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The role of the Generalist Gatekeeper
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The role of the Generalist Gatekeeper

Deciding if it is in the best interests of an individual to medicalise their problem...
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GPs are widely known for their role as gatekeeper between primary and secondary care, trying to avoid escalation wherever possible to specialist care. Often patients come to see us because they are worried that they have a diagnosable disease. They may have discussed their symptoms with family and friends, or researched their problem online, so could also have come to ask for a specific test or treatment. In these circumstances, GPs also have a role as a generalist gatekeeper, on the interface between illness and disease. This role in particular, draws on the expert generalist skills of GPs working with patients to deliver whole-person centred healthcare. Illness is an individual or personal feeling that something is wrong, which is perceived to be health related.
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Meanwhile, disease is an externally constructed understanding of when ‘our bodies go wrong’ – deviations from what we understand to be anatomical, physiological or biochemical norms. Sometimes diagnosing and treating disease may help with illness, but not always. In addition, some attempts to manage disease can make illness worse, as we’ll consider in the next section on overdiagnosis. GPs have learnt the benefits to both individuals and society, of holding the border between illness and disease; of confining people within these categories only when such labelling will be useful to them; and of minimising exposure to the harms of medical technology. This is the generalist gatekeeper role, deciding if it is in the best interests of an individual to medicalise their problem.
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The flipped consultation which we explored earlier, helps to keep patients on the illness side of the gate. In the next sections, we’ll discuss the potential harms of over-investigation and over-treatment and consider when you might use the generalist gatekeeper role in future.

In this video, Dr Annabelle Machin will discuss the role of the generalist gatekeeper. She will introduce how this links with our important role in helping to decide if it is in the best interests of an individual to medicalise their problem.

Video references

Heath I. Divided we fail. Clin Med (Lond). 2011; 11(6):576-586. DOI: 10.7861/clinmedicine.11-6-576

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WISDOM - Tomorrow’s Doctor, Today: Supporting Today’s Expert Generalist GP

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