DILUTION IN GENERAL PRACTICE

41

fication, allow individual medical schools to divide the time as they please. If this is to be the decision, I see no demerit in it. I have said already that there should be a common pathway for all doctors, but this does not require that there should be an identical pathway in different medical schools. I agree with the Nottingham report that a two-year clinical period is adequate. There is a great deal of wasted time in the present three clinical years. No doubt the operations of Parkinson’s law affect the student, but I believe that the quality and intensity of some of our clinical teaching are as much to blame. As in the residents’ training programme, so in undergraduate clinical teaching the best American schools outdistance us in the thoughtful planning of medical education. I believe that one hospital-officer year is enough for those who are not going into any sort of clinical practice and that more should not be demanded of them. After the preregistration year the years of vocational training should begin, and this should follow the lines laid down by the Colleges and other institutions. The College of General Practitioners has already stated that two further years of hospital practice should be required. The College of Pathologists might be content with one year or might require another; the decision is theirs. It would seem unreasonable to demand another clinical year of those who are going back into our preclinical departments, and of those who are going into research or medical administration. CONTENT OF THE CLINICAL YEARS

Like other published plans, the Nottingham report emphasises the value of interdepartmental teaching. This single reform can enormously enhance the value of our instruction of the clinical student, but it does require a great deal of organisation and preparation. This is inevitable if we are to bring the quality of our clinical teaching to the highest level attained in some preclinical departments. Teachers should be willing to learn how to teach, and university departments of education are ready to help. The report emphasises, too, the importance of the early introduction of clinical responsibility under adequate supervision. All doctors learn rapidly during their first house-appointment; and students who have enjoyed a term of duty in the hospitals of developing countries have benefited from the degree of responsibility which is denied them at home. Another defect in the curriculum which all medical educationalists have stated, and with which the Nottingham report agrees, is that we have given the student insufficient elective time throughout his course. Elective time has been squeezed out as more teaching time has been demanded by various departments. All students require elective time for reading and preparation; some will use it for a research project; an increasing number will enjoy a foreign travel period; and a few will use it as an extracurricular study period. But, however it is used, one must not deny the student this opportunity to charge and recharge his batteries. I have one personal suggestion in regard to the clinical curriculum-that the introductory course should be lengthened and broadened. If the clinical years are to be reduced to two, there will be a great temptation to gain some time by shortening the introductory course. The Nottingham report suggests that it should last for one month. I should like to see this increased to three months. The introductory course should be made so comprehensive that at the end of it there could be no doubt of the

student’s fitness to take some clinical responsibility. The case for this long introductory clinical course was argued in the Goodenough report, but the idea was later dropped by most schools because it was found to be tedious for both teachers and taught. This may have been because the quality of the teaching was poor and the content of the course was not so attractive as it could be made today. CENTRAL RESPONSIBILITY IN CLINICAL TEACHING

The Lancet4 has discussed the joint responsibility of the Ministry of Health and the Department of Education and Science with regard to student numbers and the supply of doctors, and it concluded that there was a need for a redistribution of responsibility between the Ministry and the Department " for planning the path of medical education and research ". There is an equal need for defining areas of responsibility with regard to undergraduate and graduate education in our teaching hospitals. In new teaching hospitals, and in reconstituted departments in old teaching hospitals, financial responsibility for construction is adequately defined by the Pater formula. In our present teaching hospitals the provision for students is often shockingly inadequate. We all recognise that there is a limited amount of money available in this country and that economic stringency will persist for some time. It would, however, be very encouraging for those of us engaged in replanning medical education to know that these problems had been considered at a high level, that conclusions had been reached, and that deficiencies would be remedied when the money became available. Particularly, it is required that the definition of the areas of responsibility between the Department and the Ministry should be made known. CONCLUSION

Much

thought, planning, and fresh design is now being

to medical education in this country. We shall discard what was good in our old system, but we may reasonably expect that tomorrow’s doctors at qualification will be better fitted to enter their vocational period of training as well-equipped medical scientists and craftsmen.

brought not

Views of General Practice DILUTION IN GENERAL PRACTICE

to

D. H. RICHARDS M.A., M.B. Cantab., D. Obst. GENERAL PRACTITIONER, OXFORD

THE problem of lightening the work-load of general practitioners has become a matter of great urgency. The number of G.P.S working in Great Britain decreases each month. The total number of doctors qualifying each year be increased for at least 10 years because of the time taken to plan and build new medical schools, and the training period subsequently required for the medical students once the new schools have been opened. Furthermore we are told that at present as many as 25% of newly qualified doctors are going abroad rather than practising in this country. The Government have assured the profession that the financial position of the family doctor will be improved. The Government could also make working conditions less frustrating for the doctor and more beneficial to the patient by making fuller use of existing manpower. This could be done with little delay. cannot

4.

Lancet, 1965, ii, 327.

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In October, 1964, Sir George Godber, chief medical officer of the Ministry of Health, asked if one of the four partners in our practice together with the health visitor attached to the practice would visit Denmark and Sweden on a World Health Organisation fellowship to investigate ways in which the Scandinavian countries were overcoming their shortage of doctors and nurses. We found that, in Sweden in particular, the shortage of doctors had existed for longer than in this country and was more severe. On average, one doctor was responsible for 12,000 patients. This was made possible by not only obtaining a high degree of efficiency in well-equipped surgeries, but also, in particular, allotting three highly trained and experienced health nurses to assist each

practitioner. The health nurses were usually thirty years old before they were accepted for a year’s special training for work in general practice. This meant that they had had wide experience before they began their special training. The nurses held their own surgeries (often in premises attached to their own houses) and did their own visiting in close cooperation with the G.P. In many cases patients made their first approach through the health nurse so that a proportion of patients were filtered’ off without seeing the doctor. In some districts nurses were empowered to see patients and admit them direct to hospital-for example, in cases of acute appendicitis-although whether this was encouraged depended on the individual G.P. In the practice in which I work we have started, with the cooperation of the medical officer of health, a small pilot scheme which has already proved a great help. This is not

the Swedish pattern but is an attempt to divest the doctor of some of the minor calls upon his time which can suitably be done by trained nurses. A married Stateregistered nurse who is paid by the local authority, holds two evening surgeries a week by appointment at our surgery premises while a doctor is consulting in another room. She herself has had general and orthopaedic experience as well as two years as a nurse in a large factory. She is responsible for doing dressings, inserting and on

removing stitches, taking blood-pressures, doing simple urinalysis, syringing ears, giving injections, estimating hsemoglobins with an electric haemoglobinometer, preparing patients for antenatal examinations, and taking cervical smears.

If the nurse were allowed to deal with certificatione.g., the giving of final certificates to patients who had recovered from minor illnesses-and to treat minor ailments and give advice to those " who were not sure if they needed to trouble a doctor ", the load at present being carried by the G.P. alone could immediately be reduced. There are many experienced married nurses in this country who are not being employed, largely because too few jobs offer working hours which can be combined with domestic responsibilities. One group have children of school age and can easily work in the mornings-e.g., at morning surgeries, while the children are at school. Another group have children below school age who like to get out two or three evenings a week after the husband has got home from work. The husband can baby-sit while the wife does an evening surgery, as in the case of our own nurse. It should be possible to give official encouragement to these married nurses to attract them back to service. They might be given tax concessions so that daily help can be provided in the house while the wife is out working. Refresher courses could be given to those who feel they

may be out of touch with up-to-date medicine. In Sweden it has been found necessary to run creches to which small

children can be taken while the mother works as a nurse during the day. In our practice we have had a health visitor (paid by the local authority) attached to the practice for the past nine years. She is responsible for her usual work as a health visitor and has greatly increased the scope of the work she did before coming to the practice. She not only looks after the mothers with young children and babies, but frequently acts as an almoner to the geriatric patients and more recently has undertaken, in selected cases, some of the doctor’s follow-up visits. In this country we are fortunate in having highly trained health visitors for whom demand exceeds supply. Many of them would be eminently suited to having added responsibilities which might make recruitment more attractive. Every practice has some problem families, usually well known to the health visitor. In cases of illness in these families the health visitor could sometimes pay the initial visit to assess the need for a visit from the doctor. Also in an epidemic a health visitor might visit some of the families to see if a child is progressing satisfactorily and obviate the need for a doctor’s visit unless complications were found to be developing. As well as the health visitor and the surgery nurse, the practice has its own district nurse and midwives attached by the Local Health Department. We have found that much time can be saved by the doctor and midwife holding joint antenatal clinics. Patients can be prepared and have their blood-pressures taken and their urine tested by the midwife so that the doctor confines himself largely to the abdominal and vaginal examinations as is customary in hospital antenatal clinics. In this way the doctor can save up to ten minutes on each patient he sees, and the midwife avoids the unnecessary duplication of a separate visit. The more closely the doctors, nurses and midwives work together, the easier it is for the patient’s confidence in the team to be increased, and for the doctor to gauge what kind of case it is suitable to ask the nurse to undertake. It has been said that if nurses are to assist doctors to a greater extent there will not be enough nurses. This problem has been met in Sweden by diluting the nursing force. Any job that can be undertaken by a reasonably capable person after a short training is done by the Swedish samaritans. These ladies undergo a four-month residential training which makes them capable of giving bed-baths, changing dressings, and helping the chronic sick and disabled, thus freeing the fully qualified nurses for more specialised duties. In my opinion the immediate prospect of lightening the doctor’s load to enable him to practise his specific skill and to spend more time on careful diagnosis, reassurance, and general psychotherapy of his patients would do more for general practice than the dubious prospect of an overfull sixty-hour week. "... Declining numbers of general practitioners or personal physicians, increasing numbers of specialists with narrow interests, may gradually involve non-physicians, members of the paramedical professions, in more of the areas once the physician’s province. Gradually, patients may learn to accept diagnostic and therapeutic activities from the paramedical workers they once demanded from physicians. The next generation, for example, may accept family medical care and personal medical service without a general practitioner."Dr. GEORGE

SILVER, Medical Care, 1965, 3, 246.