- Email: [email protected]
The primary care physician: Issues in distribution
BOOK
REVIEWS
A~c~~~~, ~~JIM ORFORD and GRW~TN EDWARDS Institute of Psvchiatrv. Maudsfev Monogranbs No. 26, Oxford University Press, 1977. f75 in, f7.56 ^
The fact that we have had to wait untii number 26 in this prestigious series from the Institute of Psychiatry for a research monograph on ~~~~01~s~ is an accurate reflection on the position of afe~ofism in the league table of psychiatric concerns. Now it has arrived, was the book worth waiting for? And does it in any way explain why alcoholism has been such an nnf~bj~~abie speciafity? The answer to both these questions is yes. For the past twenty five years the alcoholism field has been bedevilfed, even more than most other medical and psychiatric specialities, by blind prejudice masquerading as received truths and by attempts to outlaw research findings and therapeutic propositions which do not square with the conventional wisdom. Typical of this has’been the howls of outrage in the United States over several recent attempts to operate therapeutic regimes with “controfled drinking” as the outcome goal. In Great Britain the conventional wisdom has been, simifarfy, that no “real” alcoholic could possibfy drink in a “normal” way again and. certainty since the ~pa~ment of Health’s letter of advice in 1962, that the pface to persuade alcoholics of the necessity for a new drink-free fife was in group therapy in smaff speciafised in-patient units. Quite apart from its therapeutic worth the administrative poverty of this approach can be seen from the fact that by the mid 1970s England and Wales had in-patient specialist facilities for some three hundred people at a time when, at a conservative estimate, there were 500,000 people with some kind of severe alcohol-related problem. It was against this kind of background that Orford and Edwards carried out their treatment triaf. They randomly assigned one hundred married male alcoholics to either a “treatment” or an “advice* group. Those in the treatment group were given an initial eounselfing session, offered an introdu~ion to AA, offered a preemption, of titrated cat cium carbimide, and prescribed drugs to cover ~thdraw~. All patients were given an appointment to see a psychiatrig and aff wives were given an appointment to see the team social worker. A ~~tinu~~g treatment programme was drawn up beginning on an out-patient basis with an emphasis on strategies for abstenance, reality problems and interpersonal interactions. In-patient facilities Were avaifabfe if needed, plus social support for employment, housing. financial and Iegaf problems. Other agencies were cooperated with; there was regular follow up for the patient and social work support for the wife and family; missed appointments were checked on and all in all the regime was as near as possible to the Department of Heafth’s view about the total alcoholism treatment package which should ideally be avaifable. The advice group, on the other hand, were told “in sympathetic and constructive terms” at the initial session that r~ponsibifity for their condition lay in their own hands. No further appointments were given and monthfy caffs from the social worker were merely for a report on progress to be made. Anyone familiar with treatment trials in relation to any psyrho-sociaf problem will not be surprised to learn from Qrfard and Edwards that at the twelve month follow-up there was. broadfy speaking, no difference between the treatment group and the advice group. In terms of drinking behaviour. subjective rating of the severity of the drinking
problem, social adjustment and “trouble” scores, there were no significant between-group differences. At twenty four months there were as many people with “good” outcomes, in social, marital, economic terms, who were drinking in a controlied way as were abstinent, ap proximately i@- IS”/, in each case. This contrasts, of course. with most alcohohsm studies which. bv definition. exclude from their good outcome category anyone who is drinking at aif. The key question, however, is who can drink in .a controffed way and who cannot, and how can we identify them at the outset. This book raises the question again but does not enable us to answer it. AIcoholi.sm will form part of the current debate about the m-ordering of priorities in the afcohofism services. As the authors say, there is little justification for creating yet more special&d in-patient units. Ethicaffy it was impossible for the authors to include a genuinely nn-treatment group in the design of their study. I have little doubt, however, that there would have been no significant betweengroup differences there either. In sum, t&s book reports a study which needed to be done. It ought to make all those in the alcoholism treatment world think very seriously about their therapeutic strategies and goals, By being such a simple and obvious study, which should have been done a generation ago, it highlights the sad state of the art of alcoholism treatment.
Tlte Primary Cnre Physician: Issues in ~~tri~ti~ by Jaas E. C. WALKERand NORMAN L. ARMONDINO. Connecticut Health Services Research Series No. 7. 1977. f21 pp f7.50 In I974 the Primary Care Task Force of the Connecticut Commission on Hospitals and Health Care set out to determine the need for primary care physician in Connecticut. This monograph provides in rn~~~ulous detail the findings and conclusions of the Task Force. In 121 pages. Walker and Armondino pack 62 tabfes, nine figures and 30 pages of appendices, on the basis of which they conclude that: (1) There was not a shortage in the number of prfmary care physicians in Connecticut in 1974, (2) There was a relative shortage of adult primary care pbysiciam, and (3) There was geographical mald~tribution of” primary care physicians. The Task Force method of calculating available primary care physicians used the ratio of population to primary care physicians as its benchmark. First, the amounts of time devoted to primary care by the three designa{ed primary care specialties (internat medicine, pediatrics. and ge~ral/famify practice) were determined to calculate the num~r of full time equivalent primary care physicians jn each specialty. Next, population to physician ratios were cafeufated for both children and adults in each of Connecticut’s tive Health Service Areas and i69 towns. Fin&y, the adequacy of this supply was determined by calculating the need for primary care physicians, according to’an es& mated average of 2.7 primary care visits per year by adults and 2.2 by children and an lverage of 22 patients seen per day per physician. The Task Force then determine whether the primary care physician supply was adequate to meet this demand, 195
196
Book reviews
The most important of the Task Force findings includes the fact that. on average. general,‘family practitioners spend 880, of their time in primary care. compared with 63”” for internists, and 66”” for pediatricians. Based on this data, in 1974 there were only 25 too few primary care physicians in the state. However. geographical maldistribution was severe, the authors contend. since there were 97 shortage towns, 14 surplus towns. and 58 towns with an adequate supply of primary care physicians. There was a state-wide surplus of pediatric primary care of 60 full-time equivalents. In contrast, in adult medicine there was a deficit of 97 full time equivalents. Only in New Haven was there a surplus of adult primary care practitioners. Considering population changes and expected losses and gains of physicians between 1974 and 1980. the Task Force concludes that there will be a relative 130/;, decrease in the physician-population ratio by 1980. Its recommendation is that primary care residency positions be increased in Connecticut, in particular training positions in family practice and primary care training of internists. While the dedication to a microanalysis of manpower needs in Connecticut deserves plaudit. there are a number of important biases which raise questions about the validity of the authors’ conclusions. Most important are several aspects of the analysis by specialty groups. As the authors suggest. older and rural doctors generally spend more time in primary care regardless of specialty. Since general practitioners are more heavily rural and are, on average, approximately ten years older than internists. the authors cannot justify their conclusion that general practitioners spend more time in primary care than internists and pediatricians, without an analysis of covariance which accounts for the confounding variables of age and location. This absence of statistical analysis plagues the entire monograph, and is exemplified by the table and figure which show small differences between the specialties in the average number of hours spent per week in primary care. The smal! differences were not subjected to analysis of the difference of their means. much less of covariance; but the authors nevertheless conclude that the differences are important. An important bias is also introduced by calculating statewide averages for the proportion of time spent in primary care by specialty. These statewide averages, which are higher than those in New Haven and Hartford, are nevertheless applied to internists in these cities, which have as many as 40”/, pure subspecialists. and therefore artifactually increase the apparent supply of primary care internists and pediatricians in the cities. Still another bias is introduced which provides the appearance of relatively less time being spent in primary care by practicing internists and pediatricians statewide. Of the responding internists, 22% were on medical school faculty, whereas 26% of pediatricians were faculty. In a small state such as Connecticut, the influence of two medical schools can be important on the apparent patterns of practice, particularly since no family practice residencies existed in the state as of 1973. Therefore family practitioners were probably less likely to spend time teaching than they do now and certainly less than the other primary care specialists. Another bias introduced by the teaching hospitals is the role of residents who are credited in this study with being as efficient and productive per hour as the practicing physician. This bias may increase the apparent supply of primary care physicians somewhat. An important assumption made by the authors is that general practitioners and family physicians can be pooled as a common group of primary care physicians. Without evidence to support this assumption and with the knowledge that recent graduates of family practice residencies receive trainingmore similar to that of their internal meditine and pediatric counterparts than to that of the general practitioner, the assumption seems invalid. To assume that
new family physicians will replicate the old general practitioner in practice patterns is an UnJustified leap of hith. Indeed. the two groups should be clearly delineated in future manpower studies. Furthermore. the increase in subspecialized training in internal medicine and pediatrics during the past twenty years have produced two decades of subspecialty oriented physicians. As the older. more general physicians leave practice. the necessity for changes in internal medicine and pediatric manpower towards more generalis? become more pressing. It is unclear why the authors recommend. in the face of a surplus of pediatric primary care. that preference be shown to family practice training while they demonstrate that family physicians spend about a quarter of their time caring for children. The authors’ analysis of manpower by town. while discounting the feasibility of patients travelling to a neighboring town for care, overestimates the problem of geographlcal maldistribution. Only in eastern Connecticut. where large areas of deficit manpower exist. does maldistributlon by location seem important. Furthermore. since 77”,, of Connecticut’s population was urban during the study. the rural maldistribution problem can be easily overstated. Other serious questions with the accuracy of the data ace raised by the unavailability of data on doctors spending more than 48 hours per week in primary care and the need to turn to American Medical Association data as a substitute, by the omission of Obstetrics and Gynecology as an important source of primary care for young women, by the questionable inclusion of time spent by practicing physicians in emergency rooms as primary care time, and by the omission of non-physicians as primary care practitioners. This monograph represents an important effort at the microanalysis of manpower needs as a tool for health planners, but its conclusions regarding the need for primary care physicians, and especially its distribution by specialty, are based upon too many questionable assumptions and unvalidated. untested data to allow planners to rely upon them without serious reservations.
Sec”on of Generul Medicine Unioersiry of Penmylcaniu Philadelphia, PA, U.S.A.
JOHN M. EISENBERC~
!Social Change in the Development of the Nursing Profession: A Study of the Poor Law, Nursing Service, and 1848-1948, by ROSEMARY WHITE. Henry Kimpton, London, 1978. 243 pp. 86.80 From the perspective of societal changes in England between 1848 and 1948, White describes vividly the emergence of professional nursing through a century of transition. Her particular focus is on the study of the Poor Law nurses, a group which has received too little acclaim in the annals of nursing history. White’s account or these nurses also encompasses health legislation, a review of public and private health ca;e delivery systems, and the impact of individuals, institutions, and ideologies. She credits the Poor Law nurses with preserving many enduring values so vital to the nature of contemporary nursing: the maintenance of the caring function; quality assurance in practice and educational programs; autonomy in practice by refusing to “accept dominance of lay masters and continuity of care between institutions and matrons”; homes; the interdependence between medicine and nursing to assure standards of care; and a real commitment to the patient.
REVIEWS
A~c~~~~, ~~JIM ORFORD and GRW~TN EDWARDS Institute of Psvchiatrv. Maudsfev Monogranbs No. 26, Oxford University Press, 1977. f75 in, f7.56 ^
The fact that we have had to wait untii number 26 in this prestigious series from the Institute of Psychiatry for a research monograph on ~~~~01~s~ is an accurate reflection on the position of afe~ofism in the league table of psychiatric concerns. Now it has arrived, was the book worth waiting for? And does it in any way explain why alcoholism has been such an nnf~bj~~abie speciafity? The answer to both these questions is yes. For the past twenty five years the alcoholism field has been bedevilfed, even more than most other medical and psychiatric specialities, by blind prejudice masquerading as received truths and by attempts to outlaw research findings and therapeutic propositions which do not square with the conventional wisdom. Typical of this has’been the howls of outrage in the United States over several recent attempts to operate therapeutic regimes with “controfled drinking” as the outcome goal. In Great Britain the conventional wisdom has been, simifarfy, that no “real” alcoholic could possibfy drink in a “normal” way again and. certainty since the ~pa~ment of Health’s letter of advice in 1962, that the pface to persuade alcoholics of the necessity for a new drink-free fife was in group therapy in smaff speciafised in-patient units. Quite apart from its therapeutic worth the administrative poverty of this approach can be seen from the fact that by the mid 1970s England and Wales had in-patient specialist facilities for some three hundred people at a time when, at a conservative estimate, there were 500,000 people with some kind of severe alcohol-related problem. It was against this kind of background that Orford and Edwards carried out their treatment triaf. They randomly assigned one hundred married male alcoholics to either a “treatment” or an “advice* group. Those in the treatment group were given an initial eounselfing session, offered an introdu~ion to AA, offered a preemption, of titrated cat cium carbimide, and prescribed drugs to cover ~thdraw~. All patients were given an appointment to see a psychiatrig and aff wives were given an appointment to see the team social worker. A ~~tinu~~g treatment programme was drawn up beginning on an out-patient basis with an emphasis on strategies for abstenance, reality problems and interpersonal interactions. In-patient facilities Were avaifabfe if needed, plus social support for employment, housing. financial and Iegaf problems. Other agencies were cooperated with; there was regular follow up for the patient and social work support for the wife and family; missed appointments were checked on and all in all the regime was as near as possible to the Department of Heafth’s view about the total alcoholism treatment package which should ideally be avaifable. The advice group, on the other hand, were told “in sympathetic and constructive terms” at the initial session that r~ponsibifity for their condition lay in their own hands. No further appointments were given and monthfy caffs from the social worker were merely for a report on progress to be made. Anyone familiar with treatment trials in relation to any psyrho-sociaf problem will not be surprised to learn from Qrfard and Edwards that at the twelve month follow-up there was. broadfy speaking, no difference between the treatment group and the advice group. In terms of drinking behaviour. subjective rating of the severity of the drinking
problem, social adjustment and “trouble” scores, there were no significant between-group differences. At twenty four months there were as many people with “good” outcomes, in social, marital, economic terms, who were drinking in a controlied way as were abstinent, ap proximately i@- IS”/, in each case. This contrasts, of course. with most alcohohsm studies which. bv definition. exclude from their good outcome category anyone who is drinking at aif. The key question, however, is who can drink in .a controffed way and who cannot, and how can we identify them at the outset. This book raises the question again but does not enable us to answer it. AIcoholi.sm will form part of the current debate about the m-ordering of priorities in the afcohofism services. As the authors say, there is little justification for creating yet more special&d in-patient units. Ethicaffy it was impossible for the authors to include a genuinely nn-treatment group in the design of their study. I have little doubt, however, that there would have been no significant betweengroup differences there either. In sum, t&s book reports a study which needed to be done. It ought to make all those in the alcoholism treatment world think very seriously about their therapeutic strategies and goals, By being such a simple and obvious study, which should have been done a generation ago, it highlights the sad state of the art of alcoholism treatment.
Tlte Primary Cnre Physician: Issues in ~~tri~ti~ by Jaas E. C. WALKERand NORMAN L. ARMONDINO. Connecticut Health Services Research Series No. 7. 1977. f21 pp f7.50 In I974 the Primary Care Task Force of the Connecticut Commission on Hospitals and Health Care set out to determine the need for primary care physician in Connecticut. This monograph provides in rn~~~ulous detail the findings and conclusions of the Task Force. In 121 pages. Walker and Armondino pack 62 tabfes, nine figures and 30 pages of appendices, on the basis of which they conclude that: (1) There was not a shortage in the number of prfmary care physicians in Connecticut in 1974, (2) There was a relative shortage of adult primary care pbysiciam, and (3) There was geographical mald~tribution of” primary care physicians. The Task Force method of calculating available primary care physicians used the ratio of population to primary care physicians as its benchmark. First, the amounts of time devoted to primary care by the three designa{ed primary care specialties (internat medicine, pediatrics. and ge~ral/famify practice) were determined to calculate the num~r of full time equivalent primary care physicians jn each specialty. Next, population to physician ratios were cafeufated for both children and adults in each of Connecticut’s tive Health Service Areas and i69 towns. Fin&y, the adequacy of this supply was determined by calculating the need for primary care physicians, according to’an es& mated average of 2.7 primary care visits per year by adults and 2.2 by children and an lverage of 22 patients seen per day per physician. The Task Force then determine whether the primary care physician supply was adequate to meet this demand, 195
196
Book reviews
The most important of the Task Force findings includes the fact that. on average. general,‘family practitioners spend 880, of their time in primary care. compared with 63”” for internists, and 66”” for pediatricians. Based on this data, in 1974 there were only 25 too few primary care physicians in the state. However. geographical maldistribution was severe, the authors contend. since there were 97 shortage towns, 14 surplus towns. and 58 towns with an adequate supply of primary care physicians. There was a state-wide surplus of pediatric primary care of 60 full-time equivalents. In contrast, in adult medicine there was a deficit of 97 full time equivalents. Only in New Haven was there a surplus of adult primary care practitioners. Considering population changes and expected losses and gains of physicians between 1974 and 1980. the Task Force concludes that there will be a relative 130/;, decrease in the physician-population ratio by 1980. Its recommendation is that primary care residency positions be increased in Connecticut, in particular training positions in family practice and primary care training of internists. While the dedication to a microanalysis of manpower needs in Connecticut deserves plaudit. there are a number of important biases which raise questions about the validity of the authors’ conclusions. Most important are several aspects of the analysis by specialty groups. As the authors suggest. older and rural doctors generally spend more time in primary care regardless of specialty. Since general practitioners are more heavily rural and are, on average, approximately ten years older than internists. the authors cannot justify their conclusion that general practitioners spend more time in primary care than internists and pediatricians, without an analysis of covariance which accounts for the confounding variables of age and location. This absence of statistical analysis plagues the entire monograph, and is exemplified by the table and figure which show small differences between the specialties in the average number of hours spent per week in primary care. The smal! differences were not subjected to analysis of the difference of their means. much less of covariance; but the authors nevertheless conclude that the differences are important. An important bias is also introduced by calculating statewide averages for the proportion of time spent in primary care by specialty. These statewide averages, which are higher than those in New Haven and Hartford, are nevertheless applied to internists in these cities, which have as many as 40”/, pure subspecialists. and therefore artifactually increase the apparent supply of primary care internists and pediatricians in the cities. Still another bias is introduced which provides the appearance of relatively less time being spent in primary care by practicing internists and pediatricians statewide. Of the responding internists, 22% were on medical school faculty, whereas 26% of pediatricians were faculty. In a small state such as Connecticut, the influence of two medical schools can be important on the apparent patterns of practice, particularly since no family practice residencies existed in the state as of 1973. Therefore family practitioners were probably less likely to spend time teaching than they do now and certainly less than the other primary care specialists. Another bias introduced by the teaching hospitals is the role of residents who are credited in this study with being as efficient and productive per hour as the practicing physician. This bias may increase the apparent supply of primary care physicians somewhat. An important assumption made by the authors is that general practitioners and family physicians can be pooled as a common group of primary care physicians. Without evidence to support this assumption and with the knowledge that recent graduates of family practice residencies receive trainingmore similar to that of their internal meditine and pediatric counterparts than to that of the general practitioner, the assumption seems invalid. To assume that
new family physicians will replicate the old general practitioner in practice patterns is an UnJustified leap of hith. Indeed. the two groups should be clearly delineated in future manpower studies. Furthermore. the increase in subspecialized training in internal medicine and pediatrics during the past twenty years have produced two decades of subspecialty oriented physicians. As the older. more general physicians leave practice. the necessity for changes in internal medicine and pediatric manpower towards more generalis? become more pressing. It is unclear why the authors recommend. in the face of a surplus of pediatric primary care. that preference be shown to family practice training while they demonstrate that family physicians spend about a quarter of their time caring for children. The authors’ analysis of manpower by town. while discounting the feasibility of patients travelling to a neighboring town for care, overestimates the problem of geographlcal maldistribution. Only in eastern Connecticut. where large areas of deficit manpower exist. does maldistributlon by location seem important. Furthermore. since 77”,, of Connecticut’s population was urban during the study. the rural maldistribution problem can be easily overstated. Other serious questions with the accuracy of the data ace raised by the unavailability of data on doctors spending more than 48 hours per week in primary care and the need to turn to American Medical Association data as a substitute, by the omission of Obstetrics and Gynecology as an important source of primary care for young women, by the questionable inclusion of time spent by practicing physicians in emergency rooms as primary care time, and by the omission of non-physicians as primary care practitioners. This monograph represents an important effort at the microanalysis of manpower needs as a tool for health planners, but its conclusions regarding the need for primary care physicians, and especially its distribution by specialty, are based upon too many questionable assumptions and unvalidated. untested data to allow planners to rely upon them without serious reservations.
Sec”on of Generul Medicine Unioersiry of Penmylcaniu Philadelphia, PA, U.S.A.
JOHN M. EISENBERC~
!Social Change in the Development of the Nursing Profession: A Study of the Poor Law, Nursing Service, and 1848-1948, by ROSEMARY WHITE. Henry Kimpton, London, 1978. 243 pp. 86.80 From the perspective of societal changes in England between 1848 and 1948, White describes vividly the emergence of professional nursing through a century of transition. Her particular focus is on the study of the Poor Law nurses, a group which has received too little acclaim in the annals of nursing history. White’s account or these nurses also encompasses health legislation, a review of public and private health ca;e delivery systems, and the impact of individuals, institutions, and ideologies. She credits the Poor Law nurses with preserving many enduring values so vital to the nature of contemporary nursing: the maintenance of the caring function; quality assurance in practice and educational programs; autonomy in practice by refusing to “accept dominance of lay masters and continuity of care between institutions and matrons”; homes; the interdependence between medicine and nursing to assure standards of care; and a real commitment to the patient.