Brit. 3. med. Educ., 1970,4, 145-148

The Application of Anatomy and Other Basic Medical Sciences in General Practice D 0 N A L D H I N E S Plymouth, Devon

During the past few years, there has been a great upsurge of interest in the training of medical students and, at the same time, anxiety at the rapidly increasing amount of knowledge to be assimilated without an associated increase in avail- able study time. Among the greatest problems facing those interested in medical education are what to teach and what to leave out of the pre- viously accepted curriculum.

Of necessity, many of those involved with plan- ning medical courses are specialists, who in con- sequence of their being on the staff of teaching hospitals and medical schools are appointed to the relevant committees and governing bodies dealing with medical education. On the other hand, many of those being taught are destined to practise in wider fields of medicine where the exact nature and extent of their work may be unfamiliar or even unknown to those who planned their education. The recently published Report of the Royal Com- mission on Medical Education (1968) suggests that all medical students should have a wide general education well beyond the stage of the qualifying degree whatever their intended destinies. Even if the recommendations of this Royal Commission are put into practice, the problem of exactly what to teach and what to leave out of a curriculum remains an important question. The preclinid subjects have long been subjected to criticism, especially the teaching of anatomy. In the past, medical students have been expected to learn much which will never have a practical application, but exactly how to distinguish useful knowledge from the useless is a question so far unanswered.

Use of Basic Medical Knowledge The purpose of this paper is to indicate the use made by one general practitioner of basic medical scientific knowledge. Inevitably the results of the

survey are personal impressions which cannot help but reflect personal knowledge and interests. I spent a postgraduate year in a department of anatomy and hence have a greater knowledge and appreciation of that subject than of the other basic medical sciences. This paper was intended origin- ally to investigate the use made of anatomical knowledge, but the opportunity was taken to in- dude observations on other basic medical sciences. A greater personal knowledge of basic medicaI sciences other than anatomy may have resulted in a more frequent application of those subjects, such as a greater use of laboratory investigations in con- sequence of greater biochemical knowledge. Pre- sumably it would be possible to develop some degree of competence in clinical method with little or no knowledge of anatomy or physiology, but knowledge of preclinical subjects must facilitate every aspect of history taking, examination, and treatment of patients, even though that knowledge may have been applied unconsciously. Psychology is probably applied in every contact between patient and doctor, even during telephone con- versations, but for the purpose of this paper the application of psychology was restricted to the abnormal.

Nature of Analysis Because of the large numbers of people seen by the general practitioner in an average day, too detailed an analysis proved to be impossible. However, at the termination of each consultation or contact with a patient, brief notes were made of the basic medical science or sciences consciously employed during that consultation.

It was found impossible rapidly to separate pharmacology from therapeutics, or psychology from psychiatry. Maybe the practice of medicine is inseparable from applied physiology or surgery from applied anatomy, but here the distinctions

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were found easier to make. As patients consult family doctors with treatment in view, the number of prescriptions given is high, also many of the pre- scriptions written and counted in this survey were 'repeat' prescriptions - that is, those written to replenish the supplies for patients suffering from such conditions as diabetes and heart failure. Many are for simple preparations, but it is fair to state that even the simplest prescription cannot be written without a knowledge of pharmacology and therapeutics.

In some cases, a knowledge of more than one of the basic sciences was used. For instance, the treatment of middle ear disease associated with tonsillitis requires the application of pathological and therapeutic knowledge, and if, as frequently happens, the patient asks how and why infections spread from the throat to the ear, a knowledge of the regional anatomy is necessary for a satisfactory and convincing explanation. It is not suggested that the general practitioner uses such detailed knowledge as would be required by the surgeon, but a good working knowledge of many points is commonly needed. The cause of abdominal pain cannot be diagnosed satisfactorily unless the prac- titioner applies considerable anatomical knowledge. While he need not know, for instance, the names or distribution of the branches of the coeliac artery, he must obviously know the relative positions of the organs in the abdominal cavity, the ways in which pain may be referred, and a host of other similar points.

In considering the applications of pathology, it quickly became apparent that the sub-divisions of this subject were too closely interwoven for them to be considered easily in a survey where speed of note making was of paramount importance. A wide general knowledge of pathology in all its forms was applied continuously.

Analysis of Use With such an approach, notes were made of 7,500 consecutive consultations from early in September 1967 until mid-May 1968. The practice in which the survey was undertaken is approximately 9096 urban and 10% rural, with patients predominantly young or early middle aged.

The frequency of application of the various basic medical sciences was as follows, the percentage of application in consultations being given in paren- thews. The total number of consultations was

7,500: anatomy - 814 (II"~); physiology - 675 (9%); biochemistry - 17 (0.2%); pathology - 2,743 (3794); pharmacology and therapeutics - 5,861 (78%); psychology and psychiatry - 425 (604); genetics - I (O.OI~(,).

Much of the work in general practice is involved with trivialities. Nevertheless, these figures indi- cate that over a third of the consultations required a conscious application of pathological knowledge, and the fact that the frequency of applying thera- peutic knowledge was approximately double that of pathology may suggest that those suffering from a disease required more than one consultation on average.

The closeIy similar percentages for anatomy, physiology, and psychology/psychiatry are worthy of comment. While it is admitted that psychology was not separated from the clinical subject of psychiatry in this series, it would appear reasonable to suggest that psychology could be given a greater place in basic medical courses than is now the case.

The very low frequency of applying bio- chemistry is to be expected, as this is a subject more closely connected with practice in hospital. The general practitioner mny have access to the local laboratories but biochemical investigations do not play a great part in his day-to-day life.

A knowledge of genetics was used only once, and that was to explain mongolism to the unfortunate parents of a baby suffering from that condition.

Physiological Knowledge Physiological knowledge was consciously applied in 675 consultations, and it was found possible to sub-divide these as follows: blood - 127 (19%); endocrine - 295 (44%); renal function and fluid balance - 78 (127i); metabolism - 42 (6%); neurophysiology - 24 (404); digestion - 65 (9%); cardiovascular - 44 (6%).

The very frequent application of a knowledge of endocrinology results partly from the many cases of menstrual disorders dealt with by the general practitioner, but mostly from the recent upsurge of interest in the subject of oral contraception. Whether or not oral contraceptives are prescribed, the general practitioner must be prepared to face a battery of questions on the subject and consequently must apply his knowledge of the endocrine glands frequently. At this point, it is worth observing that my original store of knowledge of endocrinology, gained 20 years previously, was inadequate and

The Application of Anatomy in General Practice I47

further reading was necessary to acquire com- petence in this field.

Anatomical Knowledge The main and original purpose of this paper was to make observations on the application of anatomical knowledge in general practice. More extensive and detailed notes were therefore made in the case of anatomy than in the other basic medical sciences. A knowledge of anatomy was consciously employed in II?& of consultations, that is in a total of 814 cases, which were distributed throughout the field of anatomy in the following way, numbers in each category being given in parentheses : histology (4), vertebral column (56), embryology (14)~ skull and teeth (7), CNS (31)~ muscles of neck (2), peri- pheral nervous system (31), thyroid (I), eyes (34), temporo-mandibular joint (3), mouth and pharynx (g), lymphatic drainage of head and neck (17), nose and sinuses (20)~ ear and Eustachian tube (95), larynx (I), breast (18)~ diaphragm (I), thoracic wall (9), heart (I), lungs (IO), muscles of shoulder girdle (8), bones of upper limb ( 5 ) , shoulder joint (IZ), elbow joint (31, wrist joint (IS), hand (zz), lymphatic drainage of upper limb (4), bones of lower limb (16)~ sacroiliac joint (IO), hip joint (11), knee joint (30)~ ankle joint (IS), muscles of lower limb (5 ) , blood vessels of lower limb (18)~ lympha- tic drainage of lower limb (I), abdominal wall (28), abdominal cavity @I), perineum (61)~ anatomy of

The frequency of using a particular item of anatomical knowledge is, of course, not necessarily in proportion to its importance. For instance, a knowledge of the anatomy of the breast is probably going to be more life saving than that of the ankle joint, even though a sprained ankle is seen more frequently than the carcinomatous breast. Embryo- logy appears to be relatively unimportant in the findings of this survey, but it is interesting to note that eight of the 14 embryological subjects were cardiac. With the increasing possibilities offered by surgery in this field, the general practitioner will want to know a reasonable amount of cardiac embryology. Without such knowledge, he will fail to impress his patients and he will feel inadequate and dissatisfied with his own ability.

pregnancy (97).

Implcations for Teaching It is hoped rhat this survey will be of interest to

those involved in teaching anatomy, so perhaps it is relevant to observe that six subjects accounted for over 50% of the cases in which anatomy was applied. The six subjects were the nervous system, the vertebral column, the ear and Eustachian tube, the perineum, the abdominal cavity, and the anatomy of pregnancy. The latter was included as it is of paramount importance in practice, and is neglected by teachers of anatomy. The relation be- tween the full term foetus and the maternal body, and the anatomical points associated with the pro- cess of birth, should first of all be taught by anatomists and revised by obstetricians, not taught by the latter alone as is now the case.

Throughout this survey, it was obvious that anatomical knowledge used by a general practi- tioner was ‘living anatomy’. After all, the patient says, ‘It hurts when I do this or that’, or ‘I am unable to move this or that part of me’. Also, over 25% of the cases were involved with bones, joints, and muscles. Consequently a plea is made for a greater emphasis on function and the study of the living body. Surface anatomy, radiology, and cine films should be exploited to the full. Too often it is the clinical student who first sees a film of the living heart or the contracting stomach during a barium meal. Perhaps anatomy should be taught by means of a short introductory course of about one year, followed by detailed regional anatomy integrated with the clinical course. For instance, the student in the orthopaedic department could receive instruction on the structure and function of bones and joints at the same time as studying the diseases and injuries of those parts.

It would be impossible for any student to learn all that is known. The purpose of education must therefore be firstly to provide a basic knowledge, and secondly to develop an ability to acquire further knowledge. The latter becomes increasingly important with the widening scope and rapid advances in medicine. During the period of this survey, reference to medical literature either for refreshing the memory or for the acquisition of new knowledge was made at least once and often twice daily, and without doubt a greater basic knowledge of a subject resulted in a faster and easier acquisi- tion of the new knowledge. The more one knows, the easier it is to learn new facts.

Conclusion Medical educationalists are faced with the prob-

148 Donald Hines

lems of what to teach and what to leave out of the curriculum. This survey indicates that the basic medical sciences should not be neglected, and it is offered in the hope that it may indicate which parts of the various sciences are most relevant to general medical practice. Perhaps, too, it may stimulate similar surveys from other fields of medicine, and

in basic medical sciences for general practitioners !

Acknowledgements I wish to acknowledge the interest given to this survey by Dr John Ellis 2nd Professor R. J. Harrison.

Reference perhaps even the Of a refresher Royal Commission on Medical Education (1968). Repor[.

Crnnd. 3569, H.M.S.O.: London.