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THE PATTERN OF GENERAL PRACTICE
623
Special
Articles
THE PATTERN OF GENERAL PRACTICE A. G. RICHARDS B.A., M.B. Camb. ASSISTANT
SASKATOON SANATORIUM,
PHYSICIAN, SASKATCHEWAN,
CANADA
MOST doctors visiting Britain from Canada and elsewhere have kind words for British consultant and specialist practice, but usually they are not so favourably impressed by general practice, of which Collings (1950) made a detailed and critical survey. This unfavourable impression is created partly by conditions which indi. vidual practitioners could rectify, and by certain provisions of the’ National Health Service Act. But the pattern of general practice is largely determined by factors not easily modified by doctors or legislatorse.g., density of population, ease of communications, capital resources, and the prosperity of the community. Whereas specialist practice is basically the same the world over, general practice must adapt itself to local circumstances. To be constructive, criticism should be directed against conditions of general practice that can be modified, and against failure to adapt to those conditions that must be accepted. To set before future general practitioners an ideal type of practice which is unattainable is unfair, and also a disservice to their patients.
Existing
Patterns
A much-criticised aspect of British general practice is the limitation of scope in the treatment of organic disease, that imposed by lack of hospital privileges. In the country districts of Canada and the United States, most communities provide general practitioners with X-ray equipment, electrocardiographs, and hospitals, which in Britain and Europe would be coniined to large cities. Furthermore, owing to the dispersal of the population in such large countries many general practitioners work far away from medical centres and specialist help, and they must deal with all surgical and medical emergencies. But even in the cities the ideal of the selfsufficient practice is pursued. Since specialists in Xortli American cities usually do not confine their practice to referred cases, they are in direct competition with general practitioners, who therefore, even more than their British colleagues, feel a need for the prestige value of equipment and hospital privileges. In Britain a much lower proportion of the country’s capital resources is devoted to general practice and to hospitals than in Canada and the United States. Premises suitable for general practitioners, and even general practitioners themselves, are scarce in some areas. Because of the shortage of hospital beds the British general practitioner spends much ’time visiting and treating patients in their own homes : much of his visiting is in effect a vast ward round. Because of the shortage of practices these are large—there is an average of over 2000 patients per doctor (Hadfield 1953)—and in cities they tend to be very large. Shortage of hospital beds and the large size of his practice combine to fill the general practitioner’s day with work outside the hospital. Nevertheless, because Britain is densely populated, a reasonable standard of medical care is possible despite these shortages ; for frequent visiting is feasible, and patients need not be admitted to hospital merely because they live too far away for supervision, as is often the case in Canada. Furthermore in Britain visiting is eased by the good roads, universally tarred or "paved." Specialists are within easy reach, and the amount of major therapy
particularly
which
a
general practitioner is justified greatly reduced.
is therefore
in
undertaking
The Canadian doctor, except in the largest cities, minimises the distances he travels by having his house and office within easy reach of the hospital, by commonly advising his patients by telephone, and by visiting patients in their homes only when he must. His practice is therefore limited only by the distance patients travel to see him, which may be 40 miles or more. In Britain, because home visits constitute such a large part of his work, the general practitioner must restrict his practice to a convenient area. A hospital serves an area containing many practices, of which only a few will be near to it. A doctor whose time is filled by travelling about his practice may find it difficult to fit in a long journey to see a patient in hospital. This was my experience in a semi-rural practice in Lincolnshire, a small hospital was available to some 10 general practitioners, but in fact only 4 of us, whose practices included the hospital geographically, used it to any extent. THE HOSPITAL
It was my experience in Britain that the patients for whom I was responsible in our small general-practitioner hospital would have benefited from the care of a doctor who, if not a specialist, at least spent most of his time doing hospital work ; and I had a suspicion that my patients would have been more efficiently managed in the fully equipped hospital with resident staff 16 miles away. Doctors in large practices with several partners can afford the time for regular hospital work ; but the single practitioner or member of a small partnership finds that his few hospital patients cost him a disproportionate amount of time, effort, and worry. A doctor who does most of his work in hospital is not bothered by the feeling that he should be elsewhere ; but the practitioner attached to a hospital is always having to consider conflicting priorities, and an emergency in hospital may coincide with one outside. Hospital work requires not only skill in certain procedures and experience in interpreting special investigations, but the establishment of harmonious personal relations with all members of the staff. A hospital is an instrument, and, as with other instruments, a certain critical frequency of use is needed to maintain proficiency. The doctor who combines hospital work with a busy general practice is continually having to make the effort to change his mental orientation to a different pattern of work. This adds to his burden and impairs his efficiency. An objection to the reservation of hospitals for specialists is that patients lose the continuity of care and personal interest of their family doctor ; but the wise patient prefers to be operated on by an experienced surgeon, even if he is a stranger. A further objection is that doctors lose sight of their most interesting cases through admission to hospital. But why do doctors think these cases so interesting1 Surely because they are cases of disorders about which they were taught as students in hospital, whereas the majority of patients The late Sir James seen in general practice are not. attention to the drew Spence large number of illnesses seldom dealt with in hospital teaching (Spence et al. 1954). This division of labour between hospital practitioners on the one hand and non-hospital practitioners on the other makes for effective use of doctors in densely populated areas. Unhappily because of our undergraduate training we find it hard to accept this situation and make the best of it. There is a risk that general practice may be forced into a form to suit our training, instead of our modifying it in the best interests of patients and the profession. General practitioners usually attribute the small number of hospital beds available to them to arbitrary regulations or selfishness on the part of specialists, rather than to an inherent feature of British medical practice. Many doctors feel that their prestige is impaired by lack °
624 of hospital privileges, but British patients expect to be referred to specialists for major procedures and ’they do not think less of their own doctor because of this. In contrast, general practitioners in small towns in Western Canada do much surgery, partly because this is often essential, and partly on the assumption that their patients expect it of them. A demand by the general practitioner for hospital work or some form of specialised practice is reasonable if this will fill a local need, but it should not be allowed to prevent him giving adequate time to the rest of his patients. The general practitioner is taught as a student principally about diseases which are best treated in hospital, and he tends to think that hospital practice is the most important aspect of medicine. This is bad because he will be frustrated at being unable to practise the sort of medicine he was taught, and also because, in his quest for hospital privileges and impressive equipment, he may be diverted from his role of adviser and friend to his
patients. The overwhelming part played by the hospital and its specialist staff in our education deeply affects our ideals of medical practice. We spend so much of our early inside one that it is difficult for us to see that a hospital in relation to present-day medicine as a whole is only a specialised instrument : certainly a very large, important, impressive, and expensive instrument, and for this last reason one which must be reserved as far as possible for patients in a phase of their illness in which it is needed. Since the hospital is the scene of so much impressive, and by and large successful, medical endeavour, the student may be forgiven for thinking that it is the whole world of medicine that matters, in which the consultants are the heroes. The consultants have not been assiduous in discouraging this view. It is not surprising, therefore, that the doctor graduates as an indifferent specialist rather than as a general practitioner, and that he retains a respect for hospital privileges, access to impressive equipment, and technical skill. The original concentration of medical teaching in hospital was necessary to break the unscientific traditions of the apprenticeship system, which still is often perpetuated in assistantsbips. But general practice has become increasingly effective, recently aided by ebemotherapy and by diagnostic facilities such as the Public Health Laboratory Service. The extension of medical care to the whole community has only been possible through a great increase in the effectiveness of general practice ; similarly, the economical use of hospitals and the extension of medical care to the whole community are possible only because of the general practitioner’s work outside hospital. If general practice is limited in scope, it is because medical education did not prepare the present generation of doctors for this type of work. Introducing students to general practice is still in the experimental stage, and although this has been under way for some time in the United States and Scotland, English and Canadian universities seem to be approaching the problem more cautiously ; the colleges of general practice in England and Canada should speed this scheme. The general practitioner has a continuous responsibility for his patients, although for a phase of an illness they may be in the hands of a specialist. In fulfilling this responsibility he encounters organic disease he knows how to diagnose and treat rationally, disease he can diagnose but must refer for treatment (which if he conducts his practice well need not constitute more than 15% of his cases), organic disease which neither he nor anyone else can do more than palliate, many disorders of a probable organic origin which do not fit into any distinct syndrome, and 30% or so ailments largely psychogenic. This is a suflicient challenge to any man’s scientific and humane abilities for which he needs as much time as he can gain. Unfortunately his training has prepared him
unevenly for these various types of case. The young general practitioner not unnaturally tends to pay most attention to the types of case he has been taught about, and is apt to think that patients who do not have syn. dromes he recognises are not really ill. Yet if he attempts to select those he will help and those he feels not morally entitled to help, he creates needless difficulty for himself and unhappiness and hostility in those rejected. Treat. ment of course does not necessarily consist in granting all demands, but may consist in a firm but polite explanation why none is necessary. Until he has had much experience he tends to judge the quality of general practice by specialist criteria, and feels that he should be using methods appropriate to dealing with disease at the specialist level. Since he has to deal with comparatively large numbers of patients, inevitably part of his work consists in screening" or selecting those most suitable for specialist treatment. This should cause no shame and is an important part of his function as part of the medical team. Specialists appreciate the general practitioner who uses them efhciently on behalf of his practice. very
"
Conclusion
career
Norigid pattern for general practice should be devised. The general practitioner’s work is decided by the needs of the society he serves, but his ability to fill this need is impaired if his training gives him too rigid a conception of medical practice ; for instance, in the small towns of Western Canada he is required to do much emergency surgery which in Britain he is not. General practice fills the very big gap between the medical needs of the community and the capacity of hospitals and specialists to meet
them.
More doctors should be encouraged to become general practitioners ; and practices should be made smaller. They could then spend a greater amount of time in consultations (at present brief by Canadian standards) as friend and adviser to their patients. REFERENCES
Collings, J. S. (1950) Lancet, i. 555. Hadfield, S. J. (1953) Brit. med. J. ii, 683. Spence, J., Walton, W. S., Miller, F. J. W., Court, S. D. M. (1954) A Thousand Families in Newcastle upon Tyne. London.
THE EFFECTS OF SEPARATION FROM THE MOTHER IN EARLY LIFE D. H. STOTT M.A. Camb., Ph.D. Lond. RESEARCH
FELLOW,
UNIVERSITY OF BRISTOL INSTITUTE OF EDUCATION
LARGELY through the work of Dr. John Bowlby, there has been much discussion in recent years about how cllildren’s personalities may be affected by stays in institutions or in hospital during early life. For the present study we chose, from among 141 backward children, the 25 who had been separated from their mothers for at least ten weeks during their first four years of life. Actually the average length of their separation was over eighteen weeks in the first year, nearly seventeen in the second, and for the whole of the first four years no less than seventy-two weeks, or about one-third of their lives up to that point. Assessments of their emotional development were provided by their teachers on the comprehensive Bristol Social Adjustment Guide, and comparable information as to their domestic behaviour was obtained from interviews with the mothers or with the staff of institutions. Since emotional factors are very important for the understanding of backwardness, indications of the mutual affection between mother and child had been
Special
Articles
THE PATTERN OF GENERAL PRACTICE A. G. RICHARDS B.A., M.B. Camb. ASSISTANT
SASKATOON SANATORIUM,
PHYSICIAN, SASKATCHEWAN,
CANADA
MOST doctors visiting Britain from Canada and elsewhere have kind words for British consultant and specialist practice, but usually they are not so favourably impressed by general practice, of which Collings (1950) made a detailed and critical survey. This unfavourable impression is created partly by conditions which indi. vidual practitioners could rectify, and by certain provisions of the’ National Health Service Act. But the pattern of general practice is largely determined by factors not easily modified by doctors or legislatorse.g., density of population, ease of communications, capital resources, and the prosperity of the community. Whereas specialist practice is basically the same the world over, general practice must adapt itself to local circumstances. To be constructive, criticism should be directed against conditions of general practice that can be modified, and against failure to adapt to those conditions that must be accepted. To set before future general practitioners an ideal type of practice which is unattainable is unfair, and also a disservice to their patients.
Existing
Patterns
A much-criticised aspect of British general practice is the limitation of scope in the treatment of organic disease, that imposed by lack of hospital privileges. In the country districts of Canada and the United States, most communities provide general practitioners with X-ray equipment, electrocardiographs, and hospitals, which in Britain and Europe would be coniined to large cities. Furthermore, owing to the dispersal of the population in such large countries many general practitioners work far away from medical centres and specialist help, and they must deal with all surgical and medical emergencies. But even in the cities the ideal of the selfsufficient practice is pursued. Since specialists in Xortli American cities usually do not confine their practice to referred cases, they are in direct competition with general practitioners, who therefore, even more than their British colleagues, feel a need for the prestige value of equipment and hospital privileges. In Britain a much lower proportion of the country’s capital resources is devoted to general practice and to hospitals than in Canada and the United States. Premises suitable for general practitioners, and even general practitioners themselves, are scarce in some areas. Because of the shortage of hospital beds the British general practitioner spends much ’time visiting and treating patients in their own homes : much of his visiting is in effect a vast ward round. Because of the shortage of practices these are large—there is an average of over 2000 patients per doctor (Hadfield 1953)—and in cities they tend to be very large. Shortage of hospital beds and the large size of his practice combine to fill the general practitioner’s day with work outside the hospital. Nevertheless, because Britain is densely populated, a reasonable standard of medical care is possible despite these shortages ; for frequent visiting is feasible, and patients need not be admitted to hospital merely because they live too far away for supervision, as is often the case in Canada. Furthermore in Britain visiting is eased by the good roads, universally tarred or "paved." Specialists are within easy reach, and the amount of major therapy
particularly
which
a
general practitioner is justified greatly reduced.
is therefore
in
undertaking
The Canadian doctor, except in the largest cities, minimises the distances he travels by having his house and office within easy reach of the hospital, by commonly advising his patients by telephone, and by visiting patients in their homes only when he must. His practice is therefore limited only by the distance patients travel to see him, which may be 40 miles or more. In Britain, because home visits constitute such a large part of his work, the general practitioner must restrict his practice to a convenient area. A hospital serves an area containing many practices, of which only a few will be near to it. A doctor whose time is filled by travelling about his practice may find it difficult to fit in a long journey to see a patient in hospital. This was my experience in a semi-rural practice in Lincolnshire, a small hospital was available to some 10 general practitioners, but in fact only 4 of us, whose practices included the hospital geographically, used it to any extent. THE HOSPITAL
It was my experience in Britain that the patients for whom I was responsible in our small general-practitioner hospital would have benefited from the care of a doctor who, if not a specialist, at least spent most of his time doing hospital work ; and I had a suspicion that my patients would have been more efficiently managed in the fully equipped hospital with resident staff 16 miles away. Doctors in large practices with several partners can afford the time for regular hospital work ; but the single practitioner or member of a small partnership finds that his few hospital patients cost him a disproportionate amount of time, effort, and worry. A doctor who does most of his work in hospital is not bothered by the feeling that he should be elsewhere ; but the practitioner attached to a hospital is always having to consider conflicting priorities, and an emergency in hospital may coincide with one outside. Hospital work requires not only skill in certain procedures and experience in interpreting special investigations, but the establishment of harmonious personal relations with all members of the staff. A hospital is an instrument, and, as with other instruments, a certain critical frequency of use is needed to maintain proficiency. The doctor who combines hospital work with a busy general practice is continually having to make the effort to change his mental orientation to a different pattern of work. This adds to his burden and impairs his efficiency. An objection to the reservation of hospitals for specialists is that patients lose the continuity of care and personal interest of their family doctor ; but the wise patient prefers to be operated on by an experienced surgeon, even if he is a stranger. A further objection is that doctors lose sight of their most interesting cases through admission to hospital. But why do doctors think these cases so interesting1 Surely because they are cases of disorders about which they were taught as students in hospital, whereas the majority of patients The late Sir James seen in general practice are not. attention to the drew Spence large number of illnesses seldom dealt with in hospital teaching (Spence et al. 1954). This division of labour between hospital practitioners on the one hand and non-hospital practitioners on the other makes for effective use of doctors in densely populated areas. Unhappily because of our undergraduate training we find it hard to accept this situation and make the best of it. There is a risk that general practice may be forced into a form to suit our training, instead of our modifying it in the best interests of patients and the profession. General practitioners usually attribute the small number of hospital beds available to them to arbitrary regulations or selfishness on the part of specialists, rather than to an inherent feature of British medical practice. Many doctors feel that their prestige is impaired by lack °
624 of hospital privileges, but British patients expect to be referred to specialists for major procedures and ’they do not think less of their own doctor because of this. In contrast, general practitioners in small towns in Western Canada do much surgery, partly because this is often essential, and partly on the assumption that their patients expect it of them. A demand by the general practitioner for hospital work or some form of specialised practice is reasonable if this will fill a local need, but it should not be allowed to prevent him giving adequate time to the rest of his patients. The general practitioner is taught as a student principally about diseases which are best treated in hospital, and he tends to think that hospital practice is the most important aspect of medicine. This is bad because he will be frustrated at being unable to practise the sort of medicine he was taught, and also because, in his quest for hospital privileges and impressive equipment, he may be diverted from his role of adviser and friend to his
patients. The overwhelming part played by the hospital and its specialist staff in our education deeply affects our ideals of medical practice. We spend so much of our early inside one that it is difficult for us to see that a hospital in relation to present-day medicine as a whole is only a specialised instrument : certainly a very large, important, impressive, and expensive instrument, and for this last reason one which must be reserved as far as possible for patients in a phase of their illness in which it is needed. Since the hospital is the scene of so much impressive, and by and large successful, medical endeavour, the student may be forgiven for thinking that it is the whole world of medicine that matters, in which the consultants are the heroes. The consultants have not been assiduous in discouraging this view. It is not surprising, therefore, that the doctor graduates as an indifferent specialist rather than as a general practitioner, and that he retains a respect for hospital privileges, access to impressive equipment, and technical skill. The original concentration of medical teaching in hospital was necessary to break the unscientific traditions of the apprenticeship system, which still is often perpetuated in assistantsbips. But general practice has become increasingly effective, recently aided by ebemotherapy and by diagnostic facilities such as the Public Health Laboratory Service. The extension of medical care to the whole community has only been possible through a great increase in the effectiveness of general practice ; similarly, the economical use of hospitals and the extension of medical care to the whole community are possible only because of the general practitioner’s work outside hospital. If general practice is limited in scope, it is because medical education did not prepare the present generation of doctors for this type of work. Introducing students to general practice is still in the experimental stage, and although this has been under way for some time in the United States and Scotland, English and Canadian universities seem to be approaching the problem more cautiously ; the colleges of general practice in England and Canada should speed this scheme. The general practitioner has a continuous responsibility for his patients, although for a phase of an illness they may be in the hands of a specialist. In fulfilling this responsibility he encounters organic disease he knows how to diagnose and treat rationally, disease he can diagnose but must refer for treatment (which if he conducts his practice well need not constitute more than 15% of his cases), organic disease which neither he nor anyone else can do more than palliate, many disorders of a probable organic origin which do not fit into any distinct syndrome, and 30% or so ailments largely psychogenic. This is a suflicient challenge to any man’s scientific and humane abilities for which he needs as much time as he can gain. Unfortunately his training has prepared him
unevenly for these various types of case. The young general practitioner not unnaturally tends to pay most attention to the types of case he has been taught about, and is apt to think that patients who do not have syn. dromes he recognises are not really ill. Yet if he attempts to select those he will help and those he feels not morally entitled to help, he creates needless difficulty for himself and unhappiness and hostility in those rejected. Treat. ment of course does not necessarily consist in granting all demands, but may consist in a firm but polite explanation why none is necessary. Until he has had much experience he tends to judge the quality of general practice by specialist criteria, and feels that he should be using methods appropriate to dealing with disease at the specialist level. Since he has to deal with comparatively large numbers of patients, inevitably part of his work consists in screening" or selecting those most suitable for specialist treatment. This should cause no shame and is an important part of his function as part of the medical team. Specialists appreciate the general practitioner who uses them efhciently on behalf of his practice. very
"
Conclusion
career
Norigid pattern for general practice should be devised. The general practitioner’s work is decided by the needs of the society he serves, but his ability to fill this need is impaired if his training gives him too rigid a conception of medical practice ; for instance, in the small towns of Western Canada he is required to do much emergency surgery which in Britain he is not. General practice fills the very big gap between the medical needs of the community and the capacity of hospitals and specialists to meet
them.
More doctors should be encouraged to become general practitioners ; and practices should be made smaller. They could then spend a greater amount of time in consultations (at present brief by Canadian standards) as friend and adviser to their patients. REFERENCES
Collings, J. S. (1950) Lancet, i. 555. Hadfield, S. J. (1953) Brit. med. J. ii, 683. Spence, J., Walton, W. S., Miller, F. J. W., Court, S. D. M. (1954) A Thousand Families in Newcastle upon Tyne. London.
THE EFFECTS OF SEPARATION FROM THE MOTHER IN EARLY LIFE D. H. STOTT M.A. Camb., Ph.D. Lond. RESEARCH
FELLOW,
UNIVERSITY OF BRISTOL INSTITUTE OF EDUCATION
LARGELY through the work of Dr. John Bowlby, there has been much discussion in recent years about how cllildren’s personalities may be affected by stays in institutions or in hospital during early life. For the present study we chose, from among 141 backward children, the 25 who had been separated from their mothers for at least ten weeks during their first four years of life. Actually the average length of their separation was over eighteen weeks in the first year, nearly seventeen in the second, and for the whole of the first four years no less than seventy-two weeks, or about one-third of their lives up to that point. Assessments of their emotional development were provided by their teachers on the comprehensive Bristol Social Adjustment Guide, and comparable information as to their domestic behaviour was obtained from interviews with the mothers or with the staff of institutions. Since emotional factors are very important for the understanding of backwardness, indications of the mutual affection between mother and child had been