- Email: [email protected]
THE WORK OF THE FAMILY DOCTOR
727
Special
Articles
more
than
ever
resources
THE WORK OF THE FAMILY DOCTOR IN 1961 a subcommittee of the Standing Medical Advisory Committee was set up under the chairmanship of Dr. Annis Gillie to study the future scope of general practice. It was to suggest what the family doctor should be doing over the next ten to fifteen years, how his work should be organised, and how it should be related to that of the other branches of the Health Service. The report of its findings has been issued this week.1 DATA
The general practitioner, says the report, evolved in the first instance because he was found to be necessary. Over the past hundred years, although medicine has changed radically, his role has been recognisably the same-the provision of continuous personal care for his patients. That this tradition is valuable the subcommittee accepts; but it points out that, although there have been other bodies set up to study alternative ways of providing this care, objective data about the possibilities are still scarce. Its own assessment of the present position has been necessarily subjective, based on written and oral evidence given by individuals and organisations, and on visits to group practices, health centres, and hospital departments. The subcommittee does not consider its conclusions therefore the less valid, but it believes the time ripe for operational research in general practice comparable to that undertaken in the hospital service as a prelude to the Hospital Plan.22 It does not see its report as the last word on the subject. PRESENT
dependent on the hospital’s technological diagnosis and treatment. He needs to maintain close personal contact with all members of the hospital and local-authority services in the neighbourhood if he is to be able to interpret these services in his patient’s interest; but for this he may have little time or opportunity. Financially, too, he is at a disadvantage. Remuneration of the family doctor was outside the subcommittee’s terms of reference, but the present system is fundamental to much of the dissatisfaction. A high standard of doctoring is often incompatible with financial security, and there is no inducement to a practitioner-beyond his professional conscience-to improve his premises or equipment. Salary scales also suggest that, in official eyes, if a hospital consultant is a first-class doctor, an experienced general practitioner is not. time,
DISCONTENT
The present position of the general practitioner, says the report, is paradoxical. Greater demands are being made on him than ever before: thanks to medical advance, the aged and less physically fit survive and require continuous medical support; social improvements have facilitated nursing in the home; the mentally sick are, increasingly, to be cared for in the community; early discharge from hospital after surgery throws the responsibility for convalescence on the family doctor; and a better educated public asks more of medicine and more often. At the same time, the prestige of the general practitioner is not what it was and the popularity of his calling is declining: where an average of 43 applicants were attracted by each advertised practice vacancy in 1956, only 17 came forward in 1962. Certain difficulties currently encountered by the practitioner were repeatedly brought to the attention of the subcommittee. Because he must work a twenty-four-hour day seven days a week his other social, cultural, and family interests suffer; he feels, besides, isolated from the community he serves, most of whose members now enjoy forty-hour working weeks. His authority, like that of all professional men, has tended to diminish with the rise in the standard of general education, and the increased intrusion of certificates into the doctor-patient relation has dislodged the doctor further from his old pedestal. All these developments tend to undermine his self-confidence. Professionally, too, he may feel diffident in dealing with hospitals, suspecting that even his medical vocabulary has become out-dated. He is, at the same 1. The Field of Work of the Family Doctor: Report of the subcommittee of the Standing Medical Advisory Committee. H.M. Stationery Office, 1963. Pp. 68. 4s. 6d. 2. A Hospital Plan for England and Wales. H.M. Stationery Office, 1962. See Lancet, 1962, i, 197, 202.
for
THE
SCOPE
OF
WORK
The patient’s first line of defence against illness and disability is his own doctor, and as many as 90% of medical episodes are thought to be dealt with solely by the general practitioner. In the other 10% of instances, the practitioner is "the essential intermediary in the transmission of specialised skills to the individual ". He is
also best fitted to mobilise the resources of the welfare services on his patient’s behalf-a task of importance in the care of the increasing numbers of old people. The family doctor must be able to detect, among apparent trivialities, the first symptoms of serious physical or mental illness, or underlying and possibly unrelated anxiety. Even the routine of supplying a certificate may be medically significant since need for the certificate may bring a patient to his doctor where nothing else would. " In rehabilitation, convalescence, and resettlement," says the report, " greater use of the family doctor could and should be made." His is the task of reconciling a patient and his family to chronic disability and of providing tactful information and support in cases of progressive and incurable illness. He is responsible, too, for the maintenance of health as well as for the treatment of illness; and he is well placed to pinpoint individuals at any particular risk and to encourage early preventive measures. In this country he is expected to visit his patient’s home when asked. Home visiting is costly in terms of medical time, but, for lack of factual evidence, the subcommittee can make no recommendation about the best use of this time.
Specialties doctors ... often develop special clinical that are not the direct result of the patient’s interests demands", and this the subcommittee strongly favours. Obstetrics is especially relevant to family practice, and the demand among intending general practitioners for further post-registration experience in obstetrics is increasing. But the number of resident hospital appointments in obstetrics is " grossly inadequate to secure the minimum of six months resident obstetric training for the future general practitioners who want it ". Subsequent maintenance of the practitioner’s obstetric experience through hospital work is equally important, and more refresher courses, clinical assistantships, and staff appointments are needed. Psychiatry intrudes increasingly upon general practice. The practitioner has a heavy responsibility in the early recognition of mental disorder; moreover, many psychotic and mentally subnormal patients are now living in the community and imposing a stress upon their families
" Family
728
which is the doctor’s business to relieve. The report recommends the introduction of normal psychology into the preclinical curriculum, besides a later clerkship in the psychiatric department. More postgraduate courses and seminars in psychiatry, and more part-time appointments for family doctors in psychiatric units, are urgently needed. Since the Mental Health Act is being implemented before local authorities have provided the training-centres, hostels, and psychiatric social workers demanded of them, the current responsibility of the family doctor is especially great; in shouldering it, the mental welfare officer can be his most valuable ally.
Hospitals The report pleads throughout for the introduction of general-practitioner posts in hospitals, both to allow the doctors to develop special interests and to restore the link between hospital and family-doctor services. " The way must be open for a good and determined family doctor to be selected for a hospital staff appointment, either parallel to his work in general practice or whole-time." The introduction of the new " medical assistant " grade of hospital staff should facilitate exchange of doctors between the services. " It should be possible for a family doctor to equip himself by experience and study to diverge from general practice if he chooses.... family doctors should be able to get hospital posts in which they will have the opportunity of becoming qualified for consultant appoint-
ments."
Equally important, says the report, is the provision of general-practitioner beds in hospitals, both for obstetric cases and for cases of acute or chronic illness which could be managed at home but for the lack of adequate nursing. It applauds the Minister’s intention to provide such beds in the new district hospitals, but adds that experience shows that anything more than thirty minutes’ driving distance is likely to prevent the doctor from visiting his
beds regularly. General practitioners
must
have direct
access to
hos-
pital diagnostic departments. In pathology laboratories and X-ray departments where this has been arranged, the volume of work has not, in fact, been swollen by requests for unnecessary investigations as some had feared. In the interests of accuracy, practitioners should also be able to use hospital facilities for necropsy. The subcommittee is agreed that general practitioners should continue to have opportunities for holding postssuch as that of police surgeon-outside the health service. Personal Relations
Many of the report’s recommendations are, in essence, appeals for closer personal contact between members of the medical and auxiliary professions. Requests for help with a livelier response, says the report, if there is an existing basis of acquaintance. It therefore approves the idea of district medical centres as points of social contact. Within a single practice, partners should be careful to meet each other regularly to discuss clinical and organisational problems; and their relations with the mental welfare officer, the probation officer, and the health visitor should be kept in good repair. In some areas, indeed, local-authority field workers are attached to individual practices, and this, the report says, must become general.
meet
Among hospital staff, the consultant tends to be especially remote from the family doctor. Although consultants are probably making more domiciliary visits than ever before, the family doctor now seldom attends the patient at the same time. The true consultation is being
abandoned and its educative and stimulant value is being lost to the practitioner. Simultaneous attendance, says the report, should be reintroduced. Education "
Even now, the newly registered doctor who intends to go into general practice ... may be tempted to take up his future work without any further training " because there is no clearly defined educational path for him to follow. The report suggests that during clinical training every student should, without fail, watch the general practitioner at work and gain some insight into his position in the Health Service. The making of a family doctor should, however, begin only after registration, with supplementary house-officer appointments in, for instance, gynaecology and obstetrics, pxdiatrics, psychiatry, and anaesthetics. Training in attitudes and methods of work is, and must be, given by experienced general practitioners either under the official training scheme or within the framework of an assistantship in general practice. The subcommittee is glad to note an 18% increase in the numbers of trainee general practitioners during 1962. It owns itself impressed by the Nuffield practitioner traineeships which provide for a year of additional hospital experience followed by a year of work divided between general practice, the hospital, and the local-authority services. The doctor completing such a course will tend, says the report, to set up in practice in the neighbourhood where he has already become known; future opportunities for this planned training should therefore be provided where the need for family doctors is greatest. Training can, however, no longer be once and for all. The general practitioner has to maintain an informed interest in new medical developments and the open and inquiring mind with which he started his career. Discussion with other doctors sharpens the wits as does the conduct of research-based, perhaps, on the practice records. The family doctor is well placed to study the epidemiology and natural history of common disorders, and the subcommittee believes that the new university departments of general practice will stimulate this type of activity. The practitioner must, however, be able to set aside time for formal education. Increasingly, says the report, partnership deeds include a clause concerning study leave; and the subcommittee believes that the practitioner should devote at least 5% of his professional time to study. The majority of its members does not think anything is to be gained by statutory provision for time off for holiday or education; but it recommends positive financial inducement, besides the payment of expenses, for attendance at refresher courses. THE
MEANS
TO
THE
END
The sine qua non of the forgoing is time and its most economical use. " The quality of organisation of an individual practice should be reflected in the quantity and quality of the work of the doctors in the practice." Every practice needs secretarial staff to cope with filing, recordkeeping, book-keeping, and typing-duties which can often be shared between several part-time workers. The subcommittee finds that " it requires a partnership of four or more doctors to take full advantage of a full-time and fully qualified practice nurse, while a full-time shorthandtypist secretary is rarely used economically by less than three doctors ". Single-handed practitioners now total only a quarter of all established principals, and the difficulty of finding suitably qualified deputies is perhaps
729
largely responsible. The solution to the problem of time off is being found increasingly in partnership and group practice. These also allow sharing of the cost of equipping and staffing the practice premises: and " the modern doctor ought not to be left to labour alone without help and without modern tools as a cottage industry ". The report welcomes the plan for a General Practice Advisory Service to help doctors over matters such as building materials and storage space in their premises; if the traditional distrust of the practitioner for the regional medical officer could be overcome, the latter could properly supply similar advice. Interest-free loans should be readily available to practitioners for practice improvements, and premises, once equipped, should be fully used. Surgery hours are usually only a few in each day; between them the accommodation could be used by, for instance, local-authority clinics. The subcommittee is unanimous in recommending the intelligent use of an appointment ’
system.
-
CONCLUSION
The subcommittee believes that the family doctor can be rescued from his isolation in the Health Service without any change in the tripartite administrative structure of the service. Some such change might subsequently result from increasing functional unification-unification which the family doctor has unique opportunities of
promoting. THE work of the English defence organisations continued to expand during 1962. MEDICAL DEFENCE UNION
Membership of the Union reached a record 50,000 and in the course of the year, 1 member in 16 wrote asking for advice. The advisory and educative activities of the Union are those which have developed most dramatically. This is reflected in its report for the year.1 The Union has, for instance, in conjuction with the Royal College of Nursing, drawn up a memorandum on the retained surgical swab. 38 actions for negligence on this account were handled by the union in 1962. The document emphasises that a surgeon who relies solely the nurses’ count does not discharge his responsibility: he himself must " take such additional precautions as are reasonable ". Analysis of past incidents shows that factors predisposing to the retention of swabs, packs, or instruments include working under pressure of time, unfamiliarity of nurse or surgeon with the routine of a particular theatre, and change in the theatre personnel during an operation. To guard against this type of accident the surgeon’s cooperation is essential in performing a final check before closure; and he should abandon his conviction that " it can’t happen to me ". on
The Union has also been considering the question of for operative treatment. The wording of many consent current forms, it says, needs revision: whether the " blank cheque " type used by some hospitals would protect the surgeon in the event of an action for assault is consent
doubtful. Since the publication of an article on " human guineapigs ", the Union has repeatedly been asked by practitioners to advise on the use of new forms of treatment.
Nowadays
a doctor is expected to apply the latest treatwhich could reasonably benefit his patient. Whatever the circumstances, says the report, the test is what is reasonable.
ment
obtainable from the Medical Defence Union, Tavistock House South, Tavistock Square, London, W.C.1.
Copies
Society also reports2 excursion into the educative sphere in 1962-namely, the inauguration of a series of lectures on the medicolegal aspects of medical and dental practice. It draws attention once more to the importance which may attach to accurate contemporaneous records in
action for
an
damages:
"
The trial of an action often takes place some years after the giving rise to it, when the memories of the parties and of witnesses may well have become dimmed or less reliable.... The final result of an action ... may depend on the existenceor absence-of an entry made at the time in the patient’s records. If a certain course of treatment is advised which the patient declines to undergo, it is essential to record this fact in the notes." events
The
Society’s report includes an of inaccurate diagnosis. arising
account
of
a
case
out
A man was thrown from his bicycle because of negligence on the part of the local authority’s road-sweeper. He successfully claimed S125 from the authority for his injuries. Subsequently his condition was found to be more serious than had been thought, and he therefore claimed damages for negligence against the hospital which had first treated him and on whose assessment his first claim had been based. The judge disallowed his claim for lost damages since a doctor was not required, when examining a patient, to foresee any question connected with a third party’s liability to that
patient.
THE DEFENCE ORGANISATIONS
1.
MEDICAL PROTECTION SOCIETY
The
In
fully
a second case, allegations of negligence were successrefuted because of conflicting medical opinion.
lorry driver injured his right leg in a road accident. He to hospital, where fractures of the right tibia and third, fourth, and fifth metatarsals were confirmed by X-ray. All wounds were excised and a plaster was applied to the groin. Three weeks later the plaster was changed, the position checked radiologically, and the patient sent home on crutches. Six weeks later he started weight-bearing but immediately felt great pain and returned to the hospital. Dislocation of the hip was diagnosed at once, and subsequently treated by surgery. The man later claimed damages from the hospital, asserting that, for lack of proper examination, treatment of the dislocation had been delayed nine weeks. Experts testified on his behalf that classical signs of the dislocation must have been present on his first admission. The judge, however, preferred the explanation put forward on behalf of the defendant-that, A
was
taken
with fracture of the rim of the acetabulum, an initial transient dislocation had corrected itself but recurred as soon as weightbearing was resumed.
Public Health Anthrax of anthrax in Huddersfield for thirty years were reported this week.3 Of 2 confirmed cases, 1 proved fatal. A 3rd suspected case, a man who is now in the Bradford Isolation Hospital, was said to be not seriously ill. Fellow-workers in the woollen scouring mills, where the infection was contracted, have now been vaccinated, and the Medical Officer of Health for Huddersfield, Dr. William Turner, said that there need be no fear about the spread of the disease. THE first
cases
More
Non-smoking Compartments
London Transport is providing more accommodation for non-smokers on the Underground. For an experimental period 6-coach trains on the Circle Line and the Hammersmith and City Line will have 4 coaches for non-smokers. 2.
are
3.
Copies are obtainable from Street, London, W.1. Guardian, Sept. 30, 1963.
the Medical Protection
Society, 50, Hallam
Special
Articles
more
than
ever
resources
THE WORK OF THE FAMILY DOCTOR IN 1961 a subcommittee of the Standing Medical Advisory Committee was set up under the chairmanship of Dr. Annis Gillie to study the future scope of general practice. It was to suggest what the family doctor should be doing over the next ten to fifteen years, how his work should be organised, and how it should be related to that of the other branches of the Health Service. The report of its findings has been issued this week.1 DATA
The general practitioner, says the report, evolved in the first instance because he was found to be necessary. Over the past hundred years, although medicine has changed radically, his role has been recognisably the same-the provision of continuous personal care for his patients. That this tradition is valuable the subcommittee accepts; but it points out that, although there have been other bodies set up to study alternative ways of providing this care, objective data about the possibilities are still scarce. Its own assessment of the present position has been necessarily subjective, based on written and oral evidence given by individuals and organisations, and on visits to group practices, health centres, and hospital departments. The subcommittee does not consider its conclusions therefore the less valid, but it believes the time ripe for operational research in general practice comparable to that undertaken in the hospital service as a prelude to the Hospital Plan.22 It does not see its report as the last word on the subject. PRESENT
dependent on the hospital’s technological diagnosis and treatment. He needs to maintain close personal contact with all members of the hospital and local-authority services in the neighbourhood if he is to be able to interpret these services in his patient’s interest; but for this he may have little time or opportunity. Financially, too, he is at a disadvantage. Remuneration of the family doctor was outside the subcommittee’s terms of reference, but the present system is fundamental to much of the dissatisfaction. A high standard of doctoring is often incompatible with financial security, and there is no inducement to a practitioner-beyond his professional conscience-to improve his premises or equipment. Salary scales also suggest that, in official eyes, if a hospital consultant is a first-class doctor, an experienced general practitioner is not. time,
DISCONTENT
The present position of the general practitioner, says the report, is paradoxical. Greater demands are being made on him than ever before: thanks to medical advance, the aged and less physically fit survive and require continuous medical support; social improvements have facilitated nursing in the home; the mentally sick are, increasingly, to be cared for in the community; early discharge from hospital after surgery throws the responsibility for convalescence on the family doctor; and a better educated public asks more of medicine and more often. At the same time, the prestige of the general practitioner is not what it was and the popularity of his calling is declining: where an average of 43 applicants were attracted by each advertised practice vacancy in 1956, only 17 came forward in 1962. Certain difficulties currently encountered by the practitioner were repeatedly brought to the attention of the subcommittee. Because he must work a twenty-four-hour day seven days a week his other social, cultural, and family interests suffer; he feels, besides, isolated from the community he serves, most of whose members now enjoy forty-hour working weeks. His authority, like that of all professional men, has tended to diminish with the rise in the standard of general education, and the increased intrusion of certificates into the doctor-patient relation has dislodged the doctor further from his old pedestal. All these developments tend to undermine his self-confidence. Professionally, too, he may feel diffident in dealing with hospitals, suspecting that even his medical vocabulary has become out-dated. He is, at the same 1. The Field of Work of the Family Doctor: Report of the subcommittee of the Standing Medical Advisory Committee. H.M. Stationery Office, 1963. Pp. 68. 4s. 6d. 2. A Hospital Plan for England and Wales. H.M. Stationery Office, 1962. See Lancet, 1962, i, 197, 202.
for
THE
SCOPE
OF
WORK
The patient’s first line of defence against illness and disability is his own doctor, and as many as 90% of medical episodes are thought to be dealt with solely by the general practitioner. In the other 10% of instances, the practitioner is "the essential intermediary in the transmission of specialised skills to the individual ". He is
also best fitted to mobilise the resources of the welfare services on his patient’s behalf-a task of importance in the care of the increasing numbers of old people. The family doctor must be able to detect, among apparent trivialities, the first symptoms of serious physical or mental illness, or underlying and possibly unrelated anxiety. Even the routine of supplying a certificate may be medically significant since need for the certificate may bring a patient to his doctor where nothing else would. " In rehabilitation, convalescence, and resettlement," says the report, " greater use of the family doctor could and should be made." His is the task of reconciling a patient and his family to chronic disability and of providing tactful information and support in cases of progressive and incurable illness. He is responsible, too, for the maintenance of health as well as for the treatment of illness; and he is well placed to pinpoint individuals at any particular risk and to encourage early preventive measures. In this country he is expected to visit his patient’s home when asked. Home visiting is costly in terms of medical time, but, for lack of factual evidence, the subcommittee can make no recommendation about the best use of this time.
Specialties doctors ... often develop special clinical that are not the direct result of the patient’s interests demands", and this the subcommittee strongly favours. Obstetrics is especially relevant to family practice, and the demand among intending general practitioners for further post-registration experience in obstetrics is increasing. But the number of resident hospital appointments in obstetrics is " grossly inadequate to secure the minimum of six months resident obstetric training for the future general practitioners who want it ". Subsequent maintenance of the practitioner’s obstetric experience through hospital work is equally important, and more refresher courses, clinical assistantships, and staff appointments are needed. Psychiatry intrudes increasingly upon general practice. The practitioner has a heavy responsibility in the early recognition of mental disorder; moreover, many psychotic and mentally subnormal patients are now living in the community and imposing a stress upon their families
" Family
728
which is the doctor’s business to relieve. The report recommends the introduction of normal psychology into the preclinical curriculum, besides a later clerkship in the psychiatric department. More postgraduate courses and seminars in psychiatry, and more part-time appointments for family doctors in psychiatric units, are urgently needed. Since the Mental Health Act is being implemented before local authorities have provided the training-centres, hostels, and psychiatric social workers demanded of them, the current responsibility of the family doctor is especially great; in shouldering it, the mental welfare officer can be his most valuable ally.
Hospitals The report pleads throughout for the introduction of general-practitioner posts in hospitals, both to allow the doctors to develop special interests and to restore the link between hospital and family-doctor services. " The way must be open for a good and determined family doctor to be selected for a hospital staff appointment, either parallel to his work in general practice or whole-time." The introduction of the new " medical assistant " grade of hospital staff should facilitate exchange of doctors between the services. " It should be possible for a family doctor to equip himself by experience and study to diverge from general practice if he chooses.... family doctors should be able to get hospital posts in which they will have the opportunity of becoming qualified for consultant appoint-
ments."
Equally important, says the report, is the provision of general-practitioner beds in hospitals, both for obstetric cases and for cases of acute or chronic illness which could be managed at home but for the lack of adequate nursing. It applauds the Minister’s intention to provide such beds in the new district hospitals, but adds that experience shows that anything more than thirty minutes’ driving distance is likely to prevent the doctor from visiting his
beds regularly. General practitioners
must
have direct
access to
hos-
pital diagnostic departments. In pathology laboratories and X-ray departments where this has been arranged, the volume of work has not, in fact, been swollen by requests for unnecessary investigations as some had feared. In the interests of accuracy, practitioners should also be able to use hospital facilities for necropsy. The subcommittee is agreed that general practitioners should continue to have opportunities for holding postssuch as that of police surgeon-outside the health service. Personal Relations
Many of the report’s recommendations are, in essence, appeals for closer personal contact between members of the medical and auxiliary professions. Requests for help with a livelier response, says the report, if there is an existing basis of acquaintance. It therefore approves the idea of district medical centres as points of social contact. Within a single practice, partners should be careful to meet each other regularly to discuss clinical and organisational problems; and their relations with the mental welfare officer, the probation officer, and the health visitor should be kept in good repair. In some areas, indeed, local-authority field workers are attached to individual practices, and this, the report says, must become general.
meet
Among hospital staff, the consultant tends to be especially remote from the family doctor. Although consultants are probably making more domiciliary visits than ever before, the family doctor now seldom attends the patient at the same time. The true consultation is being
abandoned and its educative and stimulant value is being lost to the practitioner. Simultaneous attendance, says the report, should be reintroduced. Education "
Even now, the newly registered doctor who intends to go into general practice ... may be tempted to take up his future work without any further training " because there is no clearly defined educational path for him to follow. The report suggests that during clinical training every student should, without fail, watch the general practitioner at work and gain some insight into his position in the Health Service. The making of a family doctor should, however, begin only after registration, with supplementary house-officer appointments in, for instance, gynaecology and obstetrics, pxdiatrics, psychiatry, and anaesthetics. Training in attitudes and methods of work is, and must be, given by experienced general practitioners either under the official training scheme or within the framework of an assistantship in general practice. The subcommittee is glad to note an 18% increase in the numbers of trainee general practitioners during 1962. It owns itself impressed by the Nuffield practitioner traineeships which provide for a year of additional hospital experience followed by a year of work divided between general practice, the hospital, and the local-authority services. The doctor completing such a course will tend, says the report, to set up in practice in the neighbourhood where he has already become known; future opportunities for this planned training should therefore be provided where the need for family doctors is greatest. Training can, however, no longer be once and for all. The general practitioner has to maintain an informed interest in new medical developments and the open and inquiring mind with which he started his career. Discussion with other doctors sharpens the wits as does the conduct of research-based, perhaps, on the practice records. The family doctor is well placed to study the epidemiology and natural history of common disorders, and the subcommittee believes that the new university departments of general practice will stimulate this type of activity. The practitioner must, however, be able to set aside time for formal education. Increasingly, says the report, partnership deeds include a clause concerning study leave; and the subcommittee believes that the practitioner should devote at least 5% of his professional time to study. The majority of its members does not think anything is to be gained by statutory provision for time off for holiday or education; but it recommends positive financial inducement, besides the payment of expenses, for attendance at refresher courses. THE
MEANS
TO
THE
END
The sine qua non of the forgoing is time and its most economical use. " The quality of organisation of an individual practice should be reflected in the quantity and quality of the work of the doctors in the practice." Every practice needs secretarial staff to cope with filing, recordkeeping, book-keeping, and typing-duties which can often be shared between several part-time workers. The subcommittee finds that " it requires a partnership of four or more doctors to take full advantage of a full-time and fully qualified practice nurse, while a full-time shorthandtypist secretary is rarely used economically by less than three doctors ". Single-handed practitioners now total only a quarter of all established principals, and the difficulty of finding suitably qualified deputies is perhaps
729
largely responsible. The solution to the problem of time off is being found increasingly in partnership and group practice. These also allow sharing of the cost of equipping and staffing the practice premises: and " the modern doctor ought not to be left to labour alone without help and without modern tools as a cottage industry ". The report welcomes the plan for a General Practice Advisory Service to help doctors over matters such as building materials and storage space in their premises; if the traditional distrust of the practitioner for the regional medical officer could be overcome, the latter could properly supply similar advice. Interest-free loans should be readily available to practitioners for practice improvements, and premises, once equipped, should be fully used. Surgery hours are usually only a few in each day; between them the accommodation could be used by, for instance, local-authority clinics. The subcommittee is unanimous in recommending the intelligent use of an appointment ’
system.
-
CONCLUSION
The subcommittee believes that the family doctor can be rescued from his isolation in the Health Service without any change in the tripartite administrative structure of the service. Some such change might subsequently result from increasing functional unification-unification which the family doctor has unique opportunities of
promoting. THE work of the English defence organisations continued to expand during 1962. MEDICAL DEFENCE UNION
Membership of the Union reached a record 50,000 and in the course of the year, 1 member in 16 wrote asking for advice. The advisory and educative activities of the Union are those which have developed most dramatically. This is reflected in its report for the year.1 The Union has, for instance, in conjuction with the Royal College of Nursing, drawn up a memorandum on the retained surgical swab. 38 actions for negligence on this account were handled by the union in 1962. The document emphasises that a surgeon who relies solely the nurses’ count does not discharge his responsibility: he himself must " take such additional precautions as are reasonable ". Analysis of past incidents shows that factors predisposing to the retention of swabs, packs, or instruments include working under pressure of time, unfamiliarity of nurse or surgeon with the routine of a particular theatre, and change in the theatre personnel during an operation. To guard against this type of accident the surgeon’s cooperation is essential in performing a final check before closure; and he should abandon his conviction that " it can’t happen to me ". on
The Union has also been considering the question of for operative treatment. The wording of many consent current forms, it says, needs revision: whether the " blank cheque " type used by some hospitals would protect the surgeon in the event of an action for assault is consent
doubtful. Since the publication of an article on " human guineapigs ", the Union has repeatedly been asked by practitioners to advise on the use of new forms of treatment.
Nowadays
a doctor is expected to apply the latest treatwhich could reasonably benefit his patient. Whatever the circumstances, says the report, the test is what is reasonable.
ment
obtainable from the Medical Defence Union, Tavistock House South, Tavistock Square, London, W.C.1.
Copies
Society also reports2 excursion into the educative sphere in 1962-namely, the inauguration of a series of lectures on the medicolegal aspects of medical and dental practice. It draws attention once more to the importance which may attach to accurate contemporaneous records in
action for
an
damages:
"
The trial of an action often takes place some years after the giving rise to it, when the memories of the parties and of witnesses may well have become dimmed or less reliable.... The final result of an action ... may depend on the existenceor absence-of an entry made at the time in the patient’s records. If a certain course of treatment is advised which the patient declines to undergo, it is essential to record this fact in the notes." events
The
Society’s report includes an of inaccurate diagnosis. arising
account
of
a
case
out
A man was thrown from his bicycle because of negligence on the part of the local authority’s road-sweeper. He successfully claimed S125 from the authority for his injuries. Subsequently his condition was found to be more serious than had been thought, and he therefore claimed damages for negligence against the hospital which had first treated him and on whose assessment his first claim had been based. The judge disallowed his claim for lost damages since a doctor was not required, when examining a patient, to foresee any question connected with a third party’s liability to that
patient.
THE DEFENCE ORGANISATIONS
1.
MEDICAL PROTECTION SOCIETY
The
In
fully
a second case, allegations of negligence were successrefuted because of conflicting medical opinion.
lorry driver injured his right leg in a road accident. He to hospital, where fractures of the right tibia and third, fourth, and fifth metatarsals were confirmed by X-ray. All wounds were excised and a plaster was applied to the groin. Three weeks later the plaster was changed, the position checked radiologically, and the patient sent home on crutches. Six weeks later he started weight-bearing but immediately felt great pain and returned to the hospital. Dislocation of the hip was diagnosed at once, and subsequently treated by surgery. The man later claimed damages from the hospital, asserting that, for lack of proper examination, treatment of the dislocation had been delayed nine weeks. Experts testified on his behalf that classical signs of the dislocation must have been present on his first admission. The judge, however, preferred the explanation put forward on behalf of the defendant-that, A
was
taken
with fracture of the rim of the acetabulum, an initial transient dislocation had corrected itself but recurred as soon as weightbearing was resumed.
Public Health Anthrax of anthrax in Huddersfield for thirty years were reported this week.3 Of 2 confirmed cases, 1 proved fatal. A 3rd suspected case, a man who is now in the Bradford Isolation Hospital, was said to be not seriously ill. Fellow-workers in the woollen scouring mills, where the infection was contracted, have now been vaccinated, and the Medical Officer of Health for Huddersfield, Dr. William Turner, said that there need be no fear about the spread of the disease. THE first
cases
More
Non-smoking Compartments
London Transport is providing more accommodation for non-smokers on the Underground. For an experimental period 6-coach trains on the Circle Line and the Hammersmith and City Line will have 4 coaches for non-smokers. 2.
are
3.
Copies are obtainable from Street, London, W.1. Guardian, Sept. 30, 1963.
the Medical Protection
Society, 50, Hallam