Family Medicine

The Classic Papers

Michael Kidd, Iona Heath, Amanda Howe, Michael Kidd, Iona Heath, Amanda Howe

• Publisher: CRC Press
• Year: 2016
• Print ISBN: 9781846199943
• eBook ISBN: 9781315349534
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Containing papers carefully compiled for both their historical importance and contemporary relevance, Family Medicine: The Classic Papers brings together a team of experts, led by global family medicine leaders Michael Kidd, Iona Heath and Amanda Howe, who explain the importance of each selected paper and how it contributes to international health care, current practice and research.

The papers demonstrate the broad scope of primary health care delivered by family doctors around the world, showcasing some of the most important research ever carried out in family medicine and primary care. This unique volume will serve as an inspiration to current family doctors and family medicine researchers and educators, as well as to doctors in training, medical students and emerging researchers in family medicine.

CHAPTER 1

Medical humanism and our values as family doctors

Anna Stavdal

NOMINATED CLASSIC PAPER

Arthur Conan Doyle. Behind the Times. In: Round the Red Lamp – being facts and fancies of medical life. Methuen & Co., London, 1894: 1–8.

Many great writers have described experiences in family medicine. This short story illustrates how continuity of care by an experienced and loyal general practitioner (GP) should be lived and carried out, illustrating the very core of the calling of the family doctor. At the time when this story unfolded, the content of the doctor’s toolbox was extremely modest compared to the abundance available to medical practitioners in many parts of the world today. The expectations and hope for a favourable outcome when disease struck more often had to be left to fate and faith, rather than resulting from efficient treatment. It might be said that the choices that needed to be made and the dilemmas faced in those days were not nearly as pronounced and prominent as those confronting the doctor of the 21st century.

Dazzled by an ever-increasing flow of new tools, the modern doctor risks losing sight of a very central and essential ingredient in their toolbox, an ingredient based on the implicit contract between doctor and patient, something that is never up for sale: ‘I will be there when you need me. I will make an effort to understand you, in your own context, offer cure if I can, try to alleviate your pain, always offer you comfort, and I will do my utmost never to expose you to any harm. And you should know that your secrets are safe with me.’

This short story should not be read as a nostalgic story romanticising an old country doctor. On the contrary, this is a story about a modern doctor of her time who hasn’t lost sight of the core values of her profession.

ABOUT THE AUTHOR OF THIS PAPER

Sir Arthur Ignatius Conan Doyle (22 May 1859 to 7 July 1930) was a Scottish writer and physician, most noted for his fictional stories about the detective Sherlock Holmes.

He grew up in dire socioeconomic conditions, as his family became socially degraded and disadvantaged due to his father’s alcohol addiction and mental health problems.

He graduated from medical school at the age of 22, starting his career as a physician working on board ships in long-haul service. Later he trained as an ophthalmologist, and set up his own practice. After suffering losses of family members, including his wife and a son, he found comfort in spiritualism.

Arthur was a fervent advocate of justice and he personally conducted investigations into two cases, which led to two men being exonerated of the felonies of which they were accused and convicted. He could draw on experience from many fields when engaging in the public debate of his time, always advocating the need for social development.

His broad perspective in life gave him a good base for his literary endeavours and, starting out from an early age, he was a prolific writer whose works include fantasy and science fiction stories, as well as plays, romances, poetry, and even non-fiction and historical novels.

ABOUT THE NOMINATOR OF THIS PAPER

Dr Anna Stavdal has worked as a general practitioner in the same area in the city centre of Oslo for the past 27 years. For almost as long, she has held a part-time post at the University of Oslo, teaching medical students. She is a past chair of the Norwegian College of General Practice, past president of Nordic Federation of General Practice, and current vice president of WONCA Europe.

‘Search for insight, knowledge and experience from life itself. Be aware that sound patient-centred medicine presupposes deep understanding of your own self, enabling you to recognise when your own needs in the interplay with your patient, overshadow the needs of your patient. Develop your skills for self-scrutiny. Make a commitment to understand your society.’

Dr Anna Stavdal, Norway

Attribution:

This short story was originally published in an anthology called Round the Red Lamp in 1894. We acknowledge the Conan Doyle Estate Ltd, owned by the members of the Arthur Conan Doyle family.

BEHIND THE TIMES

My first interview with Dr James Winter was under dramatic circumstances. It occurred at two in the morning in the bedroom of an old country house. I kicked him twice on the white waistcoat and knocked off his gold spectacles, while he with the aid of a female accomplice stifled my angry cries in a flannel petticoat and thrust me into a warm bath. I am told that one of my parents, who happened to be present, remarked in a whisper that there was nothing the matter with my lungs. I cannot recall how Dr Winter looked at the time, for I had other things to think of, but his description of my own appearance is far from flattering. A fluffy head, a body like a trussed goose, very bandy legs, and feet with the soles turned inwards – those are the main items which he can remember.

From this time onwards the epochs of my life were the periodical assaults which Dr Winter made upon me. He vaccinated me; he cut me for an abscess; he blistered me for mumps. It was a world of peace and he the one dark cloud that threatened. But at last there came a time of real illness – a time when I lay for months together inside my wickerwork-basket bed, and then it was that I learned that that hard face could relax, that those country-made creaking boots could steal very gently to a bedside, and that that rough voice could thin into a whisper when it spoke to a sick child.

And now the child is himself a medical man, and yet Dr Winter is the same as ever. I can see no change since first I can remember him, save that perhaps the brindled hair is a trifle whiter, and the huge shoulders a little more bowed. He is a very tall man, though he loses a couple of inches from his stoop. That big back of his has curved itself over sick beds until it has set in that shape. His face is of a walnut brown, and tells of long winter drives over bleak country roads, with the wind and the rain in his teeth. It looks smooth at a little distance, but as you approach him you see that it is shot with innumerable fine wrinkles, like a last year’s apple. They are hardly to be seen when he is in repose, but when he laughs his face breaks like a starred glass, and you realise then that though he looks old, he must be older than he looks.

How old that is I could never discover. I have often tried to find out, and have struck his stream as high up as George the Fourth and even of the Regency, but without ever getting quite to the source. His mind must have been open to impressions very early, but it must also have closed early, for the politics of the day have little interest for him, while he is fiercely excited about questions which are entirely prehistoric. He shakes his head when he speaks of the first Reform Bill and expresses grave doubts as to its wisdom, and I have heard him, when he was warmed by a glass of wine, say bitter things about Robert Peel and his abandoning of the Corn Laws. The death of that statesman brought the history of England to a definite close, and Dr Winter refers to everything which had happened since then as to an insignificant anti-climax.

But it was only when I had myself become a medical man that I was able to appreciate how entirely he is a survival of a past generation. He had learned his medicine under that obsolete and forgotten system by which a youth was apprenticed to a surgeon, in the days when the study of anatomy was often approached through a violated grave. His views upon his own profession are even more reactionary than in politics. Fifty years have brought him little and deprived him of less. Vaccination was well within the teaching of his youth, though I think he has a secret preference for inoculation. Bleeding he would practise freely but for public opinion. Chloroform he regards as a dangerous innovation, and he always clicks with his tongue when it is mentioned. He has even been known to say vain things about Laennec, and to refer to the stethoscope as ‘a new-fangled French toy.’ He carries one in his hat out of deference to the expectations of his patients; but he is very hard of hearing, so that it makes little difference whether he uses it or not.

He always reads, as a duty, his weekly medical paper, so that he has a general idea as to the advance of modern science. He always persists in looking upon it, however, as a huge and rather ludicrous experiment. The germ theory of disease set him chuckling for a long time, and his favourite joke in the sick room was to say, ‘Shut the door or the germs will be getting in.’ As to the Darwinian theory, it struck him as being the crowning joke of the century. ‘The children in the nursery and the ancestors in the stable,’ he would cry, and laugh the tears out of his eyes.

He is so very much behind the day that occasionally, as things move round in their usual circle, he finds himself, to his bewilderment, in the front of the fashion. Dietetic treatment, for example, had been much in vogue in his youth, and he has more practical knowledge of it than any one whom I have met. Massage, too, was familiar to him when it was new to our generation. He had been trained also at a time when instruments were in a rudimentary state, and when men learned to trust more to their own fingers. He has a model surgical hand, muscular in the palm, tapering in the fingers, ‘with an eye at the end of each.’ I shall not easily forget how Dr Patterson and I cut Sir John Sirwell, the County Member, and were unable to find the stone. It was a horrible moment. Both our careers were at stake. And then it was that Dr Winter, whom we had asked out of courtesy to be present, introduced into the wound a finger which seemed to our excited senses to be about nine inches long, and hooked out the stone at the end of it.

‘It’s always well to bring one in your waistcoat-pocket,’ said he with a chuckle, ‘but I suppose you youngsters are above all that.’

We made him president of our Branch of the British Medical Association, but he resigned after the first meeting. ‘The young men are too much for me,’ he said. ‘I don’t understand what they are talking about.’ Yet his patients do very well. He has the healing touch – that magnetic thing which defies explanation or analysis, but which is a very evident fact none the less. His mere presence leaves the patient with more hopefulness and vitality. The sight of disease affects him as dust does a careful housewife. It makes him angry and impatient. ‘Tut, tut, this will never do!’ he cries, as he takes over a new case. He would shoo death out of the room as though he were an intrusive hen. But when the intruder refuses to be dislodged, when the blood moves more slowly and the eyes grow dimmer, then it is that Dr Winter is of more avail than all the drugs in his surgery. Dying folk cling to his hand as if the presence of his bulk and vigour gives them more courage to face the change; and that kindly, windbeaten face has been the last earthly impression which many a sufferer has carried into the unknown.

When Dr Patterson and I, both of us young energetic, and up-to-date, settled in the district, we were most cordially received by the old doctor, who would have been only too happy to be relieved of some of his patients. The patients themselves, however, followed their own inclinations, which is a reprehensible way that patients have, so that we remained neglected with our modern instruments and our latest alkaloids, while he was serving out senna and calomel to all the countryside. We both of us loved the old fellow, but at the same time, in the privacy of our own intimate conversations, we could not help commenting upon this deplorable lack of judgment.

‘It’s all very well for the poorer people,’ said Patterson. ‘But after all the educated classes have a right to expect that their medical man will know the difference between a mitral murmur and a bronchitic rale. It’s the judicial frame of mind, not the sympathetic, which is the essential one.’

I thoroughly agreed with Patterson in what he said. It happened, however, that very shortly afterwards the epidemic of influenza broke out, and we were all worked to death. One morning I met Patterson on my round, and found him looking rather pale and fagged out. He made the same remark about me. I was in fact, feeling far from well, and I lay upon the sofa all the afternoon with a splitting headache and pains in every joint. As evening closed in I could no longer disguise the fact that the scourge was upon me, and I felt that I should have medical advice without delay. It was of Patterson naturally that I thought, but somehow the idea of him had suddenly become repugnant to me. I thought of his cold, critical attitude, of his endless questions, of his tests and his tappings. I wanted something more soothing – something more genial.

‘Mrs Hudson,’ said I to my housekeeper, ‘would you kindly run along to old Dr Winter and tell him that I should be obliged to him if he would step round?’

She was back with an answer presently.

‘Dr Winter will come round in an hour or so, sir, but he has just been called in to attend Dr Patterson.’

Arthur Conan Doyle (1894)

CHAPTER 2

The transformation of family medicine into a distinct medical discipline

Michael Kidd

NOMINATED CLASSIC PAPER

Joseph S. Collings. General practice in England today: a reconnaissance. The Lancet, 1950; i: 555–85.

This paper caused a storm when it was published in 1950 in The Lancet. It was based on a survey of British general practice conducted by a young, and somewhat cocky, Australian medical graduate, Dr Joe Collings, who was working at the time as a health services researcher at Harvard University in Boston in the United States of America, and who had been seconded by the Nuffield Trust in the United Kingdom to undertake this review.

The Lancet published Joe Collings’ 30-page report in full, highlighting the poor conditions of many British general practices and the low morale of many general practitioners (GPs).

Joe Collings noted that general practice had no academic basis, with ‘no real standards for general practice. What a doctor does and how he does it depends entirely on his own conscience.’ He also stated that his observations, ‘led me to recognise the importance of general practice and the dangers of continuing to pretend that it is something which it is not.’

Joe Collings was frank in his assessment, criticising both urban and rural general practices, and stating that inner-city practice was ‘at best … very unsatisfactory and at worst a positive source of public danger’. He was not the first person to point out the deficiencies of general practice as he saw them, as George Bernard Shaw had done so 50 years earlier in his play The Doctor’s Dilemma.

Joe Collings’ paper inspired a group of concerned and responsible British GPs to join together in 1952 to form a college of general practitioners, later named The Royal College of General Practitioners (RCGP), established to provide professional leadership and to serve as an ‘academic headquarters for general practice [and] to raise the standards and status of general practice’. Some 100 years earlier there had been a similar push to create a College of General Practice but the established colleges of the Physicians and the Surgeons had vetoed that at the time. The founding of the National Health Service in 1948 had brought things to a head with British GPs becoming responsible for all personal medical care and providing the gateway for access to all other health services, but without being provided with adequate physical infrastructure, resources and financial support. For the benefit of both patients and doctors, things had to change, and, thanks at least in part to Joe Collings’ paper, they did.

The establishment of the College in the United Kingdom started a ripple effect around the world with colleges and societies of general practice and family medicine quickly being established in many other countries, especially among nations of the former British Empire. This effect continues to this day through the support provided to many other nations through the international programmes of the RCGP and other member organisations of WONCA (the World Organization of Family Doctors). Joe Collings’ report also triggered ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Acknowledgements
• 1 Arthur Conan Doyle on Medical humanism and our values as family doctors (1894)
• 2 Joseph Collings on The transformation of family medicine into a distinct medical discipline (1950)
• 3 Cees van den Dool on Anticipatory medicine – prevention as part of the consultation in family medicine (1970)
• 4 Julian Tudor Hart on The Inverse Care Law (1971)
• 5 Charles Bridges-Webb on How family medicine research can lead to systematic understanding of health and illness within a local community (1973)
• 6 Ian McWhinney on Problem-solving and decision-making in family practice (1979)
• 7 Gayle Stephens on The intellectual basis of family practice (1982)
• 8 James W. Mold and colleagues on The shift to goal-oriented medical care (1991)
• 9 James McCormick on The place of judgement in medicine (1994)
• 10 Cynthia Haq and colleagues on The development of family medicine around the world (1995)
• 11 The World Organization of Family Doctors (WONCA) on Training the world’s rural family medicine workforce (1995)
• 12 Ian McWhinney on The importance of being different (1996)
• 13 Alastair McColl, Helen Smith and colleagues on Family doctors and evidence-based medicine (1998)
• 14 Chris van Weel and Walter Rosser on The contribution of family medicine research to improving global healthcare (2004)
• 15 Igor Ŝvab and colleagues on Family medicine development in Eastern Europe (2004)
• 16 John Gabbay and Andrée le May on New perspectives on evidence-based medicine (2004)
• 17 Barbara Starfield and colleagues on The contribution of primary care to health systems and health (2005)
• 18 Julio Ceitlin on The development of family medicine in Latin America (2006)
• 19 Paul Little and colleagues on The importance of research in family medicine (2006)
• 20 James Macinko and colleagues on Family medicine development in Brazil (2006)
• 21 Barbara Starfield on Global health, equity and primary care (2007)
• 22 Harvey Chochinov on Dignity and the essence of medicine (2007)
• 23 The World Health Organization on Primary care: putting people first (2008)
• 24 Kurt Stange and Robert Ferrer on The paradox of primary care (2009)
• 25 Charles Boelen and Bob Woollard on Social accountability and medical education (2009)
• 26 Bob Mash and Steve Reid on Family medicine in Africa (2010)
• 27 Karen Barnett, Stewart Mercer and colleagues on Multimorbidity (2012)
• 28 Leiyu Shi on The impact of primary care and the importance of indicators (2012)
• 29 Iona Heath on The art of doing nothing (2012)
• 30 The State Council of the People’s Republic of China on Family medicine development in China (2013)
• 31 Amogh Basnyat on Family medicine transforming rural primary care in Nepal (2013)
• 32 The World Health Organization on Family medicine development in the nations of the Middle East (2014)
• 33 Roger Ruiz Moral and colleagues on The challenge of assisting people in improving adherence to medications (2015)
• Index