Medicine And Books

The Mystery of General Practice

BMJ 1996; 312 doi: (Published 13 April 1996) Cite this as: BMJ 1996;312:985
  1. William R Phillips

    Iona Heath Nuffield Provincial Hospitals Trust, pounds sterling8, pp 53 ISBN 0 900574 93 3

    The role of the general practitioner is changing rapidly on both sides of the Atlantic. In the United Kingdom general practitioners enter into fund holding arrangements with the National Health Service. In the United States family physicians accept capitated contracts with managed care organisations. Both arrangements require doctors to balance the competing needs of the patient, the practice, and the larger system. The opportunity is to provide services to populations with value measured by patient outcomes. The hazard is in accepting financial incentives that conflict with our role of trusted advocate of the patient under our care. In the balance hangs the solvency of our health care systems and the future of our profession.

    General practitioners' professional lives are characterised by variety, relationships, and practical problem solving. Patients appreciate that their GP is, indeed, their doctor; a doctor who specialises in them. Health services analysts recognise the GP as the only professional with responsibility for the comprehensive medical care of unselected patients with undifferentiated problems.

    General practice has always been pushed to define itself at its margins; early on by consultant physicians and surgeons, more recently by advanced practice nurses and alternative practitioners. These struggles have left the core of general practice largely unexplored by either critics or champions. In The Mystery of General Practice Iona Health examines the heart of general practice with insight and concern. She identifies two key roles of the general practitioner: interpreter of the interface between health and disease, and witness to the patient's experience of illness. It is through this interpreter role that the good GP saves the system measurable millions by providing cost effective care for the great majority of patients and efficient referral for the few who require consultant care. It is, however, through the witness role that the GP earns the understanding and trust of the patient which make this difficult job possible.

    These essential but often undervalued tasks will always require an investment of time for a return of trust. Both time and trust are now threatened. The pressure to spend fewer precious minutes of doctor time with each patient risks losing both content and context. The demand that the GP “gatekeeper” act both as guardian of scarce resources and as patient advocate threatens to violate the trust patients need in their doctor to accept efficient service, wise counsel, and appropriate care.—WILLIAM R PHILLIPS, department of family medicine, University of Washington, Seattle, USA

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