Intended for healthcare professionals


Good enough general practice

BMJ 2005; 330 doi: (Published 27 January 2005) Cite this as: BMJ 2005;330:236
  1. Malcolm Lindsay (Malcolm{at}, general practitioner
  1. the Health Centre, Galashiels

I had admitted an elderly woman with severe sciatica to the community hospital. She needed care while her pain continued. During her second evening in hospital, nurses became concerned about her deteriorating mobility, and I found that she had developed a flaccid paraparesis suggestive of cauda equina compression. I needed urgent specialist advice and telephoned the neurosurgical registrar in the city 30 miles away.

Suddenly I was struggling to survive detailed neurological interrogation. Were hip flexion and extension equally weak? Just what did I mean when I said ankle dorsiflexion was “rather” weak? Was there a sensory level on the trunk? How weak was plantar flexion? What was her post-voiding residual urine volume? At what root level did I consider the deficit was?

This was a clash of medical cultures; he from the sharp peak of the super specialty and I from the broad plains of general practice. We were speaking different languages, and mine was clearly failing to impress him. Eventually, a sufficient number of stuttered responses allowed him to advise on immediate management. As I put down the telephone, I felt deflated and experienced a pang of inadequacy.

During my career, I've forgotten more than I know. Inevitably we lose skills that we seldom practise and retain those that we constantly need. Yes, my neurological examination technique had lacked precision, and I made a note to sharpen it up. But had it been “good enough” to allow recognition of the emergency with appropriate referral? I think so. As Richard Smith highlighted in his address to new medical students,1 contentment with being “good enough” is a prerequisite for a happy medical career—and that advice surely applies to the wide expanses of general practice as much as to any other medical discipline.

The specialist registrar called back to discuss transfer arrangements. “Sorry about the poor performance in the viva,” I said.

“I'm sure I'd easily fail a viva in general practice,” he laughed. “Yes,” I said, “I'm pretty sure you would.”


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