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HOW BUSY IS THE FAMILY DOCTOR ?
1342 his
Annotations HOW BUSY IS THE FAMILY DOCTOR ?
." Busy " is
now an almost automatic adjective for doctor " or " general practitioner." The bond between them amounts almost to hyphenation, so vividly does the public and the profession think of the general practitioner as a man bowed down by days and nights of ceaseless activity. He is credited thus, and perhaps accepts the implied compliment to his powers of endurance. Seldom does he deny that he is busy (at least publicly) for perhaps to him " being busy" has become something of a habit or a kind of defensive reaction. Statistical studies of general practice have not so far shown in detail how the family doctor disposes of his working-time. This information could be obtained only from a general practitioner who was prepared to undergo a time-and-motion study of the kind more usually used as a guide to personnel management in industry. This has now been done, and Crombie and Crossrecord the findings of a general practitioner who timed his own activities, stop-watch in hand, for a period of a year. The background to the figures might perhaps have been clearer, and no precise evidence is offered of how the estimate of the population at risk (4200 patients) was made. The time spent in the care of those patients was, however, analysed by season, age-group, and condition for which the patient was seen. Separate record was made of time in actual contact with patients, time spent travelling, and time consumed by the administrative tasks which are an often unacknowledged part of the efficient management and conduct of a practice. The practice was in a betterclass suburban area with a relatively static population, and the figures may not be directly applicable elsewhere, but they show, perhaps for the first time, how busy a family doctor, practising under these circumstances, can be. The time spent in contact with patients, travelling between them, and administration, was slightly over 30 hours a week throughout the year, varying from about, 35 hours a week in the winter months, to a low level of 20 hours in August, when many of the patients of the practice were, no doubt, away on their summer holidays. Most time was spent on children and on old people, and most of the children in the practice were seen at some time during the year. There were some sex differences, particularly at older ages, which would repay closer study, though they reflect recognised differences in susceptibility to degenerative diseases. This analysis, drawn first-hand from an efficient general practice, may suggest that the family doctor is less hard pressed than is often supposed. Since his skill is applied piecemeal, in long or short contacts with patients, he will often seem very busy to those who consult him. But more information could usefully be extracted before conclusions are drawn. How much time, for example, is consumed in one year by attendances for the ritual bottle of medicine’? How busy is the doctor in a mining area, in consultations arising from bonus-shift certification rather than medical necessity? How far, in fact, could administrative and technical improvements in the manner and method of his practice, save him time and enable him to widen his vision and scope’? This knowledge can come only from inquiries in other general
" family
practices. Though some may be afraid of administrative efficiency in general practice on the false grounds that it detracts from humanity in some mysterious way, all must assume that a moral obligation rests on every family doctor to arrange and conduct his 1.
practice
Crombie, D. L., Cross, K. W. 141.
so
that he may
Brit. J. prev. Soc.
serve
Med. 1956, 10,
patients best. For long visiting lists, overcrowded surgeries, and long weary hours of hurried work the practitioner can have himself to blame. Hours saved by proper organisation might enable the family doctor to play a fuller part in preventive medicine, the success of which would progressively relieve him of further burdens. PULMONARY COLLAPSE IN CHILDREN THE Newcastle survey1 showed that few children escape a more or less severe respiratory infection at least and figures from family practices 23 once a year; illustrate that respiratory disease accounts for a large proportion of visits, many of them to children. The mortality of respiratory diseases in early life is still considerable ; 2373 children under 2 years were certified Our knowledge as dying of respiratory disease in 1954.4 of these diseases is surprisingly inadequate and these disturbing figures are a stimulus to further efforts in prevention, investigation, and treatment. Now that the pressure on hospital beds for children has been reduced, it is possible to look more closely at. some common psediatric problems. Such an investigation which throws much light on the common respiratory infections has been carried out by James and her colleagues5 at the Princess Louise (Kensington) Hospital for Children. This hospital, serving a rootless and illhoused population, admits each year a great many children who, except for bad living conditions, would be treated at home. James et al. have taken the opportunity to review the natural history of pulmonary collapse in childhood in a reasonably unselected group of cases. Of the chest films of some 5000 children, 854 showed evidence of pulmonary collapse as assessed by radiological diminution in size of one or more bronchopulmonary segments. 55% of the children were available also for follow-up examination. The results show that the most common antecedents of collapse were pertussis, upper respiratory infections, sinobronchitis (chronic paranasal sinusitis with recurrent episodes of bronchitis or collapse), pneumonia, and lower respiratory infections in that order. Asthma, tuberculosis, and measles figured much less frequently. Collapse due to measles, sinobronchitis, pertussis, and lower respiratory infection was often multilobular, whereas isolated lobar collapse tended to follow asthma, tuberculosis, and upper respiratory infections. The deflation of the lung in all these conditions was usually benign and transient. Bronchiectasis was proven in only 1-7%, but it was not looked for in the whole series. Persistent collapse was observed most often in tuberculosis, sinobronchitis, and pertussis. These differences may reflect different causes for the collapse (for example, aspiration, retention of viscid secretion, or obstruction by enlarged lymph-glands; but that is not certain. James et al. do not discuss the response to treatment. It is important to realise that the common upper respiratory infections of childhood may be followed by collapse-consolidation in the lungs. This complication may explain the long convalescence and persistent winter cough of some children, and is an argument in favour of using X rays more freely. The lung apparently re-expands readily in most cases, but it would be valuable to have more information on what physiotherapy and antibiotics can do to hasten resolution. Bronchoscopy and bronchoabsence of striking graphy are seldom indicated in the symptoms or radiological changes 6 and they should be reserved for children in whom collapse has persisted for Spence, J., Walton, W. S., Miller, F. J. W., Court, S. D. M., A Thousand Families in Newcastle upon Tyne. London, 1954. Pemberton, J. Brit. med. J. 1949, i, 306. Shaw, A. B., Fry, J. Ibid, 1955, ii, 1577. Registrar-General’s Statistical Review of England and Wales for 1954. H.M. Stationery Office, 1955. 5. James, U., Brimblecombe, F. S. W., Wells, J. W. Quart. J. Med. 1956, 25, 137. 6. See Lancet, Oct. 13, 1956, p. 770. 1.
2. 3. 4.
Annotations HOW BUSY IS THE FAMILY DOCTOR ?
." Busy " is
now an almost automatic adjective for doctor " or " general practitioner." The bond between them amounts almost to hyphenation, so vividly does the public and the profession think of the general practitioner as a man bowed down by days and nights of ceaseless activity. He is credited thus, and perhaps accepts the implied compliment to his powers of endurance. Seldom does he deny that he is busy (at least publicly) for perhaps to him " being busy" has become something of a habit or a kind of defensive reaction. Statistical studies of general practice have not so far shown in detail how the family doctor disposes of his working-time. This information could be obtained only from a general practitioner who was prepared to undergo a time-and-motion study of the kind more usually used as a guide to personnel management in industry. This has now been done, and Crombie and Crossrecord the findings of a general practitioner who timed his own activities, stop-watch in hand, for a period of a year. The background to the figures might perhaps have been clearer, and no precise evidence is offered of how the estimate of the population at risk (4200 patients) was made. The time spent in the care of those patients was, however, analysed by season, age-group, and condition for which the patient was seen. Separate record was made of time in actual contact with patients, time spent travelling, and time consumed by the administrative tasks which are an often unacknowledged part of the efficient management and conduct of a practice. The practice was in a betterclass suburban area with a relatively static population, and the figures may not be directly applicable elsewhere, but they show, perhaps for the first time, how busy a family doctor, practising under these circumstances, can be. The time spent in contact with patients, travelling between them, and administration, was slightly over 30 hours a week throughout the year, varying from about, 35 hours a week in the winter months, to a low level of 20 hours in August, when many of the patients of the practice were, no doubt, away on their summer holidays. Most time was spent on children and on old people, and most of the children in the practice were seen at some time during the year. There were some sex differences, particularly at older ages, which would repay closer study, though they reflect recognised differences in susceptibility to degenerative diseases. This analysis, drawn first-hand from an efficient general practice, may suggest that the family doctor is less hard pressed than is often supposed. Since his skill is applied piecemeal, in long or short contacts with patients, he will often seem very busy to those who consult him. But more information could usefully be extracted before conclusions are drawn. How much time, for example, is consumed in one year by attendances for the ritual bottle of medicine’? How busy is the doctor in a mining area, in consultations arising from bonus-shift certification rather than medical necessity? How far, in fact, could administrative and technical improvements in the manner and method of his practice, save him time and enable him to widen his vision and scope’? This knowledge can come only from inquiries in other general
" family
practices. Though some may be afraid of administrative efficiency in general practice on the false grounds that it detracts from humanity in some mysterious way, all must assume that a moral obligation rests on every family doctor to arrange and conduct his 1.
practice
Crombie, D. L., Cross, K. W. 141.
so
that he may
Brit. J. prev. Soc.
serve
Med. 1956, 10,
patients best. For long visiting lists, overcrowded surgeries, and long weary hours of hurried work the practitioner can have himself to blame. Hours saved by proper organisation might enable the family doctor to play a fuller part in preventive medicine, the success of which would progressively relieve him of further burdens. PULMONARY COLLAPSE IN CHILDREN THE Newcastle survey1 showed that few children escape a more or less severe respiratory infection at least and figures from family practices 23 once a year; illustrate that respiratory disease accounts for a large proportion of visits, many of them to children. The mortality of respiratory diseases in early life is still considerable ; 2373 children under 2 years were certified Our knowledge as dying of respiratory disease in 1954.4 of these diseases is surprisingly inadequate and these disturbing figures are a stimulus to further efforts in prevention, investigation, and treatment. Now that the pressure on hospital beds for children has been reduced, it is possible to look more closely at. some common psediatric problems. Such an investigation which throws much light on the common respiratory infections has been carried out by James and her colleagues5 at the Princess Louise (Kensington) Hospital for Children. This hospital, serving a rootless and illhoused population, admits each year a great many children who, except for bad living conditions, would be treated at home. James et al. have taken the opportunity to review the natural history of pulmonary collapse in childhood in a reasonably unselected group of cases. Of the chest films of some 5000 children, 854 showed evidence of pulmonary collapse as assessed by radiological diminution in size of one or more bronchopulmonary segments. 55% of the children were available also for follow-up examination. The results show that the most common antecedents of collapse were pertussis, upper respiratory infections, sinobronchitis (chronic paranasal sinusitis with recurrent episodes of bronchitis or collapse), pneumonia, and lower respiratory infections in that order. Asthma, tuberculosis, and measles figured much less frequently. Collapse due to measles, sinobronchitis, pertussis, and lower respiratory infection was often multilobular, whereas isolated lobar collapse tended to follow asthma, tuberculosis, and upper respiratory infections. The deflation of the lung in all these conditions was usually benign and transient. Bronchiectasis was proven in only 1-7%, but it was not looked for in the whole series. Persistent collapse was observed most often in tuberculosis, sinobronchitis, and pertussis. These differences may reflect different causes for the collapse (for example, aspiration, retention of viscid secretion, or obstruction by enlarged lymph-glands; but that is not certain. James et al. do not discuss the response to treatment. It is important to realise that the common upper respiratory infections of childhood may be followed by collapse-consolidation in the lungs. This complication may explain the long convalescence and persistent winter cough of some children, and is an argument in favour of using X rays more freely. The lung apparently re-expands readily in most cases, but it would be valuable to have more information on what physiotherapy and antibiotics can do to hasten resolution. Bronchoscopy and bronchoabsence of striking graphy are seldom indicated in the symptoms or radiological changes 6 and they should be reserved for children in whom collapse has persisted for Spence, J., Walton, W. S., Miller, F. J. W., Court, S. D. M., A Thousand Families in Newcastle upon Tyne. London, 1954. Pemberton, J. Brit. med. J. 1949, i, 306. Shaw, A. B., Fry, J. Ibid, 1955, ii, 1577. Registrar-General’s Statistical Review of England and Wales for 1954. H.M. Stationery Office, 1955. 5. James, U., Brimblecombe, F. S. W., Wells, J. W. Quart. J. Med. 1956, 25, 137. 6. See Lancet, Oct. 13, 1956, p. 770. 1.
2. 3. 4.