Fighting for the Soul of General Practice: The Algorithm Will See You Now

Book Title: Fighting for the Soul of General Practice: The Algorithm Will See You Now

Authors: Rupal Shah and Jens Foell

Publication Details: Intellect Books, 2023, 258 pp., $26.95 paperback

For at least a decade, the National Health Service (NHS) in the United Kingdom (UK) has been facing a crisis in primary care, which seems to have been made even worse since the COVID-19 pandemic; general practitioners are overworked, underpaid, and attacked by the media. ^{1, 2} Rupal Shah and Jens Foell, both general practitioners (GPs) in the UK, contribute to the ongoing debate through first-person accounts. They are “interested in the way professional relationships are influenced by protocol: between and within organizations; and most importantly with patients/clients/service users,” and they analyze the work of GPs through the lens of “street-level bureaucracy” (p. 3).

The issues are illustrated through short stories about interactions with patients, followed by reflections on the state of affairs. Family doctors everywhere will surely recognize in the vignettes clinical encounters they have had themselves (eg, when a patient starts the very first encounter by saying, “I need a report stating exactly what is wrong with me,” p. 57). The narratives are nicely crafted and alluring; they are able to show how many services, like telemedicine, phone consultations, and online questionnaires (all of which supposedly give more access or speed up processes) actually end up being an extra barrier for many people—especially immigrants, the elderly, the mentally challenged, and the poor. One touching anecdote recalls the relationship with a patient, a rigorous former schoolteacher and crusader for social justice, who was slowly showing signs of cognitive decline. She lived by herself and was helped by a niece who lived a bit far. Despite the accumulating difficulties with instrumental activities and even being a con victim, she did not want to discuss the possibility of having dementia. The doctor was torn between respecting the patient’s wishes and keeping her and society safer by, for example, revoking her driving rights. Eventually, she “followed the rules,” was referred and institutionalized, declining rapidly nonetheless. The doctor can only wonder whether she (the doctor) made the right decision, because she had to watch her patient lose her vibrant personality and live under circumstances for which she (the patient) never wished.

The main theme of the book is how regulations, protocol, and algorithms conflict with personalized care, one of the tenets of family medicine. The authors argue that by focusing on public health indicators and safety, algorithms take the patient away from the center of care. One brilliant example: Despite the UK NHS mission statement, “No decision about me without me,” there are multidisciplinary meetings in which

But at times the stories take lives of their own, still representing dilemmas most family physicians face, but not being clearly examples of the central issues discussed. The touching stories in Chapter 6, “Passports for Passing,” are more about the difficulty of talking about death and dying, which is a cultural trait among many western societies, than about the effects of bureaucracy on dying. Discussing limiting end-of-life care is difficult because, for most people, it is difficult to reconcile with the fact that they or their loved ones are dying, not because of forms. Chapter 7, “A Labour of Love,” narrates three house calls without a clear common theme, and also feels a bit disconnected from the rest of the book.

For medical practitioners in the UK, the publication is an important and easy to read addition to the quest for improvement in NHS primary care. For readers outside the UK, the specificities may make the book less directly relevant; however, it can be read as a warning of potential traps to other health systems, and the narratives are of interest on their own.