By Dr. Richard Armitage

As a GP, I rarely see a single-issue consultation.  One person comes with a sore throat, a bad back, and queries about their medications.  Another comes with a headache, low mood, and wanting the results of a recent blood test.  This is the nature of routine primary care.

But it creates an ethical knot: with the clock ticking, do we try to do everything in one appointment – and risk thin, unsafe care – or, do we agree to do less now, but better, and address the rest later?  That question is what drove me to write the paper recently published in the Journal of Medical Ethics.  Not because I wanted to police patients’ lists, but because I wanted to think more carefully about what GPs owe to our patients, to the people in the waiting room, and to ourselves.

Short appointments are the norm in most health systems, and consultation length varies dramatically across the world; in many countries it remains very brief indeed.  When time is scarce, attempting to address several major problems in one slot can make each decision shallower and riskier.  This is an ethical risk because rushing invites missed cues, poor safety-netting, and substantial errors that matter.

Against that backdrop, my central claim is modest but (I think) important: a transparent default of “one major problem per appointment,” coupled with fast follow-up for anything left over, can respect autonomy, promote beneficence, avoid harm, and distribute scarce time more justly.  It isn’t a rigid rule.  Patients and GPs should identify priorities together at the start; if issues are minor or tightly linked, we can safely bundle them; if two red flag problems present together, we obviously manage both.  But the ethical presumption should favour depth over breadth, because doing less – thoroughly – is often what protects people.

The paper analyses this through four major ethical principles.  Respecting autonomy doesn’t mean “the GP must handle every problem right now,” it means problems are handled in a way that is safe, explained clearly, and agreed with the patient, which may require follow-up.  Beneficence doesn’t mean “do everything,” it means “do the most good you can well in the time you have,” so GPs should prioritise the most clinically important and patient-important problem first.  Trying to squeeze several major problems into one short slot increases the risk of harm (violating non-maleficence) through misdiagnosis, unsafe prescribing, and poor safety-netting, and also makes the GP run late in ways that can harm later patients.  Justice doesn’t mean everyone getting exactly one appointment; it means fair access based on need and complexity, which means some patients appropriately need more than one appointment.  The paper also notes that routinely forcing GPs to manage multiple complex problems in one slot fuels burnout, which threatens patient safety and contributes to GPs leaving the workforce, further reducing access for everyone.

Primary care will always be messy. Our ethical commitments should help us navigate that mess without pretending it isn’t there.

Article: On multiple problems: the ethics of multiple problems in single general practitioner appointments

Author: Dr. Richard Armitage

Affiliation: University of Nottingham

Conflicts of Interest: None

Social media: @drricharmitage