Table Of ContentLucia Siegel Sommers
John Launer Editors
Clinical Uncertainty
in Primary Care
The Challenge of Collaborative Engagement
Clinical Uncertainty in Primary Care
Lucia Siegel Sommers (cid:129) John Launer
Editors
Clinical Uncertainty
in Primary Care
The Challenge of Collaborative Engagement
Editors
Lucia Siegel Sommers John Launer
Department of Family Tavistock Clinic
and Community Medicine London , UK
University of California
San Francisco , CA , USA
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Foreword
In this book, Lucia Sommers and John Launer, with the accompanying input of
their contributing authors, have done a deeply insightful and close-to-exhaustive
job of defi ning clinical uncertainty. They identify its origins, components, and sub-
types; demonstrate the ways in which, and the extent to which, it is intrinsic to
medicine – to medical science, medical technology, and medical practice; and
present a cogent case for its special relationship to primary care practice. More
important, they powerfully and convincingly advocate for the intellectual, psycho-
logical, interpersonal, and existential value that forming and participating in small
groups of primary care physicians, oriented around issues of medical uncertainty,
can have for them and, as a consequence, for the way that they relate to their
patients and the quality of care that they deliver to them. In “thickly descriptive,”
ethnographic-like, narrative ways, the authors depict the micro-dynamics of the
interactions between physicians that take place in such groups.
Their at-once descriptive and analytic materials vividly suggest how such group
dynamics – the support and stimulation that they provide – break through the other-
wise solitude of these clinicians, their uncertainty about their uncertainty, and their
educationally, psychologically, and culturally infl uenced propensity to suppose that
if they were fully competent, they should be able to function and deal with the quan-
daries that their practice entail, with self-reliant individualism. In addition, the
book identifi es extant clinical peer groups of this sort, comments in passing on the
interesting sociological fact that they are largely located in northern Europe, and
shows the patterned similarities and differences in how they function.
Clinical Uncertainty in Primary Care: The Challenge of Collaborative
Engagement not only presents a model of collegial collaboration and support, it also
implicitly legitimates it.
Renée C. Fox
Annenberg Professor Emerita of the Social Sciences
University of Pennsylvania
v
About the Editors and Authors
Lucia Siegel Sommers is an educator and health services researcher with a 40-year
history of working with clinician small groups. She holds an undergraduate degree
from the University of Pennsylvania; a master’s in social work from Bryn Mawr
University; a doctorate in public health from the University of California, Berkeley;
and completed a 2-year fellowship in health services research at Stanford University.
From 1994 through 2001, Lucia was a full-time faculty member in the Internal
Medicine Residency Program at St. Mary’s Medical Center in San Francisco and
Associate Program Director from 1997 to 2001. She is currently an assistant adjunct
professor in the Department of Family and Community Medicine at the University
of California, San Francisco, where she has taught medical students since 1996
and began the Practice Inquiry Continuing Medical Education Program in 2005.
Her published research includes studies focused on the effectiveness of medical
audit, nurse–physician collaboration to improve care and reduce costs in hospitals,
and interdisciplinary care for the frail elderly in the primary care offi ce setting.
John Launer is a family physician, family therapist, educator, and writer. He grad-
uated in English at Cambridge before studying medicine at London University.
After obtaining Membership of the Royal College of General Practitioners with
distinction in 1983, he worked for 22 years as a GP in Edmonton, North London,
and continues to work as a part-time GP. In 1994, he completed training at the
Tavistock Clinic as a family therapist and joined the senior staff there as honorary
consultant in general practice and primary care. Since then, his teaching and clinical
work have drawn together ideas from family medicine and family therapy, with a
focus on narrative and clinical supervision. John is an Associate Dean for
Postgraduate Medical Education at London University and has published fi ve previ-
ous books as author or editor, including N arrative-Based Primary Care: A Practical
Guide . He has lectured and run workshops internationally, including in the US,
Canada, Scandinavia, Israel, and Japan.
vii
viii About the Editors and Authors
Trisha Greenhalgh is Co-Director of the Global Health, Policy and Innovation
Unit at Barts and the London School of Medicine and Dentistry, London, UK. She
is dual qualifi ed, having gained a BA in Social and Political Sciences from the
University of Cambridge in 1980 and a medical degree from the University of
Oxford in 1983. She leads a program of research at the interface between social sci-
ences and medicine which seeks to celebrate and retain the traditional and the
humanistic aspects of medicine and health care while also embracing the unparal-
leled opportunities of contemporary science and technology to improve health out-
comes and relieve suffering. Her work covers such diverse themes as reclaiming
narrative and literature as legitimate components of the medical curriculum; explor-
ing how “rationing” decisions are made when demand for health care exceeds the
resources available; studying the social, political, and ethical implications of new
technologies such as networked electronic patient records; and searching for better
metaphors than “knowledge translation” to illuminate the complex links between
research and clinical practice. She is the author of 140 peer-reviewed publications
and 8 textbooks.
Professor Colin Coles is an educationist who has been working in medical educa-
tion for nearly forty years in Europe and more recently, Africa. He has extensive
experience in curriculum design, evaluation and development in undergraduate
and postgraduate medical education, as well as in continuing professional develop-
ment. His current research focuses on the cutting edge of curriculum development,
which in health care focuses increasingly on the workplace and the conditions
necessary for effective learning there. He holds the position of professor in the
Faculty of Education, Health and Social Care at the University of Winchester in the
UK, where in 1997 he helped to found a masters degree in education for medical
practitioners which now has over 150 registered students. He is an international
conference contributor, and advises several professional organizations on educa-
tional matters. He publishes widely, and with Della Fish has co-authored books on
the development of professional judgement (1998) and curriculum development in
medical education (2005).
Henry Jablonski, M.D. (Karolinska Institute), M.Sc. (Stockholm School of
Economics (SSE)), is a psychoanalyst and psychiatrist in private practice in
Stockholm. His thesis (1971) at the SSE was a critique against cost-benefi t analysis
and its reductionistic use of quantitative measures in the public health system and a
plea for the parallel use of qualitative goal descriptions and a dialogue between doc-
tors, administrators, and politicians. He has led Balint groups for GPs since the
mid-1980s and in the past decade also for hospital doctors. He is the President of the
International Balint Federation and the Swedish Society of Medical Psychology.
His major research project was on voluntary sterilization from a psychoanalytical
and family system’s perspective. He has written papers on Balint work, fi lm and
psychoanalysis, and the role of nature in depression and mourning.
About the Editors and Authors ix
Dorte Kjeldmand has been working as a GP at Eksjö Primary Health Care
Center, County of Jönköping, in the southern part of Sweden since 1989 and is a
national examiner of specialists in General Practice. She has been a certifi ed
Balint group leader since 2000 and leads a number of Balint groups. She is also a
researcher in the Department of Public Health and Caring Services , Section of
Health Services Research, University of Uppsala, where she did her 2006 disser-
tation titled “The Doctor, the Task and the Group, Balint Groups as a Means of
Developing New Understanding in the Physician-Patient Relationship.” In addi-
tion to clinical work, she is also a physician teacher and directs training at the
internship and residency levels.
John Salinsky is a general practitioner in North West London and a program direc-
tor of Whittington GP Specialty Education and Training in North London. He is a
past general secretary of the International Balint Federation and was editor of the
Journal of the Balint Society (UK), 1997–2011. He is the author, with Paul Sackin,
of W hat are you feeling, Doctor? Identifying and avoiding defensive patterns in the
consultation (Radcliffe Medical Press 2000). He has contributed chapters on Balint
groups to a number of books and has also written two books on M edicine and
Literature (Radcliffe Medical Press 2002, 2004).
Heather Armson, M.D., MCE, CCFP, FCFP, is an associate professor and the
assistant dean of Continuing Professional Development for family medicine at the
University of Calgary. She was previously the director of Practice-Based Small-
Group Learning program and is currently the director of research for The Foundation
for Medical Practice Education. Her research interests include the processes
involved in enhancing practice implementation of new knowledge, including
the roles of small-group learning, community of learners, self-assessment, and
commitment-to-change.
Ronald MacVicar is a General Practitioner in Inverness in the north of Scotland
and the Director of Postgraduate General Practice Education for the North of
Scotland Deanery of NHS Education for Scotland (NES). He spent a year on sab-
batical in Southern Ontario in 2001–2002 in part to investigate the Practice-Based
Small-Group Learning (PBSGL) program which had developed in McMaster
University over the previous decade. He has since led the implementation and
growth of PBSGL as a core workstream within NES and as an established method
of continuing professional development for a substantial proportion of Scottish
General Practitioners.
Tina Kenyon, ACSW, is a faculty member at the NH Dartmouth Family Medicine
Residency at Concord Hospital and an instructor in the Department of Community
and Family Medicine at the Geisel School of Medicine in Dartmouth. Her current
areas of interest include curriculum and faculty development, population- based
education, and organizational process improvement.
