- Email: [email protected]
MEDICAL PRACTICE OUTSIDE THE HOSPITAL
502 suicide. Both were delivered of full-term infants with severe malformations. One mother took pro-ban M three times a day for four days after a menstrual period had been overdue for four days, the total being 10 tablets (each tablet contains 6 mg. of thalidomide, 7-5 mg. of propantheline bromide, 250 mg. of dried aluminum hydroxide gel, and 80 mg. of magnesium oxide)that is, only 60 mg. of thalidomide. The baby born at full term had severe phocomelia with capillary haemangioma of the upper lip, nose, and frontal area, slight malformation of the left auricle, and coccygeal fovea. A mother took thalidomide at night with irregular intervals from before conception to the third month of pregnancy, the total being around 1300 mg. This mother’s male baby, weighing 1580 g. at birth, was sent to us and he was found to have cryptorchism on the right, and inguinal hernia on the same side. When he was four months old, the mother found that the baby’s right thumb was incapable of opposition. X-ray examination showed no abnormality except for slight hypoplasia of the pelvis. But the infant’s right thenar muscles were missing, though those on the left side were present. Department of Pædiatrics, Hokkaido University Hospital,
Sapporo, Hokkaido, Japan. Department of Obstetrics
TADASHI
KAJII.
and Gynæcology, Sapporo Medical College, Sapporo, Hokkaido, Japan.
THE PRACTITIONER’S REMUNERATION SIR,-Dr. Evans’ article (Feb. 16) deserves careful study. May we, as members of a group practice employing full secretarial, reception, and nursing staff, give
actual figures
to
illustrate his thesis ?
In the years 1960-63, the proportion of total income available fallen by 5-8%, of which staff wage increases In this period, which includes the Pilkington award, the partners’ earnings before tax increased by 1%. Allowing E350 p.a. for car expenses, our average reward for providing general medical care for 2000 patients each amounts to E1500 p.a. before tax. Our staff do relieve us of some work, and hence allow time for other activities, but in fact extra facilities soon lead to extra use, and the local district nurses, local-authority clinics, and local hospitals are all beneficiaries; we
acquainted. Another assumption
in much of the thinking about the future of general practice is that current population/doctor ratios will be maintained; indeed some plans for the future seem actually to require a considerable further reduction of this ratio. Two points arise in connection with this assumption. While there is as yet no serious falling off in recruitment of doctors, there has been and will probably continue to be a redistribution of manpower within the profession, as well as changes in the status and role"of the increasing numbers in the professions supplementary to medicine: how much of the present work of G.P.S might at some future date be done by psychologists and social workers ? Some of the redistribution of medical manpower arises in response to changing needs, but in a free society (even one with a National Health Service) other factors may be relevant. If general practice ceases to appear attractive, it will not attract willing recruits; and evidence suggests that in U.S.A.2 and Australia,3 this is happening. I have been unable to find figures which would show the trends in Britain, but I would be surprised if they are very different. Furthermore, technological advances and higher salaries in other professions, notably in the physical sciences, are beginning to siphon off talent which only a decade ago would probably have been attracted to the medical "
to the partners has account for 4-5%.
so,
MEDICAL PRACTICE OUTSIDE THE HOSPITAL SIR,-Dr. Susser’s thoughtful essay (Feb. 9), like Professor McKeown’s a year or so ago, makes assumptions about present-day trends which may not be justifiable. In the last few generations, increasing urbanisation and widespread social and cultural change have produced an anomie which we accept as a permanent feature of our society, ignoring the possibility that the present generation of children may be able to adapt more easily to urban living than their parents and grandparents. The mass media are as likely to promote as to inhibit this process of adaptation; and, as Prof. G. M. Carstairs pointed out in his recent Reith Lectures, a liberalisation of adolescent mores could have a beneficial effect on family stability in later life. If this should happen, the training in behavioural sciences which is advocated for medical students may be of less overwhelming importance in the future than some suggest-though I would agree that it is required, and deserves greater emphasis than it gets in most medical schools with which I am
believe, are our patients.
We prefer to practice in this way, but we can hardly feel that the present system of payment is fair to us, or has a desirable influence upon the development of the Health Service. ANTHONY RYLE DONALD GRANT ANN HOLLINGWORTH.
SIR,-Dr. Evans’ excellent article naturally has my support because I am one of the many practitioners in search of remuneration. But we need more than money. To be as contented as we should be for our own pleasure, for good service to the public, and for adequate recruitment to our ranks, we need freedom from fear of illness, freedom to take a holiday, and freedom from the necessity of exploiting our wives and our mortgages. Herein lies the chief " differential between the G.P. and nearly all other members of the profession. The time has surely come when locums and secretarial staff at least must be paid for out of other pockets than our own. Increases of pay to cover such expenses, all too soon outdated, only provide the same old unhealthy dilemma, such as that mentioned by Dr. Evans-" what shall I give up in order to afford to run an appointment "
system." KENNETH F. MOLE.
profession. Finally, if maintained as at present, or even altered somewhat as they may be, the discrepancies between developed and underdeveloped countries in population/doctor ratios’ and needs for medical services may not be accepted or condoned by the citizens of the world of 2000 A.D. A redeployment of medical forces to provide a more even distribution is not impossible to imagine in a world which by then might have some form of federated government-perhaps a necessity if any form of government is to survive at all. Such a redeployment would call for new values in the medical profession. The concentration of man power and resources on the minutix of medicine might then be less easy to justify; and general practitioners or their successors would have to handle larger populations than at present. Inevitably thev would have to devote more of their attention to the practice of preventive medicine, as doctors mostly do in underdeveloped countries at present. School of Public Health and Tropical Medicine, J. M. LAST. University of Sydney, Sydney, Australia.
SIR,-Among his interesting thoughts, Dr. Susser (Feb. 9, p. 317) refers to understanding of the physiology and the significance of symptoms" as making "
1. 2. 3. 4.
Lancet, 1961, ii, 1. Silver, G. A. Proc. R. Soc. Med. 1961, 54, 449. Dickson, C. H., Burton, A. W. Med. J. Aust. 1962, ii, 560. Jones, C. S. Brit. med. J. 1962, ii, 1257.
503
general practice easier. To my mind it makes general practice ever more important and, for that matter, more difficult to teach from hospital. With increasing knowledge of the genesis and meaning of symptoms it is more and more the general practitioner who will see these, and, if he knows about them, he. will be in the only position to apply the correct remedy at the time it is most likely to
be successful. So far,
unfortunately, knowledge of organisers has
not
proved very fruitful in medicine, but there can be no doubt that in time knowledge of cell chemistry and the processes that control it will enable what seem to us irreversible processes —e.g., atherosclerosis, scarring, cataract-to be reversed. Indeed, I am not sure that even now the early and admittedly empirical treatment of symptoms may not prevent the development of what would have turned into irreversible reactions. I know that such treatment is anathema or damnable heresy to many physicians, but I have used it for many years, and looking back on over forty years’ practice I am surprised to find how little really serious textbook disease my patients have shown. I do not think I have missed a lot, and I have always been ready to refer my patients to consultants, but undoubtedly it will be possible to reverse reactions in future, and I do not think it is too early to try now, tentatively, of course. I am quite sure anyhow that most of my patients have not been psychoneurotic or even psychosomatic, and because I have not treated them as such they have kept on coming. I have not treated them as an amateur psychologist but as a friend, and somehow or other Nature has helped most of them to avoid dire trouble. My bottles of medicine may be despicable, but they have done no harm and I think they have done good. The doctor of the future may have better medicines, but they will have to be used earlier and with more discrimination than I have achieved if we are to attain the ideal of prevention, and the only doctor to use them will be the good G.P. W. N. LEAK. THE FUTURE OF GENERAL PRACTICE
SlR,ňIwould venture to suggest that Dr. Wood (Feb. 16) is protected to a large extent from the medical trivia with which N.H.S. general practitioners are bedevilled because he is in private practice, and his patients have to pay him in hard cash, so they tend to think twice before picking up the ’phone. In my view there
general practice
can
(1)
The
W. R. DODDS H. MADGWICK. TOWARDS BETTER PERSONAL CARE
leading article of Feb. 23, you discuss the new concept of " family practice " as a specialty, and you ask if any British university has the foresight and courage to start a comprehensive postgraduate course designed to train the young graduate in all the aspects of personal medical care. SIR,-In
At
our recent
Medical World International Conference
90% of the illness in the country is seen and treated outside the hospital, usually by the family doctor, and yet we still do not
provide adequate training facilities
or give proper the needs and possibilities of domiciliary medicine.
be required to pay, out of his own his doctor, some part of the cost of his
treatment.
(2) The Government should heavily subsidise the G.P.’s practice running expenses. (3) The purely clerical job of issuing Ministry of Pensions and National Insurance certificates should be done by the
Ministry, on medical recommendation. N. TREVOR BURNETT. GENERAL-PRACTITIONER HOSPITALS SIR,-We wish to substantiate what Dr. Clyne and his colleagues (Feb. 2) say about the advantages of generalpractitioner hospitals. Here, in Blyth, a similar hospital to the Southall-Norwood one exists, and I regret to say is scheduled to become entirely used for geriatric patients within the next 10 years. There are thirty-six beds, including one amenity and one private room, and they serve a population of approximately 35,000. The hospital is staffed by the local general practitioners, two visiting surgeons, one physician, one E.N.T. specialist, and a gynaecologist. The general practitioners can admit their own cases or in conjunction with one of the
thought
to
P. M. ELLIOTT General Secretary, Medical Practitioners’ Union.
three ways in which N.H.S. be given a much-needed " shot in
patient should
on
Organising Family Doctor Care, the one idea that was repeatedly expressed by all the delegates was the need to enlarge the scope of general practice, to regard it as a specialty, and to provide proper training facilities, both undergraduate and graduate. These delegates practised in such widely differing countries as the U.S.A. and the U.S.S.R., Israel and Pakistan, Yugoslavia and Holland. We are following up the conference by collecting information from all over the world on postgraduate training schemes for general practice. There are tentative plans in several countries for starting such courses, but only in Yugoslavia has the course become a reality, and this is directly due to the work of Professor Vuletic at Zagreb University. We, also, hope that a British university will give a lead in this new field. The work done in Edinburgh and Manchester on the training of the undergraduate should be followed up and extended to other universities. There should be recognised departments for the teaching of family practice, fully staffed and led by a professor experienced in general practice. Over
A THOUSAND OUTPATIENTS
.
to
your
are
the arm " : pocket directly
consultants. A daily rota of General Practitioners is provided to maintain a 24-hour casualty service. During the past year there were approximately 6000 casualties, 4750 outpatient consultations, and 1030 admissions. A very happy atmosphere exists between patients and nursing and medical staff, and the hospital provides an excellent stimulus towards a good standard of general practice. It seems to us rather tragic if these hospitals are to disappear from our Health Service.
SIR,-May paper ?
I
comment on recent
letters
referring
to
my
Dr. Doddconstrues it as an " attack on general practice " but this interpretation is unjustified. The paper merely drew attention to problems revealed by an inquiry into the reciprocal roles of hospital outpatient departments and family" doctors as at present" operating. He also refers to my facile generalisations and conclusions based on " clinical impressions bearing little relation to the facts ". I confess I do not understand these comments. The paper obviously was not intended to be " clinical " in the sense of dealing with which specific clinical problems; it was a broad review could do no more than add perspective. As to " facile " assumptions, Dr. Dodd imputes to me a wish to put general practitioners under the control of a consultant physician, a view I neither expressed nor hold. The need for brevity compelled the exclusion in my final draft of several points raised by Dr. Dodd and others -in particular, the wide range of standards in general practice, from the frankly bad to the very good, a situa1.
Lancet, 1962, ii, 1219.
Sapporo, Hokkaido, Japan. Department of Obstetrics
TADASHI
KAJII.
and Gynæcology, Sapporo Medical College, Sapporo, Hokkaido, Japan.
THE PRACTITIONER’S REMUNERATION SIR,-Dr. Evans’ article (Feb. 16) deserves careful study. May we, as members of a group practice employing full secretarial, reception, and nursing staff, give
actual figures
to
illustrate his thesis ?
In the years 1960-63, the proportion of total income available fallen by 5-8%, of which staff wage increases In this period, which includes the Pilkington award, the partners’ earnings before tax increased by 1%. Allowing E350 p.a. for car expenses, our average reward for providing general medical care for 2000 patients each amounts to E1500 p.a. before tax. Our staff do relieve us of some work, and hence allow time for other activities, but in fact extra facilities soon lead to extra use, and the local district nurses, local-authority clinics, and local hospitals are all beneficiaries; we
acquainted. Another assumption
in much of the thinking about the future of general practice is that current population/doctor ratios will be maintained; indeed some plans for the future seem actually to require a considerable further reduction of this ratio. Two points arise in connection with this assumption. While there is as yet no serious falling off in recruitment of doctors, there has been and will probably continue to be a redistribution of manpower within the profession, as well as changes in the status and role"of the increasing numbers in the professions supplementary to medicine: how much of the present work of G.P.S might at some future date be done by psychologists and social workers ? Some of the redistribution of medical manpower arises in response to changing needs, but in a free society (even one with a National Health Service) other factors may be relevant. If general practice ceases to appear attractive, it will not attract willing recruits; and evidence suggests that in U.S.A.2 and Australia,3 this is happening. I have been unable to find figures which would show the trends in Britain, but I would be surprised if they are very different. Furthermore, technological advances and higher salaries in other professions, notably in the physical sciences, are beginning to siphon off talent which only a decade ago would probably have been attracted to the medical "
to the partners has account for 4-5%.
so,
MEDICAL PRACTICE OUTSIDE THE HOSPITAL SIR,-Dr. Susser’s thoughtful essay (Feb. 9), like Professor McKeown’s a year or so ago, makes assumptions about present-day trends which may not be justifiable. In the last few generations, increasing urbanisation and widespread social and cultural change have produced an anomie which we accept as a permanent feature of our society, ignoring the possibility that the present generation of children may be able to adapt more easily to urban living than their parents and grandparents. The mass media are as likely to promote as to inhibit this process of adaptation; and, as Prof. G. M. Carstairs pointed out in his recent Reith Lectures, a liberalisation of adolescent mores could have a beneficial effect on family stability in later life. If this should happen, the training in behavioural sciences which is advocated for medical students may be of less overwhelming importance in the future than some suggest-though I would agree that it is required, and deserves greater emphasis than it gets in most medical schools with which I am
believe, are our patients.
We prefer to practice in this way, but we can hardly feel that the present system of payment is fair to us, or has a desirable influence upon the development of the Health Service. ANTHONY RYLE DONALD GRANT ANN HOLLINGWORTH.
SIR,-Dr. Evans’ excellent article naturally has my support because I am one of the many practitioners in search of remuneration. But we need more than money. To be as contented as we should be for our own pleasure, for good service to the public, and for adequate recruitment to our ranks, we need freedom from fear of illness, freedom to take a holiday, and freedom from the necessity of exploiting our wives and our mortgages. Herein lies the chief " differential between the G.P. and nearly all other members of the profession. The time has surely come when locums and secretarial staff at least must be paid for out of other pockets than our own. Increases of pay to cover such expenses, all too soon outdated, only provide the same old unhealthy dilemma, such as that mentioned by Dr. Evans-" what shall I give up in order to afford to run an appointment "
system." KENNETH F. MOLE.
profession. Finally, if maintained as at present, or even altered somewhat as they may be, the discrepancies between developed and underdeveloped countries in population/doctor ratios’ and needs for medical services may not be accepted or condoned by the citizens of the world of 2000 A.D. A redeployment of medical forces to provide a more even distribution is not impossible to imagine in a world which by then might have some form of federated government-perhaps a necessity if any form of government is to survive at all. Such a redeployment would call for new values in the medical profession. The concentration of man power and resources on the minutix of medicine might then be less easy to justify; and general practitioners or their successors would have to handle larger populations than at present. Inevitably thev would have to devote more of their attention to the practice of preventive medicine, as doctors mostly do in underdeveloped countries at present. School of Public Health and Tropical Medicine, J. M. LAST. University of Sydney, Sydney, Australia.
SIR,-Among his interesting thoughts, Dr. Susser (Feb. 9, p. 317) refers to understanding of the physiology and the significance of symptoms" as making "
1. 2. 3. 4.
Lancet, 1961, ii, 1. Silver, G. A. Proc. R. Soc. Med. 1961, 54, 449. Dickson, C. H., Burton, A. W. Med. J. Aust. 1962, ii, 560. Jones, C. S. Brit. med. J. 1962, ii, 1257.
503
general practice easier. To my mind it makes general practice ever more important and, for that matter, more difficult to teach from hospital. With increasing knowledge of the genesis and meaning of symptoms it is more and more the general practitioner who will see these, and, if he knows about them, he. will be in the only position to apply the correct remedy at the time it is most likely to
be successful. So far,
unfortunately, knowledge of organisers has
not
proved very fruitful in medicine, but there can be no doubt that in time knowledge of cell chemistry and the processes that control it will enable what seem to us irreversible processes —e.g., atherosclerosis, scarring, cataract-to be reversed. Indeed, I am not sure that even now the early and admittedly empirical treatment of symptoms may not prevent the development of what would have turned into irreversible reactions. I know that such treatment is anathema or damnable heresy to many physicians, but I have used it for many years, and looking back on over forty years’ practice I am surprised to find how little really serious textbook disease my patients have shown. I do not think I have missed a lot, and I have always been ready to refer my patients to consultants, but undoubtedly it will be possible to reverse reactions in future, and I do not think it is too early to try now, tentatively, of course. I am quite sure anyhow that most of my patients have not been psychoneurotic or even psychosomatic, and because I have not treated them as such they have kept on coming. I have not treated them as an amateur psychologist but as a friend, and somehow or other Nature has helped most of them to avoid dire trouble. My bottles of medicine may be despicable, but they have done no harm and I think they have done good. The doctor of the future may have better medicines, but they will have to be used earlier and with more discrimination than I have achieved if we are to attain the ideal of prevention, and the only doctor to use them will be the good G.P. W. N. LEAK. THE FUTURE OF GENERAL PRACTICE
SlR,ňIwould venture to suggest that Dr. Wood (Feb. 16) is protected to a large extent from the medical trivia with which N.H.S. general practitioners are bedevilled because he is in private practice, and his patients have to pay him in hard cash, so they tend to think twice before picking up the ’phone. In my view there
general practice
can
(1)
The
W. R. DODDS H. MADGWICK. TOWARDS BETTER PERSONAL CARE
leading article of Feb. 23, you discuss the new concept of " family practice " as a specialty, and you ask if any British university has the foresight and courage to start a comprehensive postgraduate course designed to train the young graduate in all the aspects of personal medical care. SIR,-In
At
our recent
Medical World International Conference
90% of the illness in the country is seen and treated outside the hospital, usually by the family doctor, and yet we still do not
provide adequate training facilities
or give proper the needs and possibilities of domiciliary medicine.
be required to pay, out of his own his doctor, some part of the cost of his
treatment.
(2) The Government should heavily subsidise the G.P.’s practice running expenses. (3) The purely clerical job of issuing Ministry of Pensions and National Insurance certificates should be done by the
Ministry, on medical recommendation. N. TREVOR BURNETT. GENERAL-PRACTITIONER HOSPITALS SIR,-We wish to substantiate what Dr. Clyne and his colleagues (Feb. 2) say about the advantages of generalpractitioner hospitals. Here, in Blyth, a similar hospital to the Southall-Norwood one exists, and I regret to say is scheduled to become entirely used for geriatric patients within the next 10 years. There are thirty-six beds, including one amenity and one private room, and they serve a population of approximately 35,000. The hospital is staffed by the local general practitioners, two visiting surgeons, one physician, one E.N.T. specialist, and a gynaecologist. The general practitioners can admit their own cases or in conjunction with one of the
thought
to
P. M. ELLIOTT General Secretary, Medical Practitioners’ Union.
three ways in which N.H.S. be given a much-needed " shot in
patient should
on
Organising Family Doctor Care, the one idea that was repeatedly expressed by all the delegates was the need to enlarge the scope of general practice, to regard it as a specialty, and to provide proper training facilities, both undergraduate and graduate. These delegates practised in such widely differing countries as the U.S.A. and the U.S.S.R., Israel and Pakistan, Yugoslavia and Holland. We are following up the conference by collecting information from all over the world on postgraduate training schemes for general practice. There are tentative plans in several countries for starting such courses, but only in Yugoslavia has the course become a reality, and this is directly due to the work of Professor Vuletic at Zagreb University. We, also, hope that a British university will give a lead in this new field. The work done in Edinburgh and Manchester on the training of the undergraduate should be followed up and extended to other universities. There should be recognised departments for the teaching of family practice, fully staffed and led by a professor experienced in general practice. Over
A THOUSAND OUTPATIENTS
.
to
your
are
the arm " : pocket directly
consultants. A daily rota of General Practitioners is provided to maintain a 24-hour casualty service. During the past year there were approximately 6000 casualties, 4750 outpatient consultations, and 1030 admissions. A very happy atmosphere exists between patients and nursing and medical staff, and the hospital provides an excellent stimulus towards a good standard of general practice. It seems to us rather tragic if these hospitals are to disappear from our Health Service.
SIR,-May paper ?
I
comment on recent
letters
referring
to
my
Dr. Doddconstrues it as an " attack on general practice " but this interpretation is unjustified. The paper merely drew attention to problems revealed by an inquiry into the reciprocal roles of hospital outpatient departments and family" doctors as at present" operating. He also refers to my facile generalisations and conclusions based on " clinical impressions bearing little relation to the facts ". I confess I do not understand these comments. The paper obviously was not intended to be " clinical " in the sense of dealing with which specific clinical problems; it was a broad review could do no more than add perspective. As to " facile " assumptions, Dr. Dodd imputes to me a wish to put general practitioners under the control of a consultant physician, a view I neither expressed nor hold. The need for brevity compelled the exclusion in my final draft of several points raised by Dr. Dodd and others -in particular, the wide range of standards in general practice, from the frankly bad to the very good, a situa1.
Lancet, 1962, ii, 1219.