Journal of the Royal Society ofMedicine Volume 71 September 1978


Letters to the Editor General practice: a developing academic discipline From Professor D H H Metcalfe Department of General Practice, University ofManchester Dear Sir, Dr Longson's challenge (June Journal, p 457) to academic general practice, that it should present arguments well formulated enough to undermine the educational status quo, must be accepted. In accepting the challenge it is perhaps reasonable to hope that the same requirement of relevance to basic educational objectives are meted to the ever-increasing number of specialties seeking slots in the timetable to which Dr Longson refers! There are three important ways in which the traditional curriculum has failed to turn out the doctors that the country needs. First, there is a respectable weight of well-researched evidence, as well as an anecdotal furore, of doctors' poor performance at evolving satisfactory working relationships with patients, at understanding their needs, and at explaining to them their illness, its management and prognosis. (Could this be because, in the traditional curriculum, the student proceeds from inactive learning materials such as slides, solutions, 'pots' and cadavers to horizontal, undressed, essentially passive inpatients, and so is neither motivated nor enabled to learn to work with rather than on his patients who are, revealingly, often referred to as 'clinical material'?) Secondly, there is the continual complaint inside the profession itself that the well-documented increases in prescribing represent therapeutic irresponsibility by general practitioners who capitulate weakly to patient demand, and investigational incontinence by hospital doctors who pursue precision without reference to appropriateness - behaviours which their undergraduate education has failed to inhibit. Thirdly, but most seriously, the state's medical schools have not provided the National Health Service with doctors who have enabled it to achieve its declared objective of providing effective health care for the whole population: the social class differences in the prevalence of disease, patterns of mortality, and the receipt of medical care are not only wide but some are growing wider. This is probably because the traditional curriculum is focused on pathology to the exclusion of vulnerability.

General practice, as a discipline, can provide learning opportunities which should contribute significantly to the correction of the failures of the traditional curriculum described above. However, it has no claim to exclusive skills in the elucidation of multiple problems: geriatricians and paediatricians are also adept. Similarly, it can lay no claim to a unique understanding of the psychological and social concomitants of disease: many other specialists are both concerned and effective in this field. The unique contribution of general practice is to demonstrate the distinctive practice of medicine in the patient's own environment. An important point is that whereas in hospital activity is often doctor-initiated, much of the activity in general practice is patient-initiated. In general practice patients enter care, often with small deviations from normal health, as the result of careful consideration. The student will soon learn from observation that the patient's decision to enter care is moderated by physical, social and psychological factors of which he needs to be aware. These same factors will influence the effect of the disease on the patient's life and therefore the way in which the patient will behave with regard to his illness and its management. The student will learn the necessary skills to elucidate these factors and to establish a cooperative, rather than an authoritarian, relationship with the patient. Not only is most acute illness dealt with in general practice in its entirety, but so is most of each case of chronic disease. It is much easier for a general practitioner teacher to find a representative collection of diabetics or patients with thyroid disease than it is for a consultant physician to do so from among his inpatients. While it is, obviously, appropriate and essential that the student learns about the acute crises of illness and their management in an inpatient setting, it seems reasonable to ask that there should be some relationship between his overall experience of disease and the overall pattern of important morbidity in the population which he is learning to serve. General practice may be better able to provide this than the wards. The emerging dominance of the chronic degenerative diseases places on doctors a heavy responsibility for prevention and early diagnosis. In hospital this can only be taught by precept - in general practice, by


Journal of the Royal Society of Medicine Volume 71 September 1978


matter and the means of transmitting it to the next generation'. Three specific points arise from his letter: (1) It is sad that a Dean of Clinical Studies should suggest that a 'knowledge of behavioural sciences would depreciate [the medical student's] rudimentary skills in clinical methods'. General practitioners believe the opposite. We are convinced that a professional understanding of human behaviour and the principles which govern it helps doctors to take more sensitive and accurate histories. Understanding human behaviour is a clinical skill, and doctors without it will inevitably be limited physicians. (2) Dr Longson is wrong in suggesting that general practitioners cannot teach intellectually vigorous history-taking and careful physical examination. On the contrary, general practitioners will be particularly vigorous intellectually because they have to approach undifferentiated clinical problems without the advantage of knowing that the problem lies in a particular system of the body. They therefore have to construct questions and interpret patients' answers with the knowledge that any system of the body may be involved, or indeed more than one at once. In particular, general practitioners have a great opportunity to teach students many of the problems patients have which need to be understood in terms of both the psyche and the soma. The causes of many diseases and many important conditions such as ill-treated children lie in the home, and many life-threatening conditions, including coronary thrombosis, can well be treated there. (3) Dr Longson writes as if general practice was just another of the 'ever increasing number of specialties requesting identifiable slots in the timetable'. It is not. It is the only medical discipline in which doctors remain generalists and it is also far and away the largest - about half of all Dr Longson's students will eventually have the privilege of practising as clinicians in this way. Yours faithfully

22 June 1978


example. Here is where an instinct for risk analysis can be inculcated. An appropriate index of suspicion gives the teaching general practitioner the opportunity to demonstrate personal preventive medicine to the student. Two examples of teaching in general practice, in current use at Nottingham, demonstrate the special contribution that such teaching may make. The first arranges for a student to visit a family in which one member has a chronic disease (or is a handicapped child, or has had a stroke). The student has two or three hours in which to become acquainted with the family, take a history from the patient and examine him, and observe at first hand the implications for the family of a patient with chronic disease. Later in the week, all students on the attachment are gathered together for a report session Wyhich the general practitioner teachers and an appropriate specialist attend. The cases are reported and discussed in terms of the patient and the family needs and the extent to which they have been met, and the way in which unmet needs could or should be dealt with. Such needs will obviously fall into categories of physical, psychological and social. The student has to review his knowledge of the disease and its treatment, but he also has an important role as a patient advocate and an opportunity to improve their care. The second example is more ambitious. The students are given the task of performing clinical audit of the care of patients with a chronic disease. By consulting the literature, specialists and general practitioners, they draw up consensus criteria for the management of the disease; they use the teaching practices' disease registers to draw a sample of the patients with that disease, and examine the records to see the extent to which the patient's care conforms to their criteria. Again an appropriate specialist is invited to the report session. Is it unreasonable to suggest that educational gains can be achieved by integrating the general practitioner teacher into specialist teaching? Yours faithfully

27 June 1978 From Dr D J Pereira Gray General Practitioner, Exeter, and Senior Lecturer in General Practice, University of Exeter Sir, The letter you published in your June issue (p 457) from Dr Longson, the Dean of Clinical Studies at the University of Manchester, is most

important. General practitioner clinicians must now accept his challenge and try to show him that general practice does have 'a clear perception of its subject

Electroencephalography today From Dr G Pampiglione Department ofNeurophysiology, Hospitalfor Sick Children, Great Ormond Street, London WCJ Sir, Dr E M R Critchley's editorial, which appeared in the, July issue of the Journal (p 473), is clearly written and thorough. Electroencephalography (including electrocorticography and evoked potentials) is the only direct

General practice: a developing academic discipline.

Journal of the Royal Society ofMedicine Volume 71 September 1978 697 Letters to the Editor General practice: a developing academic discipline From P...
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