Its accuracy is greater than that of any pregnancy test yet described and its simplicity is such that we have trained house-surgeons to do the test, virtually as a sideroom method. The new antiserum and antigen are at present available only for research and trial and have not as yet been made available for marketing. The manufacturers inform us they they already have 3410 statistically analysed results to suDDort the test. Royal Samaritan Hospital for Women, Glasgow.
A DESIGN FOR GENERAL PRACTICE
SIR,-Iagree with Dr. Courtenay (Nov. 9) when he says he " cannot believe that good general practice depends on whether the surgery is called a consultingroom or not, or on anything else except clinical skill and a sound understanding of the doctor-patient relationship...." But how are these skills to be developed and, just as important, how kept up to date ? Seeing too many patients in too short a time does not bring clinical skill: being overburdened with administrative, social, and financial troubles does nothing to help ...
good doctor-patient relationship. We learn that errors occur more often because we do not look or listen than because we lack knowledge. How often are we deterred from looking and listening when we are short of time, or when our patience is fretted by frustration and fatigue ? Dr. Courtenay says that anything or anybody coming between the G.P. and his patient is potentially dangerous. Here I hold the important word to be " potentially ". From clinical thermometry and psychoanalysis to electron microscopy and chromatography we use tools which, unless we know how to use them and keep them in good order, are potentially dangerous-but therein is no good reason for trying to do without them! Good tools do not make a good craftsman from a duffer, but to say that a bad workman blames his tools is to admit that a good workman will not tolerate bad tools. Man has achieved his place in the world by the intelligent development and use of tools. With bare hands he could not even write. " The only efficiency that matters ", says Dr. Courtenay, "is the doctor’s capacity to understand and help his patient." To understand one must have lived and learned-be able to say with confidence " I am a part of all that I have met ". To be able to help is quite another matter. In country practice at least " help " only begins with understanding and sympathy and encouragement. Then, assuming at least a provisional diagnosis has been made and treatment initiated, help may extend, if it has not done so already, to warmth and comforts, home nursing and transport, phone calls and letters. Even for the superman among G.P.S to attempt to do all these things without assistance is to invite the premature curtailment of a worthy but misguided career. Few doctors would prescribe such a way of life for a patient. Good ancillary aids do not make a bad practice good, but today no practice can be called good without them. The good workman’s tools have to be good: they have to be well cared for, and repaired or replaced when they are worn out. The very word " surgery " for the G.P.’s premises is worn out, so why be afraid to replace it ? Professor Neale (Nov. 2) has drawn renewed attention to this obsolescence in two inspiring letters. I referred to it nine years ago in my article1 A Centre for Single-Handed Country Practice in which my solution of this and of many of the problems which beset the G.P. today is fully described (those who are interested may like to know that the project described has worked well over the years, and at present thinking may even make it financially, as well as medicosociallv, acceptable). 1. Brit. med.
J. 1954, ii, suppl. p. 167.
Courtenay does insist that " we always have the power teach, and sometimes even to heal our patients ". Surely neither correspondent will quarrel with me for writing this, not from my office, or my rooms, or my surgery, but from the consulting-room in my clinic. Dr.
Derrydown Clinic, St. Mary Bourne, Hants.
JOHN W. EVANS. CALLS IN GENERAL PRACTICE
SIR,-General practitioners tend to think that the National Health Service gives the patients all the rights and the doctor all the duties. As Dr. Cargill (Nov. 23). shows, the patient can without payment summon the doctor to his home at any hour of day or night for the slightest reason. Patients who habitually abuse their rights usually have a psychopathic disorder which may not always be best treated by the tolerance that Dr. Cargill shows. The N.H.S. swept away the barrier of a fee between patient and doctor, releasing on to G.P.s a flood of psychiatric illness, often in people of low intelligence. This has become a most serious but little recognised problem which Some of these patients can even endanger the N.H.S. have a diffuse disorder with much anxiety and hypochondriasis, and they can drive their doctor to distraction by endlessly consulting him; others, with a psychopathic disorder, will readily use the doctor as a weapon in battles with their fellows. At present we have little hope of curing these patients-the most we can usually offer the hypochondriacal group is some palliation and symptom tolerance, and not even that to the psychopathic group. The main characteristic of the psychopathic patients is defective moral sense, which makes it useless to appeal to their conscience. Psychopaths normally behave themselves only if they know that it is not worth doing otherwise. The G.P.’s only available sanction is removal from his list: unlike Dr. Cargill, I think it benefits the doctor, the patient, and the N.H.S. if he is prepared to use it. Where doctors do have grossly inconsiderate patients removed from their lists the disturbed minority soon learn that there is a limit to what the doctors will stand. It seems that three or four times a week Dr. Cargill is called out of hours to visits which a less tolerant person would call unnecessary. If such behaviour by patients is accepted as normal, general practice will become increasingly demoralised and unattractive to keen doctors until its continued existence may be in question. St. Pauls Cray, Kent.
L. M. FRANKLIN.
SIR,-It is disappointing that the Press did not publicise Dr. Cargill’s report on unnecessarily late calls, for they could create among the public a greater awareness of the unnecessary burden imposed on the busy general practitioner by such calls, which are often the result of lack of forethought and consideration. In this practice it has been the standard procedure when a new patient comes for registration to remind him of the importance of making the request before 10 A.M. when a visit is required. In the waiting-room is a colourful cartoon notice: " If you need a visit please ask doctor before 10 A.M.". All those whose requests for visits are received after that hour are reminded of the inconvenience and possible consequences of their lateness. In this way it has been possible over the years to reduce the number of unnecessarily late calls and consequently to organise one’s time better, to the greater benefit of all concerned.