Prioritisation Is Treatment: What Generalists Do When Guidelines Collide

Generalists do not merely implement guidelines; they decide which recommendations matter most, for whom, and in what order. In the era of multimorbidity, polypharmacy, patient complexity, fragmented care, and rising treatment burden, that work is treatment. Disease-specific guidance remains valuable, but it can become unsafe when applied cumulatively without regard to competing risks, uncertainty, treatment burden, functional priorities, and the realities of patients' lives. This Perspective argues that prioritisation should be recognised as a core clinical intervention in generalism rather than a compromise caused by time pressure. We distinguish prioritisation from adjacent concepts such as shared decision-making, deprescribing, treatment burden, and Choosing Wisely: its distinctive work is deciding what should come first now, what can wait, and what should stop. Recent evidence shows that patients and clinicians often prioritise different outcomes, that care aligned with patient priorities can improve meaningful outcomes, and that goal-oriented models offer a more coherent approach for people with multiple long-term conditions. Everyday generalist care should move from checklist completion to explicit prioritisation: identifying what matters most now, selecting the next action with the greatest likely benefit and lowest burden, and actively stopping, simplifying, or deferring care that does not support the agreed goal. Training, quality metrics, and service design should reward this work.