Author’s reply
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1786 (Published 23 March 2011) Cite this as: BMJ 2011;342:d1786
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Thanks for your response and I am sure you express the views of many
colleagues. I would like to respond on a number of important points you
raise.
Firstly, you should know that I have written previously that
commissioning should involved GP and consultants. I find the government
proposal divisive and I very much believe in collaboration.
Secondly, I raised relevant points in my response to the experts
letter which I believe are absolutely correct. Should the consultants
wish to respond again, I am happy to explore this topic further in the
responses. Thus far they have chosen not to.
Thirdly, on the vexed issue of expert versus the uppity generalist. .
I am always willing to consider expert opinion. But this is not on the
basis of an expert "status" but only on the basis of their argument. I
understand the published evidence as well as they do but have a different
perspective from primary care. Much of what I was taught in hospital and
undergraduate is not relevant or is wrong and frankly unhelpful in the
community. So I , do "respect" but not "deference"; if this seems
"ignorant and arrogant", then so be it..
Experts over saw the banking collapse, the housing bubble, the
promotion of Vioxx, the over diagnosis of cancer in screening programmes
and in the past the promotion of cigarettes ! So I wouldn't always have
faith in experts and we need more dissent in medicine not less.
Who should decide on health care the consultant or the GP ? The
answer is both, and absolutely and fundamentally, equally.
Lastly, yes many rectal examination are pointless and have no
evidence base. Another "Bad Medicine" on its way.
Competing interests: No competing interests
The correspondence between Desmond Spence General Practitioner and
John Butler et al Hospital Specialists is particularly illuminating as the
so-called reforms to the NHS by government occupy centre stage.
A GP Dr. Spence writes a provocative article on Gynaecology raising
the issue of the value of a speculum examination for a patient with a
vaginal discharge. He clearly feels it is not worth doing. It attracts a
response from Specialists who have enormous experience on the subject.
They say it is important to perform a speculum examination on a patient
with a painless vaginal discharge to identify a possible cancer of the
cervix. Surely it is only the ignorant or arrogant who would ignore that
advice from such an authoritative source of Gynaecological Oncology?
Good medicine, surgery or gynaecology is based on what we teach to
every medical student. Take a thorough history from the patient, examine
the patient fully especially the relevant part. Perhaps Dr. Spence would
shy away from the rectal examination in the patient bleeding per rectum,
or with a change in bowel habit? Does the odd haemoptysis or haematemesis
need further investigation? No wonder the UK is a bit of a laggard
regarding cancer mortality compared to its peers if such a laid back
attitude is prevalent
If this government has its way it is the General Practitioners like
Dr. Spence that will have 80% of the NHS budget. Hospital doctors like Mr.
Butler et al will be completely excluded from the commissioning process.
Those with the greatest knowledge of making diagnoses and offering
effective treatments have been deliberately ignored.
The original article by Dr. Spence and the subsequent correspondence
demonstrate just why we need equal Hospital Doctor and General
Practitioner involvement with commissioning. It needs writing in to any
bill.
Competing interests: No competing interests
Re:Who decides, the Specialist and Expert, or the GP?
KG Taylor clearly hasn't read - or perhaps hasn't understood - what
Spence has written.
Is Spence not saying precisely that argument from authority should be
questioned, and argument from evidence favoured? And that the GP is
different from gynaecology: the prior probability of serious pathology is
much lower; and the positive predictive value of the presenting symptoms
are so low as to render invasive examination inappropriate?
Taylor has not addressed these points, and has simply restated the
argument from authority put by earlier correspondents.
Competing interests: No competing interests