The specialist of the discipline of general practice
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7231.326 (Published 05 February 2000) Cite this as: BMJ 2000;320:326
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Editor-Iona Heath, Philip Evans and Chris van Weel endorse Oleson and
colleagues' appeal for revision of definitions of general practice "rooted
in a model of long term, full time, year round service in a stable
community…[which]…confuse the setting with the role and the person…[and]
may hamper change and promote failure."
The new definition they propose discards any reference to responsibilities
for continuity or for populations. They justify this by the increasing
difficulty, often impossibility, of providing either continuity or whole
population care, in almost all care systems. Neoliberal economics pushes
all systems toward fragmentation, with diverse and competing providers.
Patients are driven to shop around as consumers of episodic fixes, with
recourse to lawyers when they fail. All the intrinsic doubts and
ambiguities of human biology and culture are forced into commodity form.
The fact that 70% of health care spending goes to continuing management of
chronic disease, and that this proportion will continue to grow, is
simply ignored.
Knowing most of these authors personally, I can't believe that any of
them welcome the retreat they feel compelled to advocate. Perhaps they
think the category "general practitioner" can only be sustained by
discarding everything it has acquired in the past 30 years, beyond the
most immediate and obvious requirements of isolated doctor-patient
encounters. This may be so, but why have they chosen to sacrifice
continuity and responsibility for whole local populations, the foundations
for humane, rational, and efficient primary health care systems, just to
preserve a term already obsolete wherever care systems have got beyond the
stage where one professional had to provide the entire range of medical,
surgical, or public health skills? Primary care requires teams, with
doctors who have learned to work not as omnicompetent Rambos, but in a
collective.
They need continuity, stability, and responsibility for entire local
populations if they are to work effectively and efficiently, and help
their patients to make a difficult but necessary transition from consumer
to co-producer status. In most of the world, social conditions make this
difficult if not impossible, with care systems pushed toward rather than
away from consumerism. We live in bad times for social progress. If those
who set objectives for the next generation in primary care simply give up
the struggle, it will be harder still. If they think life is getting too
hard for innovating professionals, they should consider the lives led by
their predecessors, and by many of their patients today; it's wonderful
what people can do, if they know where they're going.
The Leeuwenhorst definition produced an effective generation of
innovators, setting appropriate objectives. Its aims are still
incompletely achieved, especially for populations. They are more relevant
today than ever before.
Prof Julian Tudor Hart
External professor,
Welsh Institute for Health & Social Care, Glyntaff
Campus,
University of Glamorgan, PONTYPRIDD CF37 1DL
Competing interests: No competing interests
Sir - Having red with interest the editorial of Heath et al1 and the
publication of Olesen et al on the new definition of general practice,2
both appearing in your February issue. Olesen et al stressed the necessity
of "the use of existing biomedical research methods and learning the
disciplines of health care services theory". Heath et al made a
considerable attempt to prove that the recognition of general practice has
been accomplished in the United Kingdom, but they also mentioned that in
many European countries this specialty is still striving for recognition.
This is even more valid in the Mediterranean countries, including Greece,
the country in which a four-year vocational training has recently been
initiated. I would therefore like to advance some additional factors,
which we consider as important to affect the recognition of general
practice as an independent discipline in countries, similar to those of
Greece.
Our experience has been gained from Crete, a Greek region with a Medical
Faculty with general practice as an independent academic discipline and
exposed its undergraduate students to the rural GPs practices. A primary
care network having been established between the Section of Social and
Family Medicine, University of Crete and 9 Health Centres functioning in
rural areas.3 We have identified keys subjects areas which we believe can
affect the opinion of the hospital physicians, and they are as follows:
a. The involvement of Primary Health Care Centres in the identification of
the populations health problems and the assessment of their health needs.3
b. The common work with hospital physicians in developing a database,
relating to the identified prevailing health problems and diseases.
Measuring the prevalence of common problems and studying their natural
course has been evaluated as an effective tool leading to recognition from
hospital physicians, who are working in countries with poor disease
surveillance in primary care.4
c. The involvement of GPs in handling emergencies in the Casualty
Department relieving the burden allocated to the hospital medical
specialists.
Admittedly the most of the above mentioned issues have been recognised in
general practice research not only in the UK but also in other North
European countries, even before the emergence of strong university
departments.5 However, there is an impression that our approach could be
tested in Southern European general practice to good effect and can
certainly contribute to the debate, which your Journal has already
initiated.
Christos Lionis
Assistant Professor of Social and Family Medicine
University of Crete, Greece
Visiting Professor of General Practice
School of Health Sciences, University of Linköping, Sweden
References
1. Heath I, Evans P, van Weel C.The specialist of the discipline of
general practice. BMJ 2000;320:326-327. (Editorial)
2. Olessen F, Dickinson J, Hjortdahl P. General practice time for a
new definition. BMJ 2000;320:354-357.
3. Lionis C and E. Trell. Health needs assessment in General
Practice: The Cretan approach. European Journal of General Practice 1999;
5: 75-77.
4. Lionis C, Koulentaki M, Biziagos E, Kouroumalis E. Current
prevalence of hepatitis A, B and C in a well defined area in rural Crete
Greece. J Viral Hepatitis 1997;4: 55-61.
5. Jones R. General practice research in the United Kingdom. In:
General practice research in Dutch Academia. Proceedings of a workshop,
Amsterdam, April 15, 1994. Royal Netherlands Academy of Arts and Sciences,
Medical Committee, Amsterdam, 1994, pp 55-58.
Competing interests: No competing interests
Olesen, Dickinson and Hjortdahl, in the article outlining a new
definition for general practice, raise a number of important issues.
Advances in medicine and changes in health care delivery systems have
brought about a number of challenges to medicine as a whole as well as
general practice and it is useful to revisit core definitions and
assumptions from time to time.
The authors criticise previous definitions which, they contend,
confuse the setting with the role and the person and they wish to arrive
at a set of functions which are applicable universally. They correctly
identify the need to define the centre or core of the discipline from
which all functions then derive. McWhinney identifies nine principles
which govern our actions and which define the discipline (McWhinney,
1997). Taken together, they define a worldview which is distinctive. The
particular menu of skills or functions that are practiced will depend on
the context and the needs of the practice population. Although some may
argue that rural general practice is a separate discipline from urban
general practice, to the extent that both strive to meet the needs of
their patients given the context in which they practice, they are both
general/family practitioners.
I see nothing wrong with being a generalist although I recognize the
political realities referred to in the accompanying editorial. The
generalist physician committed to his/her patients as distinct from a
particular therapeutic technique or set of problems or organ system will
of necessity bring to the profession of medicine as a whole a distinct
worldview which is absolutely vital at a time of fragmentation and
bureaucratization of care of the sick and dying. Unlike the authors of
this paper, I do not agree that focus on diagnosis should give way
'partially' to a more patient centred approach, rather it should give way
completely to a more patient centred approach, for a diagnosis is accurate
only insofar as it reflects the local reality of the patient and the
family. We must resist the tendency to lump all diabetics into one
category as if having abnormal regulation of glucose metabolism is somehow
a defining characteristic of the person coping with it, or a sufficient
level of diagnosis on which to base recommendations.
Vying for 'respectability' as a specialty is tantamount to trying to
become 'the noblest of Romans' and runs the risk of losing what our
discipline has most to offer the profession of medicine. Ironically,
calling general practice a specialty, may isolate the discipline even
further. While we need (and have) our own discipline specific journals, we
must work toward the day when specialty journals will solicit articles
from generalists just as many of our present general practice journals
have specialist papers.
In helping residents in family medicine understand what is
distinctive about our discipline, I find the following quotation very
useful: "The village doctor was a great success. His success was due to
his sympathy with his patients, each of whom he treated as an individual
with an idiosyncrasy of his own and worthy of special and separate
consideration. It was as if, instead of giving evry one mass-produced
medicine, he had moulded the portrait of each on his pill. He specialised
in his patients. In this way he was a real specialist, in contradisinction
to the town specialists who are identified with certain diseases or
disasters..." Going Native; Oliver St. John Gogarty. We must strive for a
definition of general practice which advances the concept of a 'medicine
of the person' (Paul Tournier, A Place for You, 1966).
Competing interests: No competing interests
There is no question at all about the reality that a general
practitioner is a specialist in his own field. Any young doctor who sets
out in general practice will find that it will take at least 5 years
(approximately the same time as being a registrar for any other
specialty), before such a practitioner has insight into this vital
specialty.
The primary skill which is acquired by practicing in the specialty of
general practice (SGP) is that expertise which involves intuition,
clinical skill and the ability to handle emergency situations
appropriately and quickly. There is no-one more qualified to do so than
the SGP. In addition, there is no other medical practitioner who knows
(often within seconds) whether there is an emergency on in a phone call or
a seemingly innocent inquiry. This is not learnt out of a book. It is
learnt by "hands on" experience.
Unfortunately this cannot be learnt without being exposed to patients
as the first line of medical contact. It is this skill which a pharmacist
simply cannot acquire. Clearly it becomes difficult to define "intuition"
and this acquired expertise which can only come through doing it. But,
every SGP knows exactly what is involved in their specialty.
It is one reason why it has always been a requirement to "do two
years of general practice" before becoming a specialist. During those two
years there is time to develope some respect for the work of the SGP. How
sad it is to think that many specialists have no idea how skilled and
unique the SGP's skill is! Even more to be lamented is the fact that
students are often taught by specialists in their clinical years and tend
to "look down" on the SGP. But, fortunately this has not deterred the
majority of colleagues from becoming SGP's. The SGP is the pivot of the
entire function of medical practice. The specialist will never be capable
of fulfilling this function. A specialist knows so much about so little
that being able to function in the SGP's role is completely beyond the
specialist.
The SGP is without doubt the backbone of Medical Practice
Competing interests: No competing interests
Specialists in people
I have read the definitions of general practice with interest, but a
dissatisfaction. None of them are succinct and they tend to stay closely
allied to traditional biomedical viewpoints.
For me the key point about general practice is that it is the only
medical speciality which is interested in people first and disease second.
As a result of this G.P.s are interested in personality, family patterns,
and the effect of these on the presentation of symptoms as much as in
diseases themselves. G.P.s (along with primary care researchers) are
probably the only group currently trying to understand the relationships
between symptoms,health and illness, and specific diseases within
communities.The focus is on the patient's response to the illness rather
than on the illness itself.
G.P.s are interested in the ecology of health and illness within
communities and in the cultural determinants of health beliefs.
G.P.s draw on a far wider range of resources than are taught in
medical school including their intuition, their knowledge of medicine,
communication skills, business skills and their own humanity.We are the
only group of doctors who stay in attendance of chronically ill patients
after the hospital clinics have lost interest.
In short general practice is a speciality where doctors have their
main interest in people and a secondary interest in disease.
The approach in general practice is broad and biocultural in contrast
to the older biomedical definitions of specialities.(2) This breadth of
approach allows G.P.s far greater flexibility and freedom in their efforts
to help patients and a great freedom from old attachments. Used to its
full potential general practice can be the powerhouse of all medicine.
Yours sincerely
Peter Davies
www.alisonlea.co.uk
1.Heath et al B.M.J. 320: 326-327
2.Morris,D Illness and culture in the postmodern age. University of
California Press,Los Angeles.1998
Competing interests: No competing interests