- Email: [email protected]
THE FAMILY DOCTOR
923 to learn
that the
quality
of
supportive service outweighs
quantity.
its
One point the conference made clear. Knowledge, technique, and apparatus exist which could be applied to the relief, comfort, and reablement of the chronically sick and crippled and their families. But the possibilities
sufficiently widely known : even when help is available, it may be neither sought nor given. The conference reached no general agreement on the critical question of whose duty and function it was to bring assistance to those who need it and to synthesise the services provided. Once again, the family doctor was called the keystone. But keystones are static.. Could it be that a more dynamic title and conception might make effective convenors and directors of effort commoner than they appear at present ? are not
UNDULANT FEVER
COOPERATION in research between others is advised more often than it is on brucellosis in man and animals
our profession and practised. A report compiled by three hygienists, a family doctor, and aveterinary surgeon shows what can be done by enthusiasm and good wilLI For some years this team examined in detail the circumstances under
which all known human infections occurred in South Oxfordshire 2; and now, taking into account what is known of the prevalence of the disease in the country as a whole, has made suggestions for its eradication. Even if the measures proposed did not fulfil this ambition they would add a lot to our knowledge. One such measure is general compulsory notification of the disease in man. The essentials of useful notification are speed and exact definition and diagnosis. For most infectious diseases this means unequivocal confirmation by the laboratory, and it " weekly may be that for undulant fever the unofficial " summary of the Public Health Laboratory Service gives a more accurate picture than could be obtained by notification under the Public Health Act, 1936. Some local authorities which made undulant fever notifiable under this Act have allowed their powers to lapse. Notification of animal infections to public-health authorities raises more difficult problems. It would probably prevent some further human infections but not very many : undulant fever is rarely epidemic. Moreover brucellosis is not the only cause of abortion in the cow, and by no means every aborting cow is seen by a veterinary surgeon : infectious disease in animals has financial implications which might make the owner unwilling to ask for veterinary advice. Compulsory slaughter of infected animals (with compensation) is a method of eradicating the disease which has worked well in countries where the incidence is low. Applied here and now, it would ruin the dairy industry and nearly bankrupt the Treasury; but it is the method of choice when other measures of control-notably vaccination—have reduced the incidence far below its present level. The comments of this report on compulsory pasteurisation orders are much to the point. The official view is that serological evidence of infection of bulked milk or of a single cow is by itself insufficient to justify such an order. The report on a biological test is often too late to be of value, but it is a pity that more laboratories do not use Mair’s cultural method for isolation.3 It is equally important that the criteria for removing an order for pasteurisation should be defined explicitly. 1
Bothwell, P. W., McDiarmid, A., Bartram, H. G., Mackenzie-Wintle, H. A., Williamson, A. R. H. Vet. Rec. Oct. 13, 1962, p. 1091. 2. Bothwell, P. W. Med. Offr, 1960, 103, 7, 85. 3. Mair, N. S.
Mon. Bull. Minist. Hlth Lab. Serv. 1955, 14, 184.
The authors of this report are unfortunate in that it is still too early to see what will be the effect of the Ministry of Agriculture’s new policy on brucellosis, or to learn the final figures for the survey of infection in dairy herds. Free vaccination with S.19 vaccine is now offered for all calves, and this may reduce the incidence of the disease to a point where more vigorous measures will be feasible. We hear that so far the response to this offer has been disappointing. That the only figures which we have for the proportion of milk, of herds, and of cows which are infected are based on intelligent guesses is an indication of our ignorance about this disease. We do not know for certain how infection is commonly passed from cow to cow; we only know how it may be passed. Recent work by Kerr and his colleaguesin Northern Ireland has demonstrated the unsuspected importance of infection limited to the udder with no or very little antibodies in the blood. This not only emphasises the dangers of intermittent excretion but gives reasonable grounds for preferring the " ring test " on milk to the classical agglutination reaction on serum. We can again only guess at the proportion of human infections derived from milk. The cowman who is infected from the products of conception of an infected cow will, almost surely, be a constant drinker of infected milk. His children, curiously enough, seldom seem to have the disease. Though 10% of our raw milk is infected, we see only 100-200 cases each year in England and Wales; and an inquiry into the reasons why we escape infection might be rewarding. A patient with undulant fever is usually subjected to close questioning on his habits: we suggest that the same procedure should be applied (together with serological examination) to every other member of the household. We do not know the infectious dose of Brucella abortus by mouth. Those whose infections are undoubtedly milkborne will sometimes admit that they are addicted to milk as others are to beer. Milk taken in tea, on the other hand, is usually raised to a bactericidal temperature. Brucellosis is primarily an agricultural problem, and until the incidence of the disease in both dairy and beef cattle is reduced far below its present level human infections will occur.
THE FAMILY DOCTOR
THE young medical
graduate, on leaving hospital and entering general practice, very soon learns that most of the patients he is now called on to treat are very different from those he has seen in hospital and on whom his medical education has been based. They do not fall into fairly clear-cut categories, as he has been led to expect; many present the vaguest of symptoms; and recognisable abnormal physical signs are often absent. Many of these people are seeking sympathy, understanding, and reassurance rather than " cure "; but they need the doctor’s help nonetheless-help which he, at first, feels powerless to give. Specialisation in medicine has increased pari passu with increase in scientific knowledge. The young doctor has been taught by specialists and examined by specialists, many of whom, nowadays, have had little or no experience of general practice; and he has left hospital with more than a smattering of scientific knowledge. But the practice of medicine is an art based on science; and the more the science progresses the greater is the danger of the art being forgotten. At the same time, as medicine becomes more complex, so the patient’s need for a real family physician 4.
Kerr,
W. R. Vet. Rec. 1960,
72, 921.
924 increases. He needs a physician who will look after the whole man, see him against the background of his family, his home, and his work, interpret him to a consultant when necessary, and the consultant to him, and generally accept responsibility for his continuous medical care. How these needs can best be met was discussed at an international conference on the Organisation of Family Doctor Care which was held in London on Oct. 22-26 under the xgis of the Medical World. Over 200 delegates attended from twenty-four different countries. Hospital medicine has been the subject of much study, research, and reorganisation.. As a result, the specialist has attained a high level of proficiency and has gained much prestige. But little more than lip-service has been paid to medicine outside the hospitals: it has been allowed to drift without organisation, and very little attempt has been made to teach the would-be general practitioner what his job is and how he should do it. A qualifying degree or diploma has been assumed to be all that he needs, and he has had to find his own way and learn largely by trial and error. Moreover, in some parts of the country, family medicine is practised under conditions which differ little from those obtaining at the turn of the century. All too often, the general practitioner is being expected to do a 20th-century job in a 19th-century setting. The broad limits of a family doctor’s job need to be defined, and his training adapted accordingly. Since much of his work lies in the province of internal medicine, including paediatrics and geriatrics, he should have sound knowledge of general medicine and understanding of epidemiology, hygiene, and social science. The personal health services at present carried out by the local authority (antenatal and postnatal care, infant welfare, nutrition, immunisation, individual health education) could well form part of family practice. And surely family planning should come within the ambit of the family doctor ? In addition, since so much psychosomatic and frank mental illness will come before him, he should have had more than an elementary training in psychiatry. These ideas led straight to a consideration of medical
education-undergraduate and postgraduate. If the family doctor’s job were defined on these or other lines, some rearrangement of the curriculum would seem to be indicated. Indeed, every medical graduate, whatever his plans for the future, would doubtless profit from a period spent in general practice as an apprentice to a senior family doctor. Some countries have evolved a higher qualification in general practice, the possession of which entitles the holder to greater remuneration and enhances his prestige. In Yugoslavia, the postgraduate training course for this qualification is spread over thirty-six months: six of these are occupied in full-time attendance at the medical school, and the remainder in part-time inservice training-three hours three times a week. Those who pass an examination at the end of this course acquire the degree of master of general medicine. In Israel a similar course lasts for four years: the requirements for registration as a specialist in family medicine are " an M.D. degree from a recognised medical school, one year’s rotating internship in a teaching hospital, two years’ apprenticeship with a recognised family practitioner, and one year’s formal training in public health, social science, and psychiatry ". Developing countries-despite the enormous difficulty of their task-are, in some ways, in a better position than we are to are
organise comprehensive family-doctor
care.
They
uninhibited by the old traditions of practice which are,
ways, obstacles to our own further progress. In a developing country the family doctor must be all things to all men. He must have diagnostic skill and know his
in
some
limitations; and he must be able to teach his patients about infectious disease, hygiene, family planning, nutrition, maternal and child welfare, and the care of the sick. Indeed, in primitive villages, he must use his diagnostic and therapeutic ability to gain the confidence of the community so that they may be receptive of his teaching of the elementary rules of hygiene. In this setting there is no distinction between preventive and curative medicine. The distinction which has grown up between them in this and other " developed " countries is meaningless and absurd today; the family doctor should play his full part in the preventive personal services. Much of the present dissatisfaction and frustration of the general practitioner in this country stems from the tripartite nature of the National Health Service-hospital, general practitioner, and public-health services-a triptych for which our own profession is, in part, responsible. Increasing specialisa. tion has widened the gap between specialist and " generalist ", between hospital and family doctor; and a gap, largely due to mutual unfounded suspicion and misunderstanding, has always existed between the family doctor and the local-authority services. Both these rifts could and should be closed by reorganisation and good will. The general practitioner should be made to feel that he " belongs " in his local hospital; he should have free access to the diagnostic departments on behalf of his patients; and he should have the right to visit any that are admitted -not to interfere with their treatment, but rather to learn of their progress and to supply background information. He should be welcome to attend wardrounds and be given the freedom of the hospital library for reference. The hospital should feel itself under strong moral obligation to inform the family doctor very promptly, by either letter or telephone, of the hospital’s findings, especially when one of his patients is being discharged. In return, the family doctor should be at pains to provide full notes on all patients referred to hospital and to supply further information when requested. This is the happy state of affairs in some hospitals, but in all too few. On the public-health side, more could be done to foster a personal relation between the family doctor and the health visitor, who can be a most valuable ally. The question has sometimes been asked whether, in modern medicine, there is a place for general practice at all. Certainly, in the United States, the number of general practitioners per head of population is fast declining. In some cities domiciliary medical care is based on the hospital and conducted by a team of specialists: in others, under a prepayment scheme, preventive and curative medical care is given by a team of general practitioners and specialists who work together under one roof and pool knowledge, equipment, and income. Americans tend to be much more specialist-conscious than we in this country; but our tendency to ape the American way of life may yet lead to greater specialist-consciousness in the National Health Service. At present, general practice and specialist practice are regarded as two distinct interdependent disciplines, one based on the home and the other on the hospital. The Cohen Committee, at least, held the family doctor to be irreplaceable and concluded thatonly general practice can ensure that the patient is treated both as an individual and in relation to his family background and environment and it alone provides for continuity of treatment at all times by one doctor ".
that the
quality
of
supportive service outweighs
quantity.
its
One point the conference made clear. Knowledge, technique, and apparatus exist which could be applied to the relief, comfort, and reablement of the chronically sick and crippled and their families. But the possibilities
sufficiently widely known : even when help is available, it may be neither sought nor given. The conference reached no general agreement on the critical question of whose duty and function it was to bring assistance to those who need it and to synthesise the services provided. Once again, the family doctor was called the keystone. But keystones are static.. Could it be that a more dynamic title and conception might make effective convenors and directors of effort commoner than they appear at present ? are not
UNDULANT FEVER
COOPERATION in research between others is advised more often than it is on brucellosis in man and animals
our profession and practised. A report compiled by three hygienists, a family doctor, and aveterinary surgeon shows what can be done by enthusiasm and good wilLI For some years this team examined in detail the circumstances under
which all known human infections occurred in South Oxfordshire 2; and now, taking into account what is known of the prevalence of the disease in the country as a whole, has made suggestions for its eradication. Even if the measures proposed did not fulfil this ambition they would add a lot to our knowledge. One such measure is general compulsory notification of the disease in man. The essentials of useful notification are speed and exact definition and diagnosis. For most infectious diseases this means unequivocal confirmation by the laboratory, and it " weekly may be that for undulant fever the unofficial " summary of the Public Health Laboratory Service gives a more accurate picture than could be obtained by notification under the Public Health Act, 1936. Some local authorities which made undulant fever notifiable under this Act have allowed their powers to lapse. Notification of animal infections to public-health authorities raises more difficult problems. It would probably prevent some further human infections but not very many : undulant fever is rarely epidemic. Moreover brucellosis is not the only cause of abortion in the cow, and by no means every aborting cow is seen by a veterinary surgeon : infectious disease in animals has financial implications which might make the owner unwilling to ask for veterinary advice. Compulsory slaughter of infected animals (with compensation) is a method of eradicating the disease which has worked well in countries where the incidence is low. Applied here and now, it would ruin the dairy industry and nearly bankrupt the Treasury; but it is the method of choice when other measures of control-notably vaccination—have reduced the incidence far below its present level. The comments of this report on compulsory pasteurisation orders are much to the point. The official view is that serological evidence of infection of bulked milk or of a single cow is by itself insufficient to justify such an order. The report on a biological test is often too late to be of value, but it is a pity that more laboratories do not use Mair’s cultural method for isolation.3 It is equally important that the criteria for removing an order for pasteurisation should be defined explicitly. 1
Bothwell, P. W., McDiarmid, A., Bartram, H. G., Mackenzie-Wintle, H. A., Williamson, A. R. H. Vet. Rec. Oct. 13, 1962, p. 1091. 2. Bothwell, P. W. Med. Offr, 1960, 103, 7, 85. 3. Mair, N. S.
Mon. Bull. Minist. Hlth Lab. Serv. 1955, 14, 184.
The authors of this report are unfortunate in that it is still too early to see what will be the effect of the Ministry of Agriculture’s new policy on brucellosis, or to learn the final figures for the survey of infection in dairy herds. Free vaccination with S.19 vaccine is now offered for all calves, and this may reduce the incidence of the disease to a point where more vigorous measures will be feasible. We hear that so far the response to this offer has been disappointing. That the only figures which we have for the proportion of milk, of herds, and of cows which are infected are based on intelligent guesses is an indication of our ignorance about this disease. We do not know for certain how infection is commonly passed from cow to cow; we only know how it may be passed. Recent work by Kerr and his colleaguesin Northern Ireland has demonstrated the unsuspected importance of infection limited to the udder with no or very little antibodies in the blood. This not only emphasises the dangers of intermittent excretion but gives reasonable grounds for preferring the " ring test " on milk to the classical agglutination reaction on serum. We can again only guess at the proportion of human infections derived from milk. The cowman who is infected from the products of conception of an infected cow will, almost surely, be a constant drinker of infected milk. His children, curiously enough, seldom seem to have the disease. Though 10% of our raw milk is infected, we see only 100-200 cases each year in England and Wales; and an inquiry into the reasons why we escape infection might be rewarding. A patient with undulant fever is usually subjected to close questioning on his habits: we suggest that the same procedure should be applied (together with serological examination) to every other member of the household. We do not know the infectious dose of Brucella abortus by mouth. Those whose infections are undoubtedly milkborne will sometimes admit that they are addicted to milk as others are to beer. Milk taken in tea, on the other hand, is usually raised to a bactericidal temperature. Brucellosis is primarily an agricultural problem, and until the incidence of the disease in both dairy and beef cattle is reduced far below its present level human infections will occur.
THE FAMILY DOCTOR
THE young medical
graduate, on leaving hospital and entering general practice, very soon learns that most of the patients he is now called on to treat are very different from those he has seen in hospital and on whom his medical education has been based. They do not fall into fairly clear-cut categories, as he has been led to expect; many present the vaguest of symptoms; and recognisable abnormal physical signs are often absent. Many of these people are seeking sympathy, understanding, and reassurance rather than " cure "; but they need the doctor’s help nonetheless-help which he, at first, feels powerless to give. Specialisation in medicine has increased pari passu with increase in scientific knowledge. The young doctor has been taught by specialists and examined by specialists, many of whom, nowadays, have had little or no experience of general practice; and he has left hospital with more than a smattering of scientific knowledge. But the practice of medicine is an art based on science; and the more the science progresses the greater is the danger of the art being forgotten. At the same time, as medicine becomes more complex, so the patient’s need for a real family physician 4.
Kerr,
W. R. Vet. Rec. 1960,
72, 921.
924 increases. He needs a physician who will look after the whole man, see him against the background of his family, his home, and his work, interpret him to a consultant when necessary, and the consultant to him, and generally accept responsibility for his continuous medical care. How these needs can best be met was discussed at an international conference on the Organisation of Family Doctor Care which was held in London on Oct. 22-26 under the xgis of the Medical World. Over 200 delegates attended from twenty-four different countries. Hospital medicine has been the subject of much study, research, and reorganisation.. As a result, the specialist has attained a high level of proficiency and has gained much prestige. But little more than lip-service has been paid to medicine outside the hospitals: it has been allowed to drift without organisation, and very little attempt has been made to teach the would-be general practitioner what his job is and how he should do it. A qualifying degree or diploma has been assumed to be all that he needs, and he has had to find his own way and learn largely by trial and error. Moreover, in some parts of the country, family medicine is practised under conditions which differ little from those obtaining at the turn of the century. All too often, the general practitioner is being expected to do a 20th-century job in a 19th-century setting. The broad limits of a family doctor’s job need to be defined, and his training adapted accordingly. Since much of his work lies in the province of internal medicine, including paediatrics and geriatrics, he should have sound knowledge of general medicine and understanding of epidemiology, hygiene, and social science. The personal health services at present carried out by the local authority (antenatal and postnatal care, infant welfare, nutrition, immunisation, individual health education) could well form part of family practice. And surely family planning should come within the ambit of the family doctor ? In addition, since so much psychosomatic and frank mental illness will come before him, he should have had more than an elementary training in psychiatry. These ideas led straight to a consideration of medical
education-undergraduate and postgraduate. If the family doctor’s job were defined on these or other lines, some rearrangement of the curriculum would seem to be indicated. Indeed, every medical graduate, whatever his plans for the future, would doubtless profit from a period spent in general practice as an apprentice to a senior family doctor. Some countries have evolved a higher qualification in general practice, the possession of which entitles the holder to greater remuneration and enhances his prestige. In Yugoslavia, the postgraduate training course for this qualification is spread over thirty-six months: six of these are occupied in full-time attendance at the medical school, and the remainder in part-time inservice training-three hours three times a week. Those who pass an examination at the end of this course acquire the degree of master of general medicine. In Israel a similar course lasts for four years: the requirements for registration as a specialist in family medicine are " an M.D. degree from a recognised medical school, one year’s rotating internship in a teaching hospital, two years’ apprenticeship with a recognised family practitioner, and one year’s formal training in public health, social science, and psychiatry ". Developing countries-despite the enormous difficulty of their task-are, in some ways, in a better position than we are to are
organise comprehensive family-doctor
care.
They
uninhibited by the old traditions of practice which are,
ways, obstacles to our own further progress. In a developing country the family doctor must be all things to all men. He must have diagnostic skill and know his
in
some
limitations; and he must be able to teach his patients about infectious disease, hygiene, family planning, nutrition, maternal and child welfare, and the care of the sick. Indeed, in primitive villages, he must use his diagnostic and therapeutic ability to gain the confidence of the community so that they may be receptive of his teaching of the elementary rules of hygiene. In this setting there is no distinction between preventive and curative medicine. The distinction which has grown up between them in this and other " developed " countries is meaningless and absurd today; the family doctor should play his full part in the preventive personal services. Much of the present dissatisfaction and frustration of the general practitioner in this country stems from the tripartite nature of the National Health Service-hospital, general practitioner, and public-health services-a triptych for which our own profession is, in part, responsible. Increasing specialisa. tion has widened the gap between specialist and " generalist ", between hospital and family doctor; and a gap, largely due to mutual unfounded suspicion and misunderstanding, has always existed between the family doctor and the local-authority services. Both these rifts could and should be closed by reorganisation and good will. The general practitioner should be made to feel that he " belongs " in his local hospital; he should have free access to the diagnostic departments on behalf of his patients; and he should have the right to visit any that are admitted -not to interfere with their treatment, but rather to learn of their progress and to supply background information. He should be welcome to attend wardrounds and be given the freedom of the hospital library for reference. The hospital should feel itself under strong moral obligation to inform the family doctor very promptly, by either letter or telephone, of the hospital’s findings, especially when one of his patients is being discharged. In return, the family doctor should be at pains to provide full notes on all patients referred to hospital and to supply further information when requested. This is the happy state of affairs in some hospitals, but in all too few. On the public-health side, more could be done to foster a personal relation between the family doctor and the health visitor, who can be a most valuable ally. The question has sometimes been asked whether, in modern medicine, there is a place for general practice at all. Certainly, in the United States, the number of general practitioners per head of population is fast declining. In some cities domiciliary medical care is based on the hospital and conducted by a team of specialists: in others, under a prepayment scheme, preventive and curative medical care is given by a team of general practitioners and specialists who work together under one roof and pool knowledge, equipment, and income. Americans tend to be much more specialist-conscious than we in this country; but our tendency to ape the American way of life may yet lead to greater specialist-consciousness in the National Health Service. At present, general practice and specialist practice are regarded as two distinct interdependent disciplines, one based on the home and the other on the hospital. The Cohen Committee, at least, held the family doctor to be irreplaceable and concluded thatonly general practice can ensure that the patient is treated both as an individual and in relation to his family background and environment and it alone provides for continuity of treatment at all times by one doctor ".