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Rapid Responses: Rapid Responses published:
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Generalists Vs Specialists.
- BM Hegde (16 December 2005)
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General practice - changing the metaphor
- Jean P Fisher (16 December 2005)
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Re: General practice - changing the metaphor
- L S Lewis (17 December 2005)
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Disconnected maps and territories
- Peter G. Davies (19 December 2005)
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Dr B M Hegde is right
- Dr Jayarman Nambiar (19 December 2005)
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General Practice -An Encompassing Role
- Dr. Pallavi Chaudhary, Dr. Nitin Mahobia , Adhoc Locum SHO(Orthopaedics),East Surrey Hospital, Redhill, RH1 5RH (19 December 2005)
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The generic art of judgement
- Michael J. Hogan (19 December 2005)
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Will Markets Destroy the Generalist?
- Graeme Mackenzie (20 December 2005)
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BM Hegde, Retired Vice Chancellor Mangalore-575 004, India
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Dear Editor, Our new doctors do get a reasonably good western type of education within the four walls of the medical college hospitals where only 0.01 per cent of the filtered sicknesses are seen by the students. Today a newly qualified MBBS doctor is incapable of practising medicine in a village all by himself/herself. This is due to their paucity of understanding of the minor illness syndromes in the community and the total dependence on hi- tech gadgets for diagnosis. We must change our medical education to train generalists that are capable of practising medicine out with the hi-tech, self defeating systems of diagnosis and management. Only a small per cent of patients would need specialized care. That could easily be done in a few hi-tech centres specially reserved for this kind of patients. The highest technology needed for universal patient care is the kind words of a good doctor, now shown by PET scan, to be able to generate powerful endorphins that stimulate the patient’s immune system. It is the immune system that heals. The future medical training must be such that the young doctor feels confident to make accurate diagnosis and arrive at management protocols based more on his bedside skills, only to be confirmed by further tests if needed. Time has come to ponder over what we do or do not do for our patients in the present modern medical hi-tech based system. A quick audit of the present system would show the lacunae. AIDS and cancer deaths are on the rise. Doctors striking work recently in Israel, years ago in Los Angeles county and Saskatchewan in Canada, has had a good effect on society. Screening apparently healthy people could be very dangerous to human health and happiness. Most, if not all, drugs used on long term basis in chronic degenerative diseases have resulted in more people suffering and dying compared to those helped by the drugs. There has never been a proper study done on drug combinations in science. While studies were done on single drug in ideal laboratory conditions, in reality, multiple drugs are used for patient care in anything but ideal situations. Patient compliance is so poor that one wonders if patients are alive because they do not take drugs in doses that are prescribed by doctors! To cap it, modern hi-tech medicine has become prohibitively expensive. Doctor is trained to look after the health of the public. Doctors are not trained only to intervene with quick- fix methods when the human machinery fails, although the latter is very important for the individual concerned at that point in time. Time and energy spent to keep the public health would lessen the need for expensive quick-fixes in the long run. Our medical education does not stress on public health. Clean drinking water for every citizen, toilets in every house, "cooking smoke" free houses in the villages to avoid cancer and heart attack deaths in women and pneumonic deaths in children below the age of five years,a damp proof house to avoid bacterial infections, and economic empowerment and education of women to improve infant and maternal mortality are vital in this effort. Time has come to change our medical education. Benjamin Rush, a great physician and one of the founding fathers of the American Constitution, had strongly pleaded for the “freedom of health care” like freedom of speech and religion. He did not succeed. The high priests in science and medicine now dictate terms to the lesser mortals. We need a cadre of well trained generalists to man our family medicine facilities. We also need a small number of specialists and sub- specialists to man our hi-tech set ups. The whole course of study, from day one, should be patient centred and community based. Class room teaching should be minimum and an occasional didactic lecture could clarify some theoretical points. The grading system of evaluation with semester credits should be the foundation of evaluation. Keen bedside observation and trying to unravel some of the clinical mysteries should form the basis of clinical research in medicine. Refutative research to demolish many myths in medicine is the need of the hour. Care should be taken to see that the generalist is not financially inferior to the sub-specialist. This disparity in the present set up, especially in the fee-for-service systems, is one of the reasons why our young doctors despise family medicine. Yours ever, bmhegde Competing interests: None declared |
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Jean P Fisher, GP Principal Robert Darbishire Practice, Manchester M14 5NP
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Editor, Heath and Sweeney rightly highlight the continuing importance of the medical generalist in primary care1. May I add to this discussion? Traditionally the GP has been referred to as the gatekeeper of secondary care, but this description focuses on secondary rather than primary care and undervalues much of the work of general practice. I would suggest that it is time for a change of metaphor. Let us instead think of the GP as the conductor of the orchestra of care; calling in the various support services and specialist opinions where necessary to ensure that the players follow the score of the patient’s choosing. Heath, I & Sweeney, K. Medical generalists: connecting the map and the territory. BMJ 2005: 331: 1462-1464. Competing interests: None declared |
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L S Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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I agree - the Gatekeeper metaphor is outdated. But be aware that practice-based commissioning may herald the return of a really 'conflicted' cheque-book version of gate-keeping ! At present, we GPs are frequently bypassed, either direct to A&E, or out-of-hours .. Though we may stand at the gate, we often have no hope of admitting or referring patients to Secondary-care services which are FULL UP, hence we are frequently dumped on, and bear the brunt of patient frustrations. Occasionally I think of myself as DOORWAY to health, but too often I feel like a DOORMAT. Competing interests: Doorway or Doormat? |
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Peter G. Davies, GP Principal, Keighley Road Surgery, Illingworth, Halifax, HX2 9LL
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"The map is not the territory ... The only usefulness of a map depends on similarity of structure between the empirical world and the map..." Korzybski's clear logic is matched by Heath and Sweeney's (1) clear map of what general practitioners think they are there to do for patients. And yet in the same issue of BMJ we have another map entirely of what general practice might be for.(2) A group of health economists, with no obvious medical knowledge or input, think that primary care could, and maybe should, be about commissioning care. The patient centered deontology surveyed by Heath and Sweeney, which is actually what most GPs think they should be doing, is absent from this new map which sees GPs as utilitarian healthcare purchasers for populations. There is currently a disconnection between what GPs think they should be focusing their energy on and what outside observers think GPs should be doing. Three years ago Marshall and Roland (3) wrote, "The new contract: renaissance or requiem for general practice?" I wonder if this question can now be asked about practice based commissioning. When I trained as a GP I worked to Heath and Sweeney's map of the territory covered by general practice. It still seems to me to be the right map of my core job, and it is far from clear to me whether commissioning should be on my map. It is also far from clear to me whether the brute realities of day by day general practice in any way register on the maps of the health economists or the department of health. If this apparent disconnection is not resolved their maps may bear no correspondence to the empirical structure of primary care and any such map would be flawed, and possibly dangerously inaccurate. 1. Heath, I and Sweeney, K. (2005) Medical generalists: Connecting the map and the territory. BMJ 331:1462-4 2. Smith, J., Dixon, J., Mays, N., McLeod, H., Goodwin, N., McLelland, S. et al (2005) Practice based commssioning: applying the research evidence BMJ 331: 1397-9 3. Marshall, M and Roland, M (2002) The New Contract: Renaissance or requiem for General Practice? British Journal of General Practice 52: 531- 2 Competing interests: None declared |
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Dr Jayarman Nambiar, associate prof MAHE,Manipal
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Medical eduation especially in India is rapidly changing, there is less emphasis on general practice with most graduates nowadays opting for specialist training. As Dr Hegde points out, only a very small fraction of illnesses need specialist care and treatment. I think we should change this system and more emphasis should be laid on general practice. Competing interests: None declared |
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Dr. Pallavi Chaudhary, Adhoc Locum SHO - Obs & Gynae . GPVTS Trainee from February 2006. East Surrey Hospital, Redhill, RH1 5RH., Dr. Nitin Mahobia , Adhoc Locum SHO(Orthopaedics),East Surrey Hospital, Redhill, RH1 5RH
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Dear Editor, In our opinion, General Practice performs the basic as well as extended roles in the management of people with illnesses. We cannot deny that GPs take care of the majority of people in the society whereas the specialists see only a fraction of them.Also, with limited availability of technology they have to rely heavily on their own knowledge, experience & medical instincts most of the time with due consideration to the risks involved.They also support the patients not only by treating the diseases but by supporting them mentally & psychologically that too in their own surroundings/society. Apart from the medical issues they have to manage man-power, resources etc without compromising the quality of services. Whatever reforms the NHS undergoes but one thing is pretty clear that the medical services cannot ignore the indispensible role of the GP's. As so much is expected of a GP the reforms in General Practice were long due. Finally, they have seen the light of the day & these reforms in the structure of GP training, the new MRCGP regulations would definitely enhance the standards that the future GP'S will have to live upto. In a way its beneficial for the GP's as well who would keep themselves updated & would be in a better position to handle more complex illnesses. More number of patients would be treatable in their own surroundings thus reducing the hospital-load & waiting periods for the patients. The upgradation of prescrption services provided by the nurses , pharmacists might reduce the work-load but on the other hand might raise the risks involved for patients.Afterall, we cannot expect few months of pharmacological training to match with the many years of structured medical studies that the doctors undergo. So, the better way would be to do some pilot with senior experienced nurses who are strongly recommended by the consultants based on their previous medical knowledge. It would be better if its done on a "pick & choose" basis rather than following a more generalised approach. Competing interests: None declared |
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Michael J. Hogan, Lecturer Dept. of Psychology, NUI, Galway
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A modest psychologist once said that an acquaintance with the details of fact is always reckoned, along with their reduction to system, as an indispensable mark of mental greatness (James, 1918). Unfortunately, reducing the dynamic facts of living systems to system requires the class of mental greatness granted to none – many minds modelling are needed (J.N. Warfield, 2003). Education needs to foster generalists - those who recognise that the art of dialogue and critical thinking are irreplacable. Without adequate training in the art of collaborative and individual thinking, the 'system' can come to dominate individuals. Only when the relevant dynamic facts of the system are internalized can the system be mastered. As the system of biomedical knowledge expands toward higher levels of complexity and organization, mental processing demands increase. With the public belief that an 'ideal' state of knowledge is accessible, expectations placed on the individual practitioner increase. A medical doctor is also asked to leave plenty of room for compassion. As the focus of care shifts from acute to chronic, and as the populations ages, the necessity for wisdom is also attached. But the mind is a limited workspace. During their general education all students need time to understand how the mind works. Without first mastering the art of dialogue and critical thinking, a system of ideals can crush the esteem of the best adapted, strongest individuals. As David Bohm notes, 'you could say that our ordinary thought in society is incoherent – it is going in all sorts of directions, with thoughts conflicting and canceling each other out. But if people were to think together in a coherent way, it would have tremendous power'. With dialogue and critical thinking, the force of the system can be optimized. But optimized never implies perfect. Siu (1957) reminds us of the good-life-reasoning of Confucius: The ancients, who wished to preserve the clear and good character of the world, first set about to regulate their national life. In order to regulate their national life, they cultivated their family life. In order to cultivate their family life, they rectified their personal life. In order to rectify their personal life, they elevated their heart. In order to elevate their heart, they made their will sincere. In order to make their will sincere, they enlightened their mind. In order to enlighten their mind, they conducted research. Their research being conducted, their mind was enlightened. Their mind enlightened, their will was made sincere. Their will being sincere, their heart was elevated. Their heart being elevated, their personal life was rectified. Their personal life being rectified, their family life was cultivated. Their family life being cultivated, their national life was regulated. Their national life being regulated, the good and clear character of the world was preserved and peace and tranquillity reigned thereafter. (p. 136). Thinking about how best to optimize human action- the gestalt of motivation, emotion, cognition, and behaviour, embodied and embedded - involves thinking about human nature. An ideal space needs to be provided for concentration and contemplation. Quality thinking takes time to develos -- it requires a system that provides the appropriate scaffolding. A collection of attitudes are thought to undergird a quality thinking process. The critical attitude is a functional cognitive and affective state defined by the Delpi report (Facione, 1990) as follows: possessing the cognitive skills of interpretation, analysis, evaluation, inference, explanation and self-regulation, along with the affective dispositions of being purposeful and self-regulatory, habitually inquisitive, well- informed, trustful of reason, open-minded, honest in facing personal biases, and willing to reconsider one’s position. A grand selection of virtues: the consensus view in the Delphi report is that it’s very likely that none possess all. Operating in potential coherence with the critical attitude is the constructive attitude, which maps onto acts of synthesis that seek to bring the products of critical thinking, the facts, into a system of relations suitable for reasoned problem-solving and decision-making. Naturally, the merger of critical and constructive attitudes is one of the more difficult challenges the thinker has to face. As noted in the Delphi report: Not every useful cognitive process should be thought of as critical thinking (CT). Not every valuable thinking skill is CT skill. CT is one among a family of closely related forms of higher-order thinking, along with, for example, problem-solving, decision making, and creative thinking. (p. 5) The merger of the critical and constructive attitudes, and their consistent application in supportive educational contexts, is fundamental to systems thinking. Doctors who are offered training in the art of quality systems thinking -- grounded in a strategy of problem-based, dialogue-based learning -- will be better inoculated against the stress of rapid change in the system. A new cohort of doctors trained in this way will put a leash on the system and bring it to heal. Only psychologists who are highly trained in the art of systems thinking can offer this training. Unfortunately, they are few and far between. But they will emerge. Quality medical doctors will embrace quality systems thinking psychologists. Together their compassion will produce something new in culture for the next generation. Facione (1990). Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction. The California Academic Press. James, W. (1918). The principles of psychology. New York: H. Holt and Company. Siu, R. G. H. (1957). The Tao of science : an essay on Western knowledge and Eastern wisdom. Cambridge, Mass.: M.I.T. Press. Warfield, J. N. (2003). A Proposal for Systems Science. Systems Research and Behavioral Science, 20, 507 - 520. Warfield, J. N. (2004). Linguistic Adjustments: Precursors to Understanding Complexity. Systems Research and Behavioral Science, 21, 123 - 145. Competing interests: None declared |
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Graeme Mackenzie, GP Whitehaven CA28 7RG
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This article defines well what we do. I feel that general practice works because we "half do things". The low incidence of true tissue disease means that we "get off" with this approach. Doing it this way we can maintain our productivity and availability (two features of general practice which are rarely mentioned and often undervalued). Of course we could do everything "properly" and remove all doubt from and more importantly responsibility for every symptom. However there can be no -one that advcates that approach! Markets may force us to "do things properly" in order to get paid properly. The system will fail very quickly and of course costs will rise. Rising costs means more money in the system which means more for markets to feed on. Have I worked it out? Competing interests: I am a GP |
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