Healthcare must not only be effective, but also personal, sustainable, and appropriate to people’s lives. Geert-Jan Geersing delivered his inaugural lecture on November 18: General practice, interesting beyond boundaries. As a general practitioner and professor, he showed how it is precisely at the boundary between diagnostics, treatment, and the human dimension that the greatest challenges, but also the greatest opportunities, lie.
In Geersing’s view, general practice is the most fascinating place to work and to conduct scientific research in. No other medical discipline involves so many boundaries: between hospital and home, illness and health, life and death, young and old. English general practitioner and professor Martin Marshall referred to general practice as a boundary specialism: the general practitioner as a boundary specialist. “It is not without reason that general practice is often referred to as ‘primary care’: the front line at the boundary of healthcare,” says Geersing. “It is precisely at those boundaries that renewal and innovation take place.”
Geersing illustrates this with a practical example involving pulmonary embolism, a blockage of one or more pulmonary arteries by a blood clot. “One example is the YEARS algorithm, which we recently validated in general practice. It is a simple algorithm based on three items: coughing up blood, signs of thrombosis in the leg, and the assessment of whether pulmonary embolism is the most likely diagnosis. This meant that the GP only had to refer 20% of all patients suspected of having a pulmonary embolism, without any more cases of pulmonary embolism being referred too late. In this way, academic GPs can improve everyday practice through multidisciplinary collaboration.”
A second example is atrial fibrillation, a condition in which the electrical impulses and conduction in the atria of the heart are disrupted. Atrial fibrillation is a complex condition that we do not yet fully understand. For some patients, it is a progressive condition that affects the heart, increasing the risk of heart failure and stroke. “We are investigating the relationship between atrial disease and atrial fibrillation to better understand this arrhythmia. Previous studies show that there are might also be subtypes of atrial fibrillation in which the risk of stroke is less relevant, which makes it difficult to predict this risk. This emphasizes the need for a personalized approach to care for these patients. We are continuing to work on this in collaboration with cardiologists and methodologists.”
Personalizing care is necessary to tailor it to the lives of patients and the work of general practitioners. An initial challenge is the growing group of vulnerable and frail elderly people with cardiovascular diseases. Geersing: “At the European Cardiology Congress in 2023, we presented the results of the FRAIL-AF trial. In frail elderly people with atrial fibrillation, switching from a well-known, traditional blood thinner to a newly developed blood thinner led to a 69 percent increase in bleeding. This was an unexpected finding, as it was completely opposite to the evidence in non-frail elderly people. Specific randomized studies in frail elderly people are necessary, because only then can a valid answer be given.”
A second boundary challenge in healthcare concerns the increasing availability of diagnostic tests and labels. Paradoxically, the increasing availability of more and more sensitive tests exacerbates the dilemma for general practitioners: patients receive a diagnostic label more quickly because the test results were abnormal. “We also refer to this as overdiagnosis. The reflex to then start treatment based on this ‘label’ is easily triggered. However, treatment is never without risk. For example, treatment with blood thinners for atrial fibrillation will not only fail to prevent thrombosis, it may actually contribute to an increased risk of bleeding.”
In addition to these challenges, three societal factors also play a role: rising healthcare costs, labor market shortages, and the negative impact of increasing diagnostics on the healthcare sector’s carbon footprint. “It is clear that this is not the problem of one person, organization, or professional group, but of multiple stakeholders together. Solutions must come from a willingness to look beyond each other’s boundaries and develop a willingness to step outside your own boundaries in order to innovate healthcare: academia and the region, hospitals and general practitioners, healthcare and welfare; each with their own role but working together multidisciplinarily on the same puzzle: ‘boundary spanning’.”
“Working on that boundary and conducting research there is immensely and boundlessly interesting,” concludes Geersing. “It’s a place where I hope to remain active for years to come as a practicing GP and scientist, because working in a diverse team is simply more fun. It is necessary to personalize patient care because the limits to growth have been reached.”
