Better Family Doctors
This is the winning entry in the " Spectator" competition for articles on this subject. The writer is compelled for professional reasons to remain anonymous.
WHAT do people reasonably expect of a family doctor ? Always that he should give them competent and sympathetic professional service; often that he should be a trusted family friend, to whom they can turn for advice over many of the problems that perplex them; some- times that he should support them in medico-legal matters. But a bald statement , of this sort does less than justice to a service that must be founded primarily upon the human relationship if it is to be fruitful and to give satisfaction to both partners in the contract. For a contract it should be, with a contribution from both sides, though mainly from the doctor's. • The quality of the service given by a family doctor is a measure of his professional skill and of his ability and readiness to bring the best-human qualities to succour those who are in need. Gentleness, tact and sympathy stand high in the list, but many more could be mentioned, such as understanding, forethought or anticipation and the self-assurance necessary to inspire confidence. In short, the doctor should be a man (or woman) whose knowledge of medicine is backed up by sound character, an attractive and convincing personality, knowledge of the world and a desire to help those that are perplexed or distressed. Any suggestions for improving the standard of his service should, therefore, take into account his professional training, his personal suitability for the job and the conditions under which be works.
For some years there have been doubts whether the present curriculum provides a suitable clinical training for doctors entering general practice. As specialism advances—so greatly to the benefit of individual patients—clinical teachers tend to concentrate their teaching upon the details of diagnosis and treatment rather than upon the broad principles of medical practice; and the patients under their care in the so-called teaching hospitals " are more and more becoming a selected group suffering from relatively rare or complex disorders, rather than a cross-section of the types that usually need the family doctor's attention.
Now it cannot be denied that students find much interest and a lively stimulus in watching the expert at work, and they feel that they are playing a part—even if small—in the advancement of knowledge. This is all to the good, and undoubtedly helps to implant in their minds the ever-continuing evolution of medical practice ; for every doctor, like the Red Queen in Alice through the Looking- Glass, has to keep running if he is not to lose ground. But the length of the student's course must be kept within reasonable limits, and familiarity with unusual types of case and with expert techniques can be overdone if there is too little time left for the study of health and how to preserve it, the practical care of patients in their own homes, the prevalence and prevention of disabilities, both physical and mental, that are related to the conditions of life today, and many other aspects of medical practice that come within the province of the family doctor rather than the consultant. There is no easy solution of this problem. In some teaching centres attempts are being made to arrange for students to visit patients in their homes—a partial return to the old apprenticeship system--and it is to be hoped that the recently formed College of General Practitioners will be able to play a useful part in fostering developments of this sort and in per- suading the teaching hospitals to add experienced family doctors to their staffs.
Again, the suggestion has been made that an additional course of study, subsequent to qualification, should be arranged for those who propose to engage in general practice. A special course of this sort might well provide valuable academic instruction; but it must be remembered that it is in the home and the private surgery that the general practitioner gives his service, which embraces to some extent every type of medical work. In other words, the practical training could be secured only by arranging for the doctor to be apprenticed to a senior colleague, and this presents a number of difficulties that could not be discussed in the space here available. I To comment upon the doctor's personal suitability for his work is to underline an aspect of practice—the " human " side of doctoring—that is almost as important as the standard of professional care, and it may be asked whether qualities which are of the spirit rather than of the hand or brain can be taught to young men and women, or whether they must be born in a person, or at any rate actively fostered during the earlier years of life. Clinical teachers who display the desired qualities in their daily contacts with patients undoubtedly influence their pupils,by their example. But the seeds they sow are more likely to coifie to full fruition if they fall upon prepared soil.
Is it possible to pick out, from the large number of applicants for training, those with a natural ability for medicine and a personal background of the best type ? It cannot be claimed that any satisfactory technique of seleCtion has yet been found, though the question is still being studied; and in the mean time, since the years of childhood are so important in forming charac- ter and moulding personality, it would seem sensible to focus particular attention upon the candidate's home-life, for it is in the dignity of a well-ordered family-circle that courtesy, respect and the social graces are learnt. When medical students lack this solid foundation, their pattern of--conduct towards patients is likely to develop as a thin veneer, or as a cloak donned for the occasion, and the so-called bedside manner may evolve as insincere posturing.
Finally, some observations upon the conditions under which the family doctor works, and their influence upon the service he gives to his patients. The right type of man, with a good professional training, desires above everything else to be employed as a doctor rather than as an official who signs certificates and permits, but he struggles against pressures which are inseparable from the conditions of life today. He has become a unit in a gigantic machine designed to provide a com- modity, " medical service," to the people, and in the process he has lost much of his individuality and is in danger of losing, to some extent, even his professional freedom.
Now it is a curious fact that in an era greatly concerned for the rights and privileges of individuals, and dominated by the belief that intelligent planning should be able to provide what is required, there is a real danger that the plan itself, its administration, its details and the welfare of all its workers may gradually assume an importance greater than the service it is intended to provide. Whether one thinks of transport or coal or the Health Service, it is the man at the " receiver " end— the passenger, the coal-user or the patient—that should rank first. But these people do not earn their livelihood by being passengers or patients, and cannot therefore band themselves mto societies or unions to express their views. Their hope is centred in the efforts their family doctors make to interpret the scheme in as efficient and human a manner as they can.
Obviously doctors should not accept responsibility for too many families. The actual number will vary from practice to practice, but it should be based rather upon visits to patients than upon surgery numbers, because it is in the home that a doctor has the best opportunities for giving the service—both curative and preventive—that should be available. The group- ing of doctors in partnership .may be an advantage to patients, because each doctor may concentrate upon a particular branch of medical practice, for instance, anaesthetics or child welfare.
Proper surgery facilities are essential; and family doctors should be closely associated with hospitals whenever this can be arranged, and if necessary in rotation. Finally, arrange- ments for family doctors to attend " refresher courses " should be extended so that the benefits of recent advances in diagnosis and treatment niay reach patients speedily.
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