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A DESIGN FOR GENERAL PRACTICE

M. J. F. COURTENAY.

SIR,-I find it ironical that Dr. Eimerl and Dr. Pin-sent (Oct. 12 and 19) can make a design for general prac-tice without trying to define its aims, while Dr. Apley(Oct. 26), as a consultant, has something wise to offer ageneral practitioner in every paragraph; and finally Pro-fessor Neale (Nov. 2), working in apparently the sameparish as Dr. Apley, congratulates Dr. Eimerl and Dr.Pinsent. This game of ring-a-ring-of-roses might beamusing if the subject was less serious.

I cannot believe that good general practice depends onwhether the surgery is called a consulting-room or not, orwhether there is a nurse, a receptionist, an appointmentsystem, or anything else except clinical skill and a soundunderstanding of the doctor-patient relationship. If theseare present " all these things shall be added unto you ".It is not that I have contempt for any of these things, and,in fact, employ them myself, but these are organisationalmatters and I am afraid that like Leonardo da Vinci weare discussing the varnish before the picture is painted.Anything or anybody coming between the G.P. and hispatient is potentially dangerous. The only efficiency thatmatters is the doctor’s capacity to understand and helphis patient.Must we for ever run after trying to do

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hospital medicinein general practice ? As Dr. Apley says, " hospital illness isnot an entity but only an episode in the life of the patient andhis family". I should like to add that it is only an episode inthe professional life of his general practitioner. Nor can socialmeasures alone deal with the patient’s problems, dealing onlywith his external situation, and leaving his internal situationunexplored. I have yet to see rehousing cure anything in theway of illness in a personal sense, however necessary it may besocially speaking.

I think that the dissatisfaction of us general practitionersstems from a feeling that we need the specialist and the

hospital, but have doubts as to whether they need us. It’snonsense, of course, so before we jam our boot in the hospitaldoor, we must ask ourselves what real use we can be to thehospital doctor while our patient is there. Any time a G.P.spends in hospital is likely to be wasted unless it bears on ourown patient-care responsibility. We might avoid admittingpatients unnecessarily and arrange their discharge (eitherearlier or later) at a more appropriate stage than can be judgedby the hospital alone. It is often at the latter point thatcommunication between the two utterly breaks down, as

protocol seems to demand a great deal of communicationbetween the two before the patient is admitted, but none at allbefore the patient is discharged into the G.P.’s care. It is up tous to prove to our hospital colleagues that we can be of use tothem as well as the patient.We may appear to deal with episodic illness, but we

really deal with a person suffering disturbances of healththat we are also heir to; but with our twin skills of medical

understanding and professional detachment, we alwayshave the power to teach, and sometimes even to heal ourpatients.

After all, we have the whole patient. What more canwe want ?

London, S.W.18.

INCREASE IN LITIGATION

SIR,-I was interested in your annotation of Oct. 5 inwhich you suggested that free legal aid was an importantreason for the increased litigation against the medicalprofession.

The rise in legal action against doctors has been even greaterin the U.S.A. than in Britain, and there is no free legal aid here.

In the U.S.A. legal action most commonly results when adoctor presses aggressively for payment of his medical fees afteran unsuccessful case, the unfortunate patient or relative havingoften been placed in the hands of a debt-collector.As you said, in recent years there has been diminished

readiness to accept the doctor as infallible, but it is often somelack of consideration for, or unkind action to, the patient or hisrelatives which finally provokes the legal attack. Much litigationcan be prevented by sympathetic explanation, even, sometimes,when the doctor has been clearly at fault, and I think it is

significant that the rise in litigation in both the U.S.A. and theUnited Kingdom has followed the decline of the " old familydoctor "-

R. J. LUCKVisiting Research Fellow.

Peter Bent Brigham Hospital,Boston, Mass.

OLD AGE A REGRET

GERALD TEWFIK.

SIR,-I was very interested in Dr. Kemp’s article

(Nov. 2) and particularly his recommendations for theeducation of the elderly.

I wonder, however, whether he has gone far enough." Doctors then have a task peculiar to their profession tohelp their elderly patients to keep hope and morale hightill the very end. The patient who believes that he is donefor and finished has said goodbye to health as well as tohappiness and purpose." Here Dr. Kemp seems to regarddeath as the final disaster which should not be con-

templated during life, and this attitude leaves the mostimportant part of the education of the elderly unmentioned.There does come a time when death is a normal stage in

man’s destiny, and the doctor who has educated and caredfor his patients throughout the other hurdles of life mayalso be required to help during this final step. For a man tobe happy and heahhy, he must be prepared and willing torelinquish his life at any time and in any case where it canno longer be usefully preserved. In my experience manyelderly people suffer from hypochondriasis as a result offear of death.We know that in life mental and spiritual factors are

more important than the physical in maintaining happi-ness and a sense of purpose. We do not lose our peacein preparing for death, but, being freed from fear, areable to live more fullv.

SPINAL INJURIESSIR,-Like Mr. Hardy (Oct. 19) I have followed this

correspondence with interest. Like him, I feel that weare all trying to do our best for the patient in restoring andpreserving as much function as we can. It is for this veryreason that, having seen some 2000 traumatic paraplegics,of whom over 80 had been treated by open reduction andfixation, I am convinced that conservative treatment is thebetter method. Incidentally, I have noticed that out of 450recently injured cases admitted to this hospital in the pastsix years, only 9 cases had been plated before admission-a figure which does not support the statement that mostsurgeons agree that operative reduction and fixation is thebest treatment. I have seen too many cases in which openreduction and fixation have resulted in an increase of the

patient’s disability to be concerned whether the fault is oneof principle or of technique-the more so since the safer,if perhaps more exacting, method of conservative treat-ment is available.Mr. Holdsworth’s comparison (Aug. 24) of a fractured spine

with a fracture of the tibia and fibula does not give duerecognition to the splinting effect of the trunk muscles inthoracolumbar fractures. This makes it relatively easy, byconservative methods, to prevent redislocation and allow the