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How can we get back to patient-based medicine?

The days of the family doctor have gone, but it can live on in a new guise says Dr Rick Appleton

I was born in 1934. At about the age of fifteen I decided to become a family doctor.

Immediately after qualifying and doing the hospital residencies necessary for registration I found a small country practice with a single handed principal and an expanding list. I was fortunate enough to be offered a partnership.

My new partner and I shared the same ideology and together set out to build the practice further in the determined belief that ours would become the best practice, not only in our town but in our county as well.

We regarded our patients as our friends and equals and that our mission in life was not just to cure their illnesses and help them to be well but also to be a companion, guide and sympathiser to people whose lives had been turned upside down by sickness, disability and death.

I fear I may often have failed people in my 38 years in practice which is a source of regret to me but it was not for the want of trying. Despite this, the practice grew to three times its former size and supported five doctors before I retired.

We were fortunate to be practicing during the golden age of general practice.

Sadly with the progress of modern medicine the days of the family doctor are gone for ever. He/she has morphed into a ‘primary care practitioner’. Examples of family doctors may still be found existing in isolated rural areas but are, at best, an endangered species.

So what are primary care practitioners?

• Quite a large proportion are part-timers.

• They frequently live outside the area of their practice so having little social contact with their practice community.

• They often practice from beautiful, modern, purpose built premises housing many doctors.

• They have large administrative and ancillary staffs.

• They work ‘office hours’ and are free of responsibility at evenings, nights and weekends.

• They are highly scientific using a vast array of tests to make diagnoses.

Consequently and inevitably far less emphasis is placed on clinical skills and assessments.

• Referral rate to hospital tends to be high. [Even if they were to treat a patient absolutely correctly, if something were to go wrong, there would be no legal defence against failure to seek specialist advice]

• Consultants tend to be highly specialised concentrating on ever narrowing areas of expertise and ‘general’ physicians and surgeons are few and far between.

• There is the tendency to be motivated by targets set by politicians and by fear of being accused of doing something wrong. rather than by real needs

• Because of the financing structure, performing anything more than the most basic of procedures

is subject to financial considerations.

• Casualty work is nearly always passed to the local A&E department.

• Much practical work (e.g. blood sampling and simple tests) is allocated to nurses who run ‘clinics’ for these purposes.

• They are extremely busy. There is a danger that ‘the system’ may take precedence over patient’s immediate needs and consequentially it may be difficult to distinguish between activity and effectiveness

• There is a tendency for a victim mentality which argues ‘It is not my fault – I can’t help it – something or someone else is to blame’

• There is a tendency to believe that patients need to adapt to the system rather than the system adapt to the patient’s needs and that patient discipline is needed to achieve this objective.

• Visits to patient’s homes are few and far between.

• Computer technology is extensively used.

There are many advantages in modern medical centres and in modern trends in practice but it is hard to conceive of a family doctor (as described above) being able to function within this context.

Fifty years ago the title ‘family doctor’ summed up the aspirations and encompassed the guiding principles of good general practice

I am not suggesting that this would be either possible or even desirable. We have moved on.

I perceive however that a rather worrying thing about this new concept is that it creates an environment where it is all too easy to forget that doctors should not be concentrating primarily on treating illnesses (and meeting targets) but rather in treating people with illnesses.

There is the very real danger that the personal empathy necessary for effective medicine can be completely sidelined.

Today, regrettably, a patient’s experience of seeking help in their time of need can be stressful, traumatic, frustrating, unreasonably drawn out, require multiple contacts and may have an unsatisfactory conclusion; this inevitably leads to them feeling that no one really cares about them personally.

The consequences of this on recovery and inevitably the efficiency of the whole system are in my opinion potentially very serious and as such need to be recognised and avoided. Sympathetic communication, explanation and involvement with the problems not only of the illness but also of ‘the system’ are essential and this requires a very definite mindset on the part of doctors in the tradition of the old family doctor.

This danger needs to be humbly recognised and every possible measure taken to avoid and correct the problem. Primary care practitioners must fight to maintain their autonomy and the control over their practices in order to enable them to practice traditional, patient-based medicine as a first priority.

If this can be achieved then perhaps the concept of family doctor is not extinct after all, but is living on in a new guise.

Dr Rick Appleton is a retired GP in Cheshire

How can we get back to patient-based medicine?