Sul, —Dr. H. B. Tipler draws the wrong, If " obvious,"
inference from Sir Ernest Graham-Little's point that overworked general practitioners refer trivial cases to hospital. Consultants rarely see the the majority of these cases: it is the junior resident s4ff—house physicians and house surgeons—who do so, and their life is becoming a misery and their legitimate duties seriously interfered with, owing to the huge influx of patients with minor ailments into casualty and out-patient departments. In addition, unwarranted responsibility is thrust on newly-qualified and inexperienced men and women, who try conscientiously to make sure that they do not miss a serious case in the rush. I have been a resident in a number of hospitals, London and Provincial, both before the war and since July 5, 1948, and also did several months' general practice as a locum in a very good country practice last year, so I can claim some knowledge of the problem.
From the resident's point of view the amount of extra work is really advantage—indeed he is often out of pocket—in doing the hundred and one little jobs he used to do in the old days: More important, there is precious little credit or thanks either if he does do them, and unrecognised effort becomes tedious even to the most altruistic. Why, therefore, spend money on, say, instruments for minor surgery when no allowance is made for outlay and upkeep, and when the patient is suitably impressed with the importance of his case, and the doctor's concern for it, if he is sent to hospital to have an abscess lanced or .a toe-nail removed ?
From the resident's point of view, the amount of extra work is really staggering. Casualty departments—many of which have no full-time officer, but depend on residents' seeing cases in turn when they can spare time from their other work—are literally crammed to the doors. At most hospitals there is an unofficial "black list" kept by the residents of local G.Ps., who will dump anything and everything on the hospital at any hour of the day or night. The wonder is that these lists are usually so short, and that so many G.Ps. are still coping so well. The answer to that is that they were brought up in the old school of " service." The residents of the 'present, most of whom will be the G.Ps. of the future, are developing a very different outlook: all but the most cynical are either " agin " G.Ps. as the immediate source of extra unnecessary (and unpaid) work, or, more sympathetically, see the G.P.'s problems and are against the system which is perpetuating them. The cynical may go into general practice for what they can get out of it ; the others never if they can help it—and, if they do, they will be disillusioned before they even start.
This situation seems to me to offer a far more Serious problem than that raised in sterile discussions about what classes of the population are demanding more treatment, and why. The same doctors with the same training are treating the same patients in the same practices and the same hospitals as before. Reclassification of sections of the popula- tion has changed nothing material, but it is bringing about a radical change of attitude. More patients—though not as many as some make out—are developing the " something-for-nothing " mentality, and more doctors are allowing their standards to slip—from disillusion and physical and mental fatigue.
The hundred trivial cases who would perfectly successfully have looked after themselves in the old days—or been treated free at a voluntary hospital (this seems to be often forgotten)—will still be well worth seeing if the one early case of serious illness is spotted in the process. Under the present system it is less, rather than more likely to be so diagnosed, and something is needed to give the G.P. back his pride in his work, and the junior resident that respect for his seniors which will encourage him to go into general practice and try to emulate them. • One cannot instil enthusiasm by Act of Parliament, but one can certainly throttle it.—
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