1005 A DESIGN FOR GENERAL PRACTICE SIR,-Ifind it ironical that Dr. Eimerl and Dr. Pin(Oct. 12 and 19) can make a design for general practice without ...

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SIR,-Ifind it ironical that Dr. Eimerl and Dr. Pin(Oct. 12 and 19) can make a design for general practice without trying to define its aims, while Dr. Apley (Oct. 26), as a consultant, has something wise to offer a general practitioner in every paragraph; and finally Professor Neale (Nov. 2), working in apparently the same parish as Dr. Apley, congratulates Dr. Eimerl and Dr. Pinsent. This game of ring-a-ring-of-roses might be amusing if the subject was less serious. I cannot believe that good general practice depends on whether the surgery is called a consulting-room or not, or whether there is a nurse, a receptionist, an appointment system, or anything else except clinical skill and a sound understanding of the doctor-patient relationship. If these are 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 organisational sent

and I

am afraid that like Leonardo da Vinci we the varnish before the picture is painted. discussing or Anything anybody coming between the G.P. and his patient is potentially dangerous. The only efficiency that matters is the doctor’s capacity to understand and help his patient.

matters are

Must we for ever


after trying to do hospital medicine in general practice ? As Dr. Apley says, " hospital illness is not an entity but only an episode in the life of the patient and his family". I should like to add that it is only an episode in the professional life of his general practitioner. Nor can social measures alone deal with the patient’s problems, dealing only with his external situation, and leaving his internal situation unexplored. I have yet to see rehousing cure anything in the way of illness in a personal sense, however necessary it may be run

socially speaking. I think that the dissatisfaction of us general practitioners from a feeling that we need the specialist and the hospital, but have doubts as to whether they need us. It’s nonsense, of course, so before we jam our boot in the hospital door, we must ask ourselves what real use we can be to the hospital doctor while our patient is there. Any time a G.P. spends in hospital is likely to be wasted unless it bears on our We might avoid admitting own patient-care responsibility. patients unnecessarily and arrange their discharge (either earlier or later) at a more appropriate stage than can be judged by the hospital alone. It is often at the latter point that communication between the two utterly breaks down, as protocol seems to demand a great deal of communication between the two before the patient is admitted, but none at all before the patient is discharged into the G.P.’s care. It is up to us to prove to our hospital colleagues that we can be of use to them as well as the patient. stems

We may appear to deal with episodic illness, but we really deal with a person suffering disturbances of health that we are also heir to; but with our twin skills of medical understanding and professional detachment, we always have the power to teach, and sometimes even to heal our

patients. After all, want ?


have the whole

patient. What

more can







SIR,-Iwas interested in your annotation of Oct. 5 in which you suggested that free legal aid was an important reason for the increased litigation against the medical profession. The rise in legal action against doctors has been even greater in 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 a doctor presses aggressively for payment of his medical fees after an unsuccessful case, the unfortunate patient or relative having often 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 some lack of consideration for, or unkind action to, the patient or his relatives which finally provokes the legal attack. Much litigation can 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 the United Kingdom has followed the decline of the " old family doctor "-


Peter Bent

Brigham Hospital, Boston, Mass.



Research Fellow.


SIR,-I was very interested in Dr. Kemp’s article (Nov. 2) and particularly his recommendations for the education of the elderly. I wonder, however, whether he has gone far enough. " Doctors then have a task peculiar to their profession to help their elderly patients to keep hope and morale high till the very end. The patient who believes that he is done for and finished has said goodbye to health as well as to happiness and purpose." Here Dr. Kemp seems to regard death


the final disaster which should




templated during life, and this attitude leaves the most important 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 cared for his patients throughout the other hurdles of life may also be required to help during this final step. For a man to be happy and heahhy, he must be prepared and willing to relinquish his life at any time and in any case where it can no longer be usefully preserved. In my experience many elderly people suffer from hypochondriasis as a result of fear of death. We know that in life mental and spiritual factors are more important than the physical in maintaining happiness and a sense of purpose. We do not lose our peace in preparing for death, but, being freed from fear, are able to live more fullv. GERALD TEWFIK. SPINAL INJURIES SIR,-Like Mr. Hardy (Oct. 19) I have followed this correspondence with interest. Like him, I feel that we

trying to do our best for the patient in restoring and preserving as much function as we can. It is for this very reason that, having seen some 2000 traumatic paraplegics, of whom over 80 had been treated by open reduction and are


convinced that conservative treatment is the better method. Incidentally, I have noticed that out of 450 recently injured cases admitted to this hospital in the past six years, only 9 cases had been plated before admissiona figure which does not support the statement that most surgeons agree that operative reduction and fixation is the best treatment. I have seen too many cases in which open reduction and fixation have resulted in an increase of the patient’s disability to be concerned whether the fault is one of principle or of technique-the more so since the safer, if perhaps more exacting, method of conservative treatment is available.

fixation, I


Mr. Holdsworth’s comparison (Aug. 24) of a fractured spine a fracture of the tibia and fibula does not give due recognition to the splinting effect of the trunk muscles in thoracolumbar fractures. This makes it relatively easy, by conservative methods, to prevent redislocation and allow the