The nature of general medical practice

The Future General Practitioner published by the Royal College of General Practitioners in 1972 defined the general practitioner as a doctor who provided primary, personal and continuing care (Royal College of General Practitioners 1972). This core definition was restated by the Leeuwenhorst Working Party in 1977. The Royal College has recently published a further report The Nature of General Medical Practice (1996). The change in title from the ‘general practitioner’ to ‘general medical practice’ reflects a change in emphasis away from the individual doctor to the ‘team’. The unique and valuable contribution of general practice to undergraduate medical education, particularly to those whose subsequent career would be in other disciplines, was to demonstrate the difference between primary and secondary care, and the importance of personal and continuing care. Primary care has been defined by Barbara Starfield as: ‘… first-contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system’ (Starfield 1994). In addition to general practitioners providers include accident and emergency departments, some nurses and the friendly neighbourhood pharmacist. The content of primary care differs from that of secondary care in three main ways. First, the problems that are presented do not always signify the presence of disease. The commonest reason for choosing to consult is the need for reassurance. Other reasons include need for diagnosis and treatment, legitimization of sick-role, problems of living with the human condition, surveillance of chronic disease, and rarely prevention. Second, the prior probability of serious or life-threatening disease is much lower. Third, even today, the patient is seldom a ‘new’ patient and is known by, and knows the doctor. It can therefore be recognized that it is sometimes more important to know the person who has the disease, than to know the disease that the person has. It is now 30 years or more since Theodore Fox published his papers ‘The Personal Doctor’ and ‘The Purposes of Medicine’ (Fox 1960, 1965). Since then threats to ‘the personal doctor’ have multiplied and Sir Theodore's worst fears have been more than justified (McCormick, in press). ‘More and more, as the years go by, the person who devises and performs new miracles is going to be more concerned with things rather than people: and the growth of scientific medicine makes it imperative that he should be balanced by someone who is concerned with people rather than things’ (Fox 1965). He also expressed the fear that, ‘the particular object of his (the doctor's) independent existence may be defeated if he leaves all dressings to the nurse, sympathy to the receptionist, messages to the secretary and the solution of home problems to the social worker … if somebody else is to do all the small things for the patient under the doctor's distant supervision, personal contact will be reduced to a minimum…’ (Fox 1960). Contact which is the necessary prerequisite for knowing the person. There is no doubt that, while the possibility of continuing care remains, it has been eroded by the growth of group practice, duty rotas especially for work ‘out of hours’, mobility within society and the growth of the ‘team’. While in general practice the contract is still ostensibly between the patient and a named doctor, in the case of patients attending hospital, outside the private sector, the contract is with St Elsewhere's rather than with Mr X or Dr Y. The Future General Practitioner was a document about the the role of the doctor. The Nature of General Medical Practice is a document about the team and is perhaps appropriate to the late 1990s. If this is a gain, it is achieved at considerable loss. One of the major losses is the erosion of the possibility that medical undergraduates will be exposed to, and learn the importance of personal doctoring, the importance of recognizing the uniqueness of the person who seeks our help.