We argue that the two other central features of general practice, set out in our introduction, constitute two further dimensions of generalism, which we have called evidentiary, and reflexive. Let us consider the first of these.
In Mrs B's consultation, what we see is the interplay of two ways of knowing. We see the doctor deploying a biomedical ‘way of knowing’, and Mrs B replying from her biographical ‘way of knowing’. The former is played out in the description of the evidence-based strategies for improving the biochemical parameters. The second is framed by the patient's stunning response, which comes directly from her lived experience.
We have called this dimension of general practice ‘evidentiary’, to concentrate our attention on the type of evidence that is being used by each participant, in their respective contributions to the consultation described above. The doctor and the patient each use explanations that are created from quite separate types of evidence. The doctor's is based on the biomedical model, predicated on scientific experiments. The patient's emerges from the unique history of her life, which has made her precisely what she has come to be. What we want to stress here is the link between these two different ‘ways of knowing’, and of ‘making sense’ of the world.
The doctor's explanatory model reflects a framework of knowledge that arises from the fruits of scientific experiments, regarding that as superior to, and more robust than, the subjective knowledge of lived experience. In turn, this preference betrays a particular view of the world, a single, ‘out there’ entity, measurable and verifiable. The patient's contribution comes from her unique lived experience. In offering her contribution in this form, the patient is expressing the importance, to her, of knowledge from quite a different source than the doctor's — the figurative knowledge of her own life.6
This knowledge in turn betrays a different way of gazing upon the world, one in which our knowledge of the world in constructed incrementally and subjectively over time. Here, in this world view, there is much less certainty about the nature of a single measurable reality.
To see why this is important, we need to draw on some basic terms in medical philosophy. Philosophers would précis the preceding paragraph by saying that each contributor to this consultation drew from their respective explanatory model, each of which was based on a different epistemological framework. ‘Epistemology’ here refers to the nature of knowledge that we create in order to make sense of the world. Now, in turn, the creation of a particular epistemological framework betrays a preference for seeing the world in a particular way. Philosophers call this an ontological view, where the term ‘ontology’ refers to one's understanding of the nature of the world. So, we argue that, as this consultation swings from biomedical to biographical phases, something really profound, philosophically, has happened. What we see now is a clash of two ways of seeing the world, two ways of knowing it, and two ways of explaining that understanding. The consultation represents, in short, an intersection of two epistemological frameworks.
So what? For us, the importance of this analysis is threefold. First, the analysis allows us to theorise about ‘context’ at the philosophical root of that concept. When we recognise ‘context’, in terms of a patient's unique circumstances, we enter into an exchange where the conversation moves paradigms, and speculates about different ways of seeing the world. Second, the analysis allows us to consider the relationship between these worldviews. Is one inherently superior? Who says? Can the two coexist compatibly? Are there circumstances where one should always dominate? Third, this analysis helps us see this individual consultation as a microcosm of a macro-conversation about the medicalisation of society, where the debate is another illustration of two quite distinct ontological views. Thus, when medical experts advocate the implementation of guidelines that will ‘medicalise’ three quarters of Europe's population by virtue of their risk of heart disease7
they are coming from a particular view of the world based on this idea of a single, measurable reality — what philosophers call scientific positivism. And when we talk of reflexivity below, we will see how this involves a passionate understanding of the terms of such a debate, as opposed to an intellectually celibate stance of so-called ‘objectivity’. Those who question the validity of that view, asserting the importance of quality of life, do so from a different perspective, which derives from a (philosophically) quite different set of propositions.