Like synchronised swimming, general practice is much harder than it looks

I have always admired the elegance and precision of synchronised swimming, so to better understand the Olympic sport, I set out to have a go for myself.

I felt I had all the required credentials — I can swim, tread water, and wave my arms about. I was also a talented underwater hand-stander in my childhood, winning many competitions against my siblings.

I have a swimsuit, I know how to add sequins, and I feel comfortable enough to try the nose-plug device. I was all set. How hard could it be?

So I headed out to the pool with a few friends for a trial run. We pumped up the music and jumped in. It didn’t quite go to plan.

I nearly drowned my friend who was trying to lift me up for a pose, and my legs muscles have never been so sore. It seems that synchronised swimming is harder than it looks.

Had I done my homework properly, I would have learned that synchronised swimmers are elite athletes. They have amazing cardiovascular fitness, thanks to training in the pool, gym and dance studio. They are master story-tellers through dance, and can out-swim the average person by many miles.

They are the generalists of the Olympic pool.

From the top of the water it looks like a smooth and simple dance in the water routine. But what you can’t see are all the complex manoeuvres that are going on under the water.

You also can’t see the amount of preparation, planning and training that goes into the sport.


Mining magnate Gina Rinehart is one of the biggest financial supporters of the Australian synchronised swimming team. Millions of dollars are spent every year on the science of synchronised swimming — physiologists, nutritionists, sports scientists, and technicians all work together to find the perfect combination for these elite athletes.

This is why synchronised swimming reminds me a lot of general practice, although without the million-dollar research budget.

The senior GP in full flight practising quality medicine in a busy clinic looks like they are doing a simple job, but you can only see the surface. They make it look easy.

General practice is a specialty that cannot be done by anyone else “just as well”, even though it’s not very flashy and sometimes seems simple.

Without an underwater camera, much of general practice, like synchronised swimming, remains a mystery.

Primary care research is in its infancy compared with other areas of medical research, and general practice research is even more undiscovered.

Our colleagues in tertiary care look at what we do and often assume we are practicing ‘little hospital’ medicine. The same research methods, theories, and outcomes are slapped onto general practice.

The ‘primary care paradox’ finds that patients who are looked after by system specialists have better disease specific outcomes (like HbA1c levels in diabetes).1

But patients who are looked after by GPs have better overall functional outcomes at a lower cost.

Is it really a paradox though, or are we not measuring the right things in primary care — the things that really matter to the health of our patients?

When you reduce general practice to bits and parts, you don’t actually measure what matters.

Pay-for-performance measures are an example where if you choose the ‘wrong measure’, it can detrimentally affect the practice of GPs, or the morale of others.

The ‘Quality Outcomes Framework’ used to manage payments to GPs in the UK has been reported to be on the way out.

It has been described as reducing general practice to a “tick box” style of practice that has overstayed its usefulness.2

What we do know from the work of the great US paediatrician and public health physician Professor Barbara Starfield is that a health system with strong primary care works more efficiently and effectively.3

From another American, family medicine expert Professor Kurt Stange, we know that healthcare with less fragmentation and better continuity gives better patient outcomes.4

But we do not have solid ways of measuring these important things in general practice.

There is so much we don’t know about how and why general practice works, and how we can get the best out of our daily work.

We are still developing sophisticated research tools to have an ‘underwater camera’ vision of what is happening in general practice.

Our synchronised swimming champions have more in common with us than we realise.

For me, however, I think I’ll stick to my day job.


1. Kurt Stange, The paradox of primary care,
2. Roger Jones,
3. Barbara Starfield (collection of papers at WONCA)
4. Kurt Stange, The problem of fragmentation,


First published on 3 July 2017 at Medical Observer (editor Jo Hartley)



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