A plethora of partialists

Jobbing Doctor mourns the demise of the General Physician

When I was a young doctor, many years ago, most hospital physicians were described as General Physicians. They were proficient in dealing with the whole patient, and could manage a wide variety of illnesses. I remember working for a general physician, and loved the way they could manage a widely differing number of subjects.

If you had a patient who was non-specifically unwell, then you could ask for an opinion and would get a valid judgement.

Then we started with a relatively new animal, the Consultant Physicians 'with an interest in' an area of specialty. My last general medicine job in the 1970s was in a hospital where there were three consultants, one with a special interest in cardiovascular disease, one in respiratory and one in gastroenterology. But they were all general physicians as well.

As Jobbing Doctor moved towards a career in general practice, the number of consultants blossomed, and we started to get whole departments forming, with their own rotas, and their own cases. Respiratory doctors would be on call for respiratory problems, and cardiologists for hearts etc.

I went into GP-land, and we still had a group of consultants to whom you could refer a variety of problems. However, around five years ago the last of those that I would describe as a General Physician finally retired, and with him went a wealth of general experience.

What we have now is a plethora of partialists. They are good in their own little area of medicine, but increasingly hopeless elsewhere. I was reminded of this by a man I saw this morning who is under a rheumatologist, a gastroenterologist, a nephrologist and a vascular surgeon. They are all focussing on their own areas, and not really listening to the patient. As soon as he mentions a symptom that is outside their little domain, the glazed look appears, and their immediate response is to assess the likely specialty and cross-refer. They have stopped being holistic practitioners, and started to become partialists. When they can't find a solution in their own little area, they switch off and move onto the next patient.

This is intensely irritating for me and the patient, as quite often their advice clashes. I have patients on non-steroidals prescribed for orthopaedic problems, and stopped by nephrologists and cardiologists. Tunnel vision evident.

So now, the only general physician in these patients' lives is now me.

This makes life difficult, as my patient sometimes says to me that 'they just don't listen'.

The story of lack of listening is too prevalent and repeated to be a chance finding. I find myself discharging more and more people from follow-up because they are not getting any benefit from seeing a series of partialists.

Partialism is of value, sometimes. If someone has ischaemic heart disease, then it is not a problem for them to help manage with what, essentially, is coronary artery plumbing. There are areas where conditions are confined to that one small area.

One area where generalism still seems evident is in care of the elderly. This can be of value if you have complex elderly patients who need this: but, to be honest, the geriatricians are largely duplicating what is done in general practice.

I do, however, object to not being considered a specialist in primary care. I am described as 'just a GP'; how patronising is that?! So when people call themselves specialists, they are - but the other side of the coin is that they are also calling themselves partialists.

Their value, but also their shortcomings, are very evident to the Jobbing Doctor.

The Jobbing Doctor is a general practitioner in a deprived urban area of England.