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Subjunctive medicine: enacting efficacy in general practice

Subjunctive medicine: enacting efficacy in general practice
Subjunctive medicine: enacting efficacy in general practice
Modern general practice is complex. Issues such as multimorbidity, polypharmacy and chronic illness management can make applying myriad single condition evidence-based guidelines increasingly difficult. This is compounded because the problems presented in general practice often require both clinical and social solutions. In response to these issues, generalist clinicians are now expected to practise ‘person-centred care’: enabling and empowering patients by combining the technical rationality of medical science with individual values, needs and preferences. To explore this difficult undertaking we conducted an ethnography of a general practice surgery in England, including participant observation, interviews, and focus groups with patients, clinicians, and support staff, from February 2018 to March 2019. Our findings suggest that clinicians in our study faced considerable constraints, broadly conceived as the limits of biomedicine and the structural constraints of general practice. However, they mitigated these by getting into good habits, which we conceive in two categories: using expert judgement and taking patients seriously. We further propose that clinicians did not merely will themselves towards these good habits but developed and adapted them by intuitively adopting a second-order ‘meta’ habit of enaction – treating each consultation as collaboratively co-created anew. This suggests an important feature of the general practice consultation: it is conducted as much in the subjunctive as the indicative mood. Developing this proposition, we propose a more general form of medical practice – subjunctive medicine – extolling the value of the co-created social order of the general practice consultation itself. We suggest that practising subjunctive medicine may help clinicians sustainably and resiliently achieve the aims of person-centred care in modern general practice.
Enactivism, England, Ethnography, General practice, Grounded theory, Person-centred care
0277-9536
1-9
Hardman, Douglas, Iain
bf7ba905-0d04-4d1f-9686-f9a3a3d642db
Geraghty, Adam
2c6549fe-9868-4806-b65a-21881c1930af
Lown, Mark
4742d5f8-bcf3-4e0b-811c-920e7d010c9b
Bishop, Felicity
1f5429c5-325f-4ac4-aae3-6ba85d079928
Hardman, Douglas, Iain
bf7ba905-0d04-4d1f-9686-f9a3a3d642db
Geraghty, Adam
2c6549fe-9868-4806-b65a-21881c1930af
Lown, Mark
4742d5f8-bcf3-4e0b-811c-920e7d010c9b
Bishop, Felicity
1f5429c5-325f-4ac4-aae3-6ba85d079928

Hardman, Douglas, Iain, Geraghty, Adam, Lown, Mark and Bishop, Felicity (2020) Subjunctive medicine: enacting efficacy in general practice. Social Science & Medicine, 245, 1-9, [112693]. (doi:10.1016/j.socscimed.2019.112693).

Record type: Article

Abstract

Modern general practice is complex. Issues such as multimorbidity, polypharmacy and chronic illness management can make applying myriad single condition evidence-based guidelines increasingly difficult. This is compounded because the problems presented in general practice often require both clinical and social solutions. In response to these issues, generalist clinicians are now expected to practise ‘person-centred care’: enabling and empowering patients by combining the technical rationality of medical science with individual values, needs and preferences. To explore this difficult undertaking we conducted an ethnography of a general practice surgery in England, including participant observation, interviews, and focus groups with patients, clinicians, and support staff, from February 2018 to March 2019. Our findings suggest that clinicians in our study faced considerable constraints, broadly conceived as the limits of biomedicine and the structural constraints of general practice. However, they mitigated these by getting into good habits, which we conceive in two categories: using expert judgement and taking patients seriously. We further propose that clinicians did not merely will themselves towards these good habits but developed and adapted them by intuitively adopting a second-order ‘meta’ habit of enaction – treating each consultation as collaboratively co-created anew. This suggests an important feature of the general practice consultation: it is conducted as much in the subjunctive as the indicative mood. Developing this proposition, we propose a more general form of medical practice – subjunctive medicine – extolling the value of the co-created social order of the general practice consultation itself. We suggest that practising subjunctive medicine may help clinicians sustainably and resiliently achieve the aims of person-centred care in modern general practice.

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More information

Accepted/In Press date: 18 November 2019
e-pub ahead of print date: 21 November 2019
Published date: January 2020
Keywords: Enactivism, England, Ethnography, General practice, Grounded theory, Person-centred care

Identifiers

Local EPrints ID: 437418
URI: http://eprints.soton.ac.uk/id/eprint/437418
ISSN: 0277-9536
PURE UUID: fdb86ca5-8d2d-46b9-b34c-0e06a55fce2d
ORCID for Douglas, Iain Hardman: ORCID iD orcid.org/0000-0001-6717-2323
ORCID for Adam Geraghty: ORCID iD orcid.org/0000-0001-7984-8351
ORCID for Mark Lown: ORCID iD orcid.org/0000-0001-8309-568X
ORCID for Felicity Bishop: ORCID iD orcid.org/0000-0002-8737-6662

Catalogue record

Date deposited: 29 Jan 2020 17:36
Last modified: 10 Jan 2022 03:04

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Contributors

Author: Douglas, Iain Hardman ORCID iD
Author: Adam Geraghty ORCID iD
Author: Mark Lown ORCID iD
Author: Felicity Bishop ORCID iD

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