Generalists in medicine

Stuart Handysides's series of articles on enriching careers in general practice (the sixth and last of which is published today (p 513)) has amassed many facts and useful opinions about the state of general practice today.*RF 1-6* The accelerating pace of change makes the beginning of 1994 a good time to take stock.

Handysides correctly identifies the current importance of morale, career development, inevitable change, partnerships, teamwork, and management in general practice. The question we must answer is, how can we sustain the challenge and privilege of being personal doctors in the front line of a cash limited health service when more and more is being asked of us by professional bodies, the government, and patients? We offer six approaches that seem both theoretically sound and practical in aiding enjoyment of ordinary NHS general practice.

Firstly, we think and practise as “generalists,” a term thatlinguistically and professionally balances “specialists” and that describes most closely the core of our job as doctors. Relating to the whole person and all parts of the body and mind is intellectually fascinating but emotionally demanding. It means getting to know patients as people, including their families7 and homes,8 and analysing how psyche and soma interact. This offers an opportunity for research that is not available to specialist medicine.

Secondly, we believe that the future lies with multi-professional teams, including practice managers, practice and community nurses, health visitors, midwives, physiotherapists, counsellors, and computer staff as they can share skills, spread work, and support each other.

Thirdly, patients consult NHS general practitioners on average five times a year,7 and in many practices they average another annual consultation with practice nurses. A family of four can therefore expect to consult their general practitioner more than 200 times over the average of 11 years that patients are registered with a single practice. The organisational challenge is to focus all these contacts for the patients' benefit. We believe that continuity for both patients and their doctors is currently undervalued - it takes years to begin to understand patients fully as people. In our partnersHip we therefor encourage patients to see and get to know the same doctor as far as possible

Personal lists8 are therefore critical for continuity, and even with holidays, half days, and rotas it is possible to average two consultations a year per person. Mutual understanding and therapeutic relationships can then slowly build up.^9,10 Such regular, long term contact between patients and their family doctors generates a wealth of information about physical, psychological, and social aspects of health. The fourth issue is therefore computer recording. It takes time to enter information but little time to recall it.

Desk top, networked microcomputers are the mechanical slaves that general practice needs to systematise its base for research, teaching, and clinical care. Computerised summaries, warnings about drug interactions, and search and recall procedures take much of the drudgery out of doctoring and are beginning to produce new levels of quality and efficiency leading to new forms of job satisfaction. We call such up to date computerised information about lifestyle, current problems, risk factors, and chronic diseases “living epidemiology” and see it as the key to assessing the health needs of small populations. Just as the discovery of anaesthetics in the nineteenth century allowed surgeons to develop their skills so in this century microcomputers are allowing general practitioners to organise and analyse their information and so develop the discipline of general practice.

Computerised audits comparing the care provided by different partners in a practice are now possible. The comparisons are private and internal to the practice, are highly educational, and promote personal professional development by highlighting the strengths and weaknesses of all the doctors.

The Royal College of General Practitioners' fellowship by assessment offers a similar external goal and reward.11 By making personal relationships progressive and by making practice data progressively fuller and more interesting a logical career development emerges for the medical generalist within a group practice and a community.

Finally, as Handysides writes, general practice is a human service. The Royal College's motto, cum scientia caritas (compassion with science), well describes the two legs on which our subject stands. Generalists always have been and always will be concerned with whole person medicine, human problems, and human values.