- Email: [email protected]
General Practice
1161
LEADING ARTICLES
himself
specialist cast in the same mould; whereas Professor SCOTT put it, he ought to be " a really, specialist in anti-specialisation ". That specialisation should be carried to great lengths in hospital is inevitable; and some specialists limit their work so successfully that they almost seem to be deciding what disease their patient is allowed to have. Hence public and profession alike have reason to be troubled by the approaching extinction of the general physician or internist who was a true consultant. For the general practitioner to discuss a patient’s problem with a succession of specialists is frustrating and often unrewarding; " and equally unsatisfactory is the alternative of sending the patient to a specialist who passes him on to a succession of colleagues". If uninhibited specialisation is going to abolish the consultant general physician as we know him, the gap will have to be filled. Perhaps, Professor ScoTT suggested, the general practitioner of the future must himself become the consultant who interprets the patient to the hospital and the hospital to the patient. If that is what we want, we shall have to think much more boldly about the postgraduate training of the family doctor. But if he became more of a general physician with duties in hospital, would he still be a general practitioner ? For Professor SCOTT the two essentials of general practice are direct access by the patient to the doctor, and continuity of access: unless these are preserved, he said, general practice will disappear. On the other hand, pretty well all the problems now facing the practitioner arise from their preservation. For example, under any system giving direct and easy access, it must always be the patient who decides what his doctor, on a given day, will be doing-whether he will be kept busy with trivialities or will be free to go into a few cases more deeply.. This was said recently in another way by JACOB 1 when he made the important point that, under our capitation system, the patient’s care varies with the requirements of other patients in the practice: the doctor’s responsibility is not so much towards individuals as towards a group-a section of the population-which he has agreed to look after. What care, and how much of it, he can give to any one person will depend on the demands made by the rest of the group. When a country arranges for all its citizens to have access to a general practitioner-even if that practitioner is not a fully qualified doctor-it gives those citizens, as Professor SCOTT said, " a potent and eloquent means of expressing not only their medical but also their social needs "; and " a country which offers this kind of service is indeed asking for trouble ". The history of the National Health Service shows that our own profession was none too clear about the nature and range of latent needs, and therefore could not say what training and tools would be required for meeting them. In the long run, however, it is only the citizens themselves who can draw the dividing line between medical and social care: and, even when drawn, the line is never sharp or constant. This is because the needs of society-of which medical care is a
as
THE LANCET LONDON
28
NOVEMBER
1964
General Practice THE state, and fate, of general practice affect us all: as Prof. RiCHARD ScoTT said in his Mackenzie lecture to the College of General Practitioners last Saturday, nobody in Medicine can afford to stand on the sidelines. To the hospital doctor, for instance, the practitioner serves as a buffer protecting specialised Medicine from the demands of society. Moreover, general practice is perpetually, if inconspicuously, absorbing the techniques of the hospital, and thereby relieving special departments. of part of their load; so the hospital has an interest in seeing that practitioners are not themselves too heavily burdened to accept new responsibilities. The quality of medical care, as Professor SCOTT remarked, depends not only on the price society is prepared to pay for it, or even on society’s characteristics, but also on the balance and cohesion of the medical profession itself. Major advance is unlikely until Medicine regards itself as a unity-" not a heterogeneous collection of troglodytes, each busily burrowing away in his own particular hole ". Only when we have achieved some sense of belonging to each other as a
profession
can we
begin
to
respond coherently
to
the pressure, stimuli, and needs of society, and thus eventually influence our own evolution. Specialisation is necessary if medical knowledge is to advance: its benefits are obvious. But in our eagerness to enjoy them, have we not (Professor SCOTT asked) staked more than we can afford of our total resources of money, time, and manpower ? Research and practice are interdependent : neither can flourish very long without the other. But today, in hospital, the tendency is for more doctors to look after fewer patients, whereas in general practice the tendency is for relatively fewer doctors to look after more patients. This redistribution of medical manpower is still going on, despite the fact that the general practitioner can now do so much more for his patient than formerly. Its reversal by any massive reinforcement of general practice can hardly be expected until more students adopt the general practitioner as their model. At present, trained by specialists, the most able of them usually aspire to be specialists too. Again, though they " are certainly as altruistic as their predecessors, and are probably more socially knowledgeable and sensitive than previous generations, this does not mean that cash and kudos do not influence their choice ". Finally, when he does go into practice, not only does the young doctor find himself obliged to do little things for many patients, which may (wrongly) seem to him a waste of time; but he may not be in a position to do big things even for a few. This is because he is denied the tools which as a student he was taught to use. He is all too liable to conclude that the answer for him is to become
1.
Jacob,
A. Lancet, Oct. 3, 1964, p. 748.
1162
As Professor ScoTT about the time, the tools, and the training it requires". But many of the problems of the general practitioner are "... the xtiology of much of the disease we encounter now, as he implied, problems in which the whole should be equally concerned. in general practice, and many of the factors which
one-are so
closely interrelated.
put it:
profession
complicate our management of the sick person, have their origins in social maladjustment and in inadequate or faulty interpersonal relationships. To the extent that this is so our therapy will become less concerned with manipulating the patient’s blood chemistry and more preoccupied with the physical, economic, and social factors in the patient’s environment. The decision which is taken as to whether such problems will be regarded as the sole responsibility of the medical profession, or the exclusive concern of society or as a field which requires a full partnership between medicine and other related social agencies, will be a major factor in determining the future of general practice." task is to look after a population at risk, he may feel that his preventive function should have more emphasis than it generally gets today. Traditionally, it is the patient who goes to the doctor, not the doctor to the patient; but sometimes it should be the doctor who takes the first step.23 In actual fact this has been done for years, whenever a doctor has asked his patient to come to a child-welfare clinic or an antenatal clinic; but, as Professor Sco’rT pointed but, we are now adding routine overhauls in middle or old age, presymptomatic screening for glycosuria, glaucoma, ansemia, and carcinoma of the cervix, and other examinations for specially vulnerable groups-not to mention suggestions for pre-marriage counselling and preparation of the elderly for retirement. Besides being a doctor in the old curative sense, the practitioner is being asked to adopt the methods and techniques of the epidemiologist and the medical officer of health. " To do this he has to learn how to use auxiliary personnel and colleagues from disciplines other than Medicine, and to become himself a member of a team in the field of
If,
as
JACOB
argues, the
practitioner’s
public-health practice." Advances in medical knowledge do not, of course, arise only from the physical sciences, and better understanding of the social and behavioural sciences have latterly done much to widen our medical horizons. Quite as much as medical science, social cultures and social action determine the role of our profession in society; and, whatever quick action may now be needed to improve the general practitioner’s lot, and his service to patients, it ought to be in the same direction as "our ultimate goal, which Professor SCoTT described as to render more effective the relationships on the one hand between the general practitioner and his specialist colleagues, and, on the other hand, the relationship between general practice and the medical and social agencies at work in the community". Furthermore, because we are dealing with a dynamic and not a static situation, whatever is done must allow for change. Professor SCOTT urged that the College of General
Practitioners, though never a political organisation, should " produce yardsticks by which we can measure quality of care in general practice, and be more specific 2. 3.
Backett, E. M. ibid. 1960, ii, 1075. Terris, M. ibid. Sept. 26, 1964; p. 653.
Diagnosis
of Renovascular
Hypertension
HIGH blood-pressure due to renal-artery stenosis is often clinically indistinguishable from essential hyperfension, although the age of onset, the family history, the presence of an abdominal bruit, and the appearance of the optic fundi may provide helpful clues. Intravenous pyelography can be carried out without much disturbance to the patient; but, if there is still suspicion of renal-artery stenosis, the clinician faces a dilemma. Should he stop investigating, or go on ? If he goes on, his patient has to face the small but appreciable risks of renal arteriography or ureteric catheterisation, or both, for the sake of a rather slim chance of surgical relief. If he stops, his patient may miss the chance of a cure. A simple screening test is needed to pick out those patients in whom surgically curable renovascular hypertension is likely to be found. Radio-isotope renography looked promising, but false negatives and false positives have made physicians reluctant to rely exclusively upon this test. Furthermore, many hospitals have not the necessary apparatus. Renin and angiotensin are commonly present in the blood in slightly increased concentration in most kinds of chronic renovascular hypertension in man and animals 1-3 (except perhaps in the experimental situation of unilateral renal-artery stenosis and contralateral nephrectomy in certain species 4). Therefore, assay of renin and angiotensin in the blood seems a possible way of deciding whether hypertension is renovascular or not. (Whether renin and angiotensin are responsible for chronic renal hypertension is, of course, a different problem.) Already some investigators have reported on the6 diagnostic value of renin and angiotensin assay,5 using renal-vein blood; but no assay method available at present is yet practicable for a routine hospital laboratory. Recently KAPLAN and SILAH7 8 proposed a simple indirect test to determine the amount of angiotensin in the blood. This method depends on the logarithmic relation between a dose of angiotensin and the rise in blood-pressure it provokes. A given amount of angiotensin will have a smaller pressor effect if the initial blood level is high rather than low, because the proportional increment in concentration will be less. Alternatively, a given rise of blood-pressure will be produced by a smaller dose of angiotensin if the initial blood concentration of angiotensin is low rather than high. To perform the test, an intravenous saline drip was set up, and when the blood-pressure (taken by sphygmomanometer) was stable, angiotensin was added at a standard rate. The rate of infusion was then increased until a sustained 1. 2. 3. 4. 5. 6. 7. 8.
Helmer, O. M. Canad. med. Ass. J. 1964, 90, 221. Brown, J. J., Davies, D. L., Lever, A. F., Robertson, J. I. S. ibid. p. 201. Robertson, J. I. S. J. Physiol. 1963, 166, 27P. Schaechtelin, G., Regoli, D., Gross, F. Amer. J. Physiol. 1963, 205, 303. Morris, R. E., Jr, Robinson, P. R. Bull. Johns Hopk. Hosp. 1964, 114, 127. Grollman, A. Canad. med. Ass. J. 1964, 90, 299. Kaplan, N. M., Silah, J. G. J. clin. Invest. 1964, 43, 659. Kaplan, N. M., Silah, J. G. New Engl. J. Med. 1964, 271, 536.
LEADING ARTICLES
himself
specialist cast in the same mould; whereas Professor SCOTT put it, he ought to be " a really, specialist in anti-specialisation ". That specialisation should be carried to great lengths in hospital is inevitable; and some specialists limit their work so successfully that they almost seem to be deciding what disease their patient is allowed to have. Hence public and profession alike have reason to be troubled by the approaching extinction of the general physician or internist who was a true consultant. For the general practitioner to discuss a patient’s problem with a succession of specialists is frustrating and often unrewarding; " and equally unsatisfactory is the alternative of sending the patient to a specialist who passes him on to a succession of colleagues". If uninhibited specialisation is going to abolish the consultant general physician as we know him, the gap will have to be filled. Perhaps, Professor ScoTT suggested, the general practitioner of the future must himself become the consultant who interprets the patient to the hospital and the hospital to the patient. If that is what we want, we shall have to think much more boldly about the postgraduate training of the family doctor. But if he became more of a general physician with duties in hospital, would he still be a general practitioner ? For Professor SCOTT the two essentials of general practice are direct access by the patient to the doctor, and continuity of access: unless these are preserved, he said, general practice will disappear. On the other hand, pretty well all the problems now facing the practitioner arise from their preservation. For example, under any system giving direct and easy access, it must always be the patient who decides what his doctor, on a given day, will be doing-whether he will be kept busy with trivialities or will be free to go into a few cases more deeply.. This was said recently in another way by JACOB 1 when he made the important point that, under our capitation system, the patient’s care varies with the requirements of other patients in the practice: the doctor’s responsibility is not so much towards individuals as towards a group-a section of the population-which he has agreed to look after. What care, and how much of it, he can give to any one person will depend on the demands made by the rest of the group. When a country arranges for all its citizens to have access to a general practitioner-even if that practitioner is not a fully qualified doctor-it gives those citizens, as Professor SCOTT said, " a potent and eloquent means of expressing not only their medical but also their social needs "; and " a country which offers this kind of service is indeed asking for trouble ". The history of the National Health Service shows that our own profession was none too clear about the nature and range of latent needs, and therefore could not say what training and tools would be required for meeting them. In the long run, however, it is only the citizens themselves who can draw the dividing line between medical and social care: and, even when drawn, the line is never sharp or constant. This is because the needs of society-of which medical care is a
as
THE LANCET LONDON
28
NOVEMBER
1964
General Practice THE state, and fate, of general practice affect us all: as Prof. RiCHARD ScoTT said in his Mackenzie lecture to the College of General Practitioners last Saturday, nobody in Medicine can afford to stand on the sidelines. To the hospital doctor, for instance, the practitioner serves as a buffer protecting specialised Medicine from the demands of society. Moreover, general practice is perpetually, if inconspicuously, absorbing the techniques of the hospital, and thereby relieving special departments. of part of their load; so the hospital has an interest in seeing that practitioners are not themselves too heavily burdened to accept new responsibilities. The quality of medical care, as Professor SCOTT remarked, depends not only on the price society is prepared to pay for it, or even on society’s characteristics, but also on the balance and cohesion of the medical profession itself. Major advance is unlikely until Medicine regards itself as a unity-" not a heterogeneous collection of troglodytes, each busily burrowing away in his own particular hole ". Only when we have achieved some sense of belonging to each other as a
profession
can we
begin
to
respond coherently
to
the pressure, stimuli, and needs of society, and thus eventually influence our own evolution. Specialisation is necessary if medical knowledge is to advance: its benefits are obvious. But in our eagerness to enjoy them, have we not (Professor SCOTT asked) staked more than we can afford of our total resources of money, time, and manpower ? Research and practice are interdependent : neither can flourish very long without the other. But today, in hospital, the tendency is for more doctors to look after fewer patients, whereas in general practice the tendency is for relatively fewer doctors to look after more patients. This redistribution of medical manpower is still going on, despite the fact that the general practitioner can now do so much more for his patient than formerly. Its reversal by any massive reinforcement of general practice can hardly be expected until more students adopt the general practitioner as their model. At present, trained by specialists, the most able of them usually aspire to be specialists too. Again, though they " are certainly as altruistic as their predecessors, and are probably more socially knowledgeable and sensitive than previous generations, this does not mean that cash and kudos do not influence their choice ". Finally, when he does go into practice, not only does the young doctor find himself obliged to do little things for many patients, which may (wrongly) seem to him a waste of time; but he may not be in a position to do big things even for a few. This is because he is denied the tools which as a student he was taught to use. He is all too liable to conclude that the answer for him is to become
1.
Jacob,
A. Lancet, Oct. 3, 1964, p. 748.
1162
As Professor ScoTT about the time, the tools, and the training it requires". But many of the problems of the general practitioner are "... the xtiology of much of the disease we encounter now, as he implied, problems in which the whole should be equally concerned. in general practice, and many of the factors which
one-are so
closely interrelated.
put it:
profession
complicate our management of the sick person, have their origins in social maladjustment and in inadequate or faulty interpersonal relationships. To the extent that this is so our therapy will become less concerned with manipulating the patient’s blood chemistry and more preoccupied with the physical, economic, and social factors in the patient’s environment. The decision which is taken as to whether such problems will be regarded as the sole responsibility of the medical profession, or the exclusive concern of society or as a field which requires a full partnership between medicine and other related social agencies, will be a major factor in determining the future of general practice." task is to look after a population at risk, he may feel that his preventive function should have more emphasis than it generally gets today. Traditionally, it is the patient who goes to the doctor, not the doctor to the patient; but sometimes it should be the doctor who takes the first step.23 In actual fact this has been done for years, whenever a doctor has asked his patient to come to a child-welfare clinic or an antenatal clinic; but, as Professor Sco’rT pointed but, we are now adding routine overhauls in middle or old age, presymptomatic screening for glycosuria, glaucoma, ansemia, and carcinoma of the cervix, and other examinations for specially vulnerable groups-not to mention suggestions for pre-marriage counselling and preparation of the elderly for retirement. Besides being a doctor in the old curative sense, the practitioner is being asked to adopt the methods and techniques of the epidemiologist and the medical officer of health. " To do this he has to learn how to use auxiliary personnel and colleagues from disciplines other than Medicine, and to become himself a member of a team in the field of
If,
as
JACOB
argues, the
practitioner’s
public-health practice." Advances in medical knowledge do not, of course, arise only from the physical sciences, and better understanding of the social and behavioural sciences have latterly done much to widen our medical horizons. Quite as much as medical science, social cultures and social action determine the role of our profession in society; and, whatever quick action may now be needed to improve the general practitioner’s lot, and his service to patients, it ought to be in the same direction as "our ultimate goal, which Professor SCoTT described as to render more effective the relationships on the one hand between the general practitioner and his specialist colleagues, and, on the other hand, the relationship between general practice and the medical and social agencies at work in the community". Furthermore, because we are dealing with a dynamic and not a static situation, whatever is done must allow for change. Professor SCOTT urged that the College of General
Practitioners, though never a political organisation, should " produce yardsticks by which we can measure quality of care in general practice, and be more specific 2. 3.
Backett, E. M. ibid. 1960, ii, 1075. Terris, M. ibid. Sept. 26, 1964; p. 653.
Diagnosis
of Renovascular
Hypertension
HIGH blood-pressure due to renal-artery stenosis is often clinically indistinguishable from essential hyperfension, although the age of onset, the family history, the presence of an abdominal bruit, and the appearance of the optic fundi may provide helpful clues. Intravenous pyelography can be carried out without much disturbance to the patient; but, if there is still suspicion of renal-artery stenosis, the clinician faces a dilemma. Should he stop investigating, or go on ? If he goes on, his patient has to face the small but appreciable risks of renal arteriography or ureteric catheterisation, or both, for the sake of a rather slim chance of surgical relief. If he stops, his patient may miss the chance of a cure. A simple screening test is needed to pick out those patients in whom surgically curable renovascular hypertension is likely to be found. Radio-isotope renography looked promising, but false negatives and false positives have made physicians reluctant to rely exclusively upon this test. Furthermore, many hospitals have not the necessary apparatus. Renin and angiotensin are commonly present in the blood in slightly increased concentration in most kinds of chronic renovascular hypertension in man and animals 1-3 (except perhaps in the experimental situation of unilateral renal-artery stenosis and contralateral nephrectomy in certain species 4). Therefore, assay of renin and angiotensin in the blood seems a possible way of deciding whether hypertension is renovascular or not. (Whether renin and angiotensin are responsible for chronic renal hypertension is, of course, a different problem.) Already some investigators have reported on the6 diagnostic value of renin and angiotensin assay,5 using renal-vein blood; but no assay method available at present is yet practicable for a routine hospital laboratory. Recently KAPLAN and SILAH7 8 proposed a simple indirect test to determine the amount of angiotensin in the blood. This method depends on the logarithmic relation between a dose of angiotensin and the rise in blood-pressure it provokes. A given amount of angiotensin will have a smaller pressor effect if the initial blood level is high rather than low, because the proportional increment in concentration will be less. Alternatively, a given rise of blood-pressure will be produced by a smaller dose of angiotensin if the initial blood concentration of angiotensin is low rather than high. To perform the test, an intravenous saline drip was set up, and when the blood-pressure (taken by sphygmomanometer) was stable, angiotensin was added at a standard rate. The rate of infusion was then increased until a sustained 1. 2. 3. 4. 5. 6. 7. 8.
Helmer, O. M. Canad. med. Ass. J. 1964, 90, 221. Brown, J. J., Davies, D. L., Lever, A. F., Robertson, J. I. S. ibid. p. 201. Robertson, J. I. S. J. Physiol. 1963, 166, 27P. Schaechtelin, G., Regoli, D., Gross, F. Amer. J. Physiol. 1963, 205, 303. Morris, R. E., Jr, Robinson, P. R. Bull. Johns Hopk. Hosp. 1964, 114, 127. Grollman, A. Canad. med. Ass. J. 1964, 90, 299. Kaplan, N. M., Silah, J. G. J. clin. Invest. 1964, 43, 659. Kaplan, N. M., Silah, J. G. New Engl. J. Med. 1964, 271, 536.