QUALITY IN GENERAL PRACTICE

650

QUALITY IN GENERAL PRACTICE SiR,—It is obvious, reading Mr. Honigsbaum’s article1 and his reply (Sept. 9, p. 534) to your leading article (Aug. 26, p. 411), that he aims to approach his subject scientifically. I feel, therefore, a little anxious in countering his arguments because I am unable to produce a factual balance-sheet

list of statistics. Even three points in his letter.

or a

to comment on

so

I would like

Firstly, one must challenge his statement about group practice being " little more than a rota and financial partnership ". One of the main delights in working in a group is the ability to share experiences and ask one’s colleagues for advice. I feel certain from my contacts with other group practices that my own group is not unique in discussing cases, seeking help from each other, and arranging joint consultations. It is all done in a very informal manner over coffee or by asking a colleague to at a rash, listen to a heart murmur, complex case-history. In addition we meet as a group weekly to discuss clinical and administrative problems and are now also having a monthly meeting to look at more complex long-term problems. Until now, I would not have thought this worth recording. Secondly, the main function of a general practitioner is suggested as a choice between a " junior consultant or senior social worker ". Again I have no statistics but would be willing to state emphatically that the majority of my colleagues see themselves in neither role. I suggest that consultants and social workers do not regard us that way either. Possibly then The Lancet was right in describing Mr. Honigsbaum’s review as not " fair " nor presenting a " balanced judgment ". Finally, Mr. Honigsbaum presents us with a clinical example of a patient complaining of a pain in the stomach, and assumptions are made on what a patient wants and what the doctor will do. It really is not good enough. One morning in general practice would show Mr. Honigsbaum that patients’ desires are many and various (even though they may have similar problems) and that doctors’ actions in the main are to respond to these wishes in a sophisticated, professional manner. We aim to offer effective, efficient primary medical care and to diagnose using physical, psychological, and social concepts. The object is to synthesise and not to compart-

spare

a moment to

look

or comment on a

mentalise them. The theoretical patient with stomach pain might well have had an argument with his employer which aggravated the situation. But he might well be drinking too much alcohol, eating badly, be unhappily married, and/or showing the first objective evidence of a gastric ulcer. A good general practitioner will unravel the problem, because he is not a junior consultant or a senior social worker but someone experienced in the problems of primary medical care. Could I suggest that the unpublished work that goes on in this country should now be investigated by Mr. Honigsbaum ? I am certain that the Royal College of General Practitioners could point him in the right direction. University Health Service, 32 Pritchatts Road,

Birmingham

B15 2SE.

K. G. DICKINSON.

" leader, he cries: Where is your evidence ? " He considers himself entitled to make imputations as follows without the slightest scrap of evidence: " The general practitioner will have his tendency reinforced by the stress placed on social work to make hasty diagnoses without proper physical examination." You were right, amongst other points, to draw attention to the evidence of vocational training development and the emergence of departments of general practice. Mr. Honigsbaum dismisses this with fine rhetoric but ignores the welldocumented effect of teaching and education in general practice which stimulates self-appraisal and criticism, as McWhinney and others have pointed out-in fact, the very thing that Honigsbaum is trying to encourage, as havee others before him. The vocational trainee conference in Newcastle earlier this year amply proved to those who believe we can train our bright young men and women without pulling up our socks that they are living in the past. Today’s general practice is alive with critical assessment, and it is unfortunate that Mr. Honigsbaum is unaware of it. Your valid leader with its call for greater effort and more critical appraisal is well taken, and is an encouragement for the strenuous efforts made by many in and out of the Royal College of General Practitioners, but you do scant service to the report published by the late Dr. Collings (whose evidence was based on hard worked personal visitation of general practice) by suggesting that Mr. Honigsbaum’s paper may have remotely similar significance.

West Granton Medical Group, 191 Crewe Road North, Edinburgh EH5 2NT.

SIR,-I like Honigsbaum. This

E. V. KUENSSBERG.

man

has guts and the

courage of

sincerely felt convictions. It takes his kind of perspicacity and perseverance to bring to our attention, with such force, the lack of utilisation of wash-basins by general practitioners. I like Honigsbaum because he says he is not a general practitioner-and I believe him. He does, however, say that " The general practitioner’s main role is, and must always be, that of a primary diagnostician in clinical medicine ". It takes real guts to define somebody else’s role with such conviction. Honigsbaum does not say that he is a patient, although it may be reasonable to expect that he could be one and that, when he describes the wants of a patient, he refers to his personal desires as, in his letter to you, he makes no reference to published material-as is his usual wont. When Honigsbaum says that a patient, complaining of a pain in the stomach, wants his general practitioner to make a proper physical examination, I can believe that this is exactly what Honigsbaum would want. At the same time, it should be recognised that the population of the United Kingdom runs into a few millions, and until they have been asked, it is not really safe to say what they would want. I like Honigsbaum because he is human. He can talk of standards in general practice; of wash-basins; of babies and bath-water, in a single letter. This man has diverse interests. It occurs to me that Honigsbaum might not want me to like him.

I hone

not.

2 Saxfield

said to Alice in rather a scornful tone: " When I use a word it means what I choose it to And so it is with Frank mean, neither more nor less." he When Honigsbaum. says " now ", he means nine years ago, though in his letter to you (Sept. 9, p. 534) " over five years " is the new range of " now ". But not only are measures of time so misused. In attacking your excellent

SIR,-Humpty-Dumpty

1.

Honigsbaum, F. J.

R. Coll. gen.

Practnrs, 1972, 22, 429.

Drive, Baguley Hall, Manchester M23 8PJ.

GARETH LLOYD.

CATERING FOR MINORITY-GROUPS SiR,-Many of the Ugandan immigrants are vegetarians. This society will be pleased to advise hosts, social workers, doctors, and hospitals on the provision of balanced vegetarian fare in the U.K. Many embarrassments in catering