although no one clear definition exists-is their medical situation complex to manage (e.g. multimorbidity with polypharmacy and multiple providers) or perhaps their lived experiences have led to psychological and/or social complexity? 

Shared decision making has been described by NICE as when health professionals and patients work together putting people at the centre of decisions about their own treatment and care. NICE describe some of the benefits, how they are supporting shared decision making and patient decision aids. However SDM is not necessarily simple to achieve in the time allotted to GP consultations. This article explores reasons for failures in SDM such as: doctors’ perceptions about patients’ desire to share decisions; doctors’ ability to facilitate shared decision making; concerns regarding time pressures; apprehension about what patients will demand; and a false perception by clinicians that they are already doing SDM effectively. Another article calls for more honesty on what is possible regarding SDM: Shared decision making a need for honesty Despite these challenges there is evidence of development of language around SDM, for example with medication taking, with movement from the concept of patient 'compliance' to 'adherence' and more recently the concept of 'concordance' being used. To understand these better, read the core tip section of the following article.

Continuity of Care encompasses several aspects, including the consistency of care with a healthcare professional over time, quality of the interpersonal relationships between healthcare professionals and patients, and availability of information about the patient when being seen by different GPs and healthcare professionals. General practitioners value continuity of care, often considering it to be a core value of their profession, while many patients value a personal doctor to coordinate and integrate their care, especially those with long term conditions. Continuity of care is associated with reduced hospital admissions and reduced outpatient services but is under threat from new models of care.

• • the understanding that peoples health is affected by povery, lifestyle, opportunities, choices available etc 

  • https://fingertips.phe.org.uk/profile/wider-determinants

  • https://www.gov.uk/government/publications/health-profile-for-england/chapter-6-social-determinants-of-health