CAN HOSPITAL TRAINING PRODUCE GOOD GENERAL PRACTITIONERS?
ACMANEWS (News Magazine of the Australian Chinese Medical Association)
Vol 3, No 4, September 1993, page 10
INTRODUCTION
A medical graduate is an undifferentiated doctor with the flexibility of outlook and training in knowledge, skills and attitude necessary to progress in any field of medical endeavour. The postgraduate training is for helping graduates reach a desirable standard for independent practice.
General practice can be defined shortly as a distinct medical discipline which deals specifically with the delivery of primary, continuing, comprehensive and whole-patient care to the individual and the family in their natural environment. Arising from the definition, we can see that there are a number of special features which make general practice unique.
The words ‘general’ and ‘comprehensive’ do not imply knowing everything about everything. They indicate a range of interest and a level of expertise that is broad but not inclusive(1). But, is general practice simply the practice of various hospital based discipline in the community? It is the structure and process of general practice rather than a specific body of knowledge which makes it unique. McWhinney has stated “although much is derived from other disciplines, the knowledge required is different in degree and in kind from that needed by the specialists in these subjects”.(2).
STRUCTURE AND CONTENT OF GENERAL PRACTICE vs HOSPITAL PRACTICE
In general practice, there is a high prevalence of symptoms and discomfort, but a low prevalence of frank diseases(3). “Many complaints are obscure, vague, undifferentiated, unusual, bizarre, non-physiologic or non-anatomic.”(4) Other fields of medicine encounter these problems too, but few to the same extent as general practice.(4) Only about half of the general practitioners’ diagnostic vocabulary is obtained from hospital experience. An extra 250 diseases’ must be learnt in general practice itself because these are rarely encountered in the hospital setting.(5)
Many newly graduated undifferentiated doctors or hospital trained doctors found themselves totally unprepared to encounter the illness outside the hospital and have so much trouble in applying their hard learned knowledge to the handling of undifferentiated illness.(6) Professor Bass said, “When I graduated, I knew an awful lot. The problem was that the patients did not have anything I knew about”(7) Sir James Mackenzie said, “I was not long engaged in my new sphere (of general practice) when I realized that I was unable to recognize the ailments in the great majority of my patients.”(8) Cassell said, “When the hospital trained doctor goes into practice, he may go into depression. He finds that he has few patients of what he often saw in the hospital. The patients with uninteresting diseases of yesterday are now his daily patient. “(9)
Hospital approach to patients tends to separate the disease from the man, and the man from his environment. McWhinney indicated that medicine of specialist is of entities rather than the medicine of relations, while illness seen in general practice is intimately related to the personality and life experience of the patient. The patient is inseparable from the environment.(10)
Stephens has also argued, “the content of family medicine is the ordinary more than the extraordinary, the common more than the rare. It is on the problem more than the disease, the organism more than the cell. It is on the behaviour of the organism more than the biochemistry, and on the sociality of the individual more than the individuality. “(1)
McWhinney pointed out that ‘Many of the problems are persistent and disabling, associated with marked anxiety or mood change and out of proportion to physical or laboratory findings. All of these require something more on the part of the physician than a standard operation procedure which was learnt in hospital training.“(4)
General practitioners commit to a person rather than a particular technique or a particular group of diseases. General practice has no boundaries and is open-ended. It is this long-term doctor-patient relationship, which has no end point, crucial for healing.
PROCESS OF GENERAL PRAC TICE vs HOSPITAL PRACTICE
Medical students in hospitals see patients who are usually at the end of the chain of decisions leading to diagnosis, hospitalisation and treatment. They see patients with diagnoses rather than those with problems. Thus they have little opportunity to practise the data gathering and hypothesis generating skills that the general practitioner first seeing the patient with the symptom complex must use.(1)
Because of the uniqueness of the structure of general practice, one of the most important skills is the ability to sort serious from trivial and self-limiting ill ness. The sensitivity, specificity, and predictive value of clinical data and tests vary greatly with the prevalence and distribution of illness in the population. The general practitioner must learn the symptoms and tests which have the highest sensitivity and predictive value for a family practice population. Most textbooks are written about the later stages of disease and do not describe tests in the terms of their sensitivity, specificity and predictive value.(12)
Dudley said, “Family physicians live on the boundary between the concepts of health and illness; between the perspectives of psychology and sociology; between the history of the patient and his own future; between the concepts of ‘cure’ and ‘care’. At the boundary, there are confusion, discomfort and uncertainty.”(13)
He defined diagnosis as “the substance of a decision upon which action is based at any point in the patient’s course.” He substituted utility for pathology by pro viding a management rather than a disease-naming diagnosis.(13) Specialists usually need to be very much sure of a diagnosis, while in general practice, we are quite happy to deal with the problems even though we are unsure of the diagnosis.
Hypothesis of problems springs into consciousness as we respond to the cues. The incoming information is matched with other information stored in the mind’s filing system. The greater the doctor’s experience he got by working in a range of hospital specialities, the more powerful will his or her hypotheses be.(4) However, it has been shown that at most we can handle five to six hypotheses at a time. The less likely hypotheses serve only to disturb the deductive process.
Assessments
‘History’
Besides using the common disease categories, family physicians use other types of categories to help them in dealing with early and undifferentiated ill ness. We can use the eliminative diagnosis to define what the patient does not have and hence can make management decisions prior to, or instead of, diagnostic decisions such as discontinuing the search and observe the patient, expecting the illness to be minor and self-limiting.(4)
Hospital consultations are often disease-centred. The patient-centred general practice consultations occur in the patient’s own habitat or home which provides a unique opportunity to explore the relationship between environment, physical and social factors, and the patient and the illness. We adopt a multi-factorial ideology for understanding ill ness.
We try to gain sufficient under standing of the patient’s experiences of life and views of the world, in a sense to be able to view the world as they do.
The range of background experiences affects the way the doctor functions. Doctors with hospital training in various specialties have assumptions based around the medical model and expectations about how patients should behave. General practitioners need to have an open mind and a broad approach to en able them to understand people who come from a broader sense. It takes a great deal of maturity to be sensitive to those different levels, not a range of hospital specialty training.
Balint noted the inadequacies of the hospital specialty clinical method for reaching any deep understanding of the patient’s illness. “The need was to listen, not to ask questions.” He also made the distinction between traditional diagnosis and overall diagnosis, i.e. the search for a pathologic source versus an attempt to understand the patient and the doctor-patient relationship.(14)
The doctors in the various training specialties, like in the cabinet or an ivory tower, are too high or mighty to under stand what is going on in the grass root community. Only those being trained in the community can fully understand the problems there and then.
‘Examination’
With low prevalence of certain diseases in the community, and hence low incidence of rare signs, some hard-won clinical knowledge and skills learnt in the medical school or hospital training may be lost. We concentrate on those physical signs that help us in our every day work.(5) Some skills to elicit certain signs are lost not because they are not accurate, but because they become superfluous or seldom influence our diagnostic or management decisions. The general practitioner must be prepared to discard tests that do not help him. The general practitioner must learn from experience how full an examination is indicated in different patients.
The daily living assessment, examining the patient’s capability in his environment, frequently reveals much more than any formal physical examination.
‘Investigations’
A high proportion of hospital patients have serious disease and the doctor can justifiably order complex investigations.
In deciding on a search strategy, a doctor may be heavily influenced by the rules of the hospital. Such rules, applied with the best of intentions but regardless of individual situations, lie behind some of the over-investigation that occurs in hospitals.(4) In general practice the proportion of trivial diseases is high, and wide spread application of hospital diagnostic techniques is often unjustified.(5) The variation of predictive value with prevalence means that a test that is indicated in a hospital may be contradicted in general practice.(4) A GP should be selective in deciding who and to what extent to investigate.
General practice uses minimal technology and exercises a lot of compassion, not only for the patient’s overall well being but also for their purses. Training in more hospital specialties allows the doctor to learn to use more kinds of technologies which are hardly used in the low-tech general practice. The doctor at the same time learns more about diseases and he becomes more ‘medicalised’ and needs more effort to unlearn it when he becomes a general practitioner. The end point of the search on any particular occasion in general practice is the point at which enough information is available for an informed decision to be made without avoidable risk to the patient.(4)
The difference in the time scale between hospital medicine and family medicine is one of the most difficult things for beginners in family medicine to grasp. In general practice, the prevalence of serious disease is low, and delay may be used as a deliberate strategy to change the probability of diagnosis and hence the predictive value of the doctor’s assessment.
This approach can save many unnecessary investigations in self-limiting ill nesses.(16) We can keep an eye on our patients over a period of time, some times over a span of months or years and within this period, the patient can approach us whenever he likes. Used skillfully, time is a valuable diagnostic and therapeutic tool.
‘Management’
Krebs had argued that “the whole is more than the sum of its parts.”(16) So having attained knowledge and skills in managing the different parts of the body does not ensure capability of managing the whole person well. Treatment, whether specific or non-specific, is only a part of management which, among other things, includes a decision of whether or not to treat and the assumption of responsibility for that decision.(1)
Specialty training leads doctors to regard healing more of the tissues and wounds in pathological terms. Therapeutics, while providing cure in some cases may do so at a cost, e.g. side effects, overdose, and when a cure is not available for a particular disease, there is a loss of interest in the patient. Many discussions of treatment stop some where like when the patient becomes blind. In general practice, management is a lot more than the treatment of illness. It has to do with the continuity of care and the understanding of the family, having a real role in educating and helping people adjust to life and to illness. We speak of healing of people and this cannot be learnt in hospital training.
Cassells said, “The patient must be cared for, not only for the time of hospitalization but for the months or years of his survival - and so must his spouse and his parents. Further, efforts must be made to minimize the patient’s disability, to maximize his function and work capacity, and to handle fear and dread, be cause when these things are done well, the patient, quite simply, is healthier for a longer time, and when they are done poorly, the patient does poorly,. ..dealing with these aspect of the patient’s illness was not part of his training... .the ideal for which the doctor was trained turns out not to exist in the real world. ..our chief resident was trained to a very high level of performance and excellence, but for the real world he is not excel lent. “(9)
A common fault in management is the failure to consider the effect of management on the ecology of the family.(4) A lack of examination of the spiritual con sequences of disease raises the possibility that the disease is cured but the patient is not healed.
It is the notion that the personal characteristics of the physician and the quality of communication between the patient and the physician are important variables in determining the outcome of patient management. Houston spoke of “doctor as a therapeutic agent” and Michael Balint “doctor as a drug”. Balint states that “by far the most frequently used drug in general practice was the doctor himself.. .it is the whole atmosphere in which the drug was given and taken that matters.”(14) How to use “Doctor” as a medicine in general practice can be learnt in general practice only. Having attained knowledge and skill in a wide range of specialties cannot help to reduce uncertainty. Problems of identity, confidence and honesty are rarely settled by changing fields(1), nor can they be settled by increasing fields.
Recording Tools
To fulfill his role in general practice, a general practitioner needs a special kind of problem-orientated, family orientated medical record as different from those used in the hospital. The age-sex register or disease register can help him to identify the high risk groups which are more vulnerable to certain conditions. Proper use of these recording tools can contribute much in general practice re search and education of trainees.
PREPARATION FOR BEING A GENERAL PRACTITIONER
For optimal functioning, a general practitioner requires a broad and rigorous training(4) and the hospital component is an essential part of this training. It provides our trainees with the opportunities to consolidate their basic knowledge and to refine their basic clinical skills learned during their undergraduate and intern years before they enter the more independent general practice component of their vocational training.
Training in various specialties only cannot prepare a doctor to become a good general practitioner. Hospital training tends to encourage clinicians to adopt a disease-centred approach rather than a patient-centred one. It also fails to provide an opportunity for clinicians to see undifferentiated illness, early stage of diseases, attend patients in their own environment as well as an opportunity to practise gate-keeping. It may even produce clinicians who place excessive emphasis on technology and often lack the desire to examine the psychosocial consequences of disease which raises the possibility that the disease is cured but the patient is not healed. In fact, the doctor has to unlearn the hospital approaches when he be comes a general practitioner.
Stephens argued that the self-under standing and human communicative skills materially affect the way we practice medicine and manage every thing .(15) He concluded that the general practitioner should learn the knowledge and skill in general practice to confront relatively large numbers of unselected patients with unselected conditions, distinguish between a common and a life- threatening problem, learn about coping with diagnostic uncertainty, the epidemiology of disease/disorder in the community and carry on therapeutic relationships with patients with time.(14) Counselling and communication skills, especially in the field of preventive medicine, are essential to this ongoing relationship. Proper approach to a patient can be learnt only by training in the community. Balint said, “The faith that heals, heals not through argument but by contagion.”(l5)
How we perceive and interpret the world is shaped by our mental constructs. We see what we know. A doctor who has learnt clinical problem solving in a hospital tends to have a frame of reference appropriate for patients with serious and well-defined diseases in their later stages. If he uses this frame of reference for solving problems in general practice, he will get into difficulties.(4) If the environment of learning excludes certain variants of illness, these will be excluded from the doctor’s frame of reference. He has to learn a frame of reference, a taxonomic vocabulary and body of knowledge that will enable him to understand and interpret the phenomena of illness (9) and take into account problems rarely encountered in the hospital. Learning a new frame of reference in vocational training, the trainee can acquire the knowledge in shorter time and with less risk to himself and his patients. It would be easier for him if his early experience of clinical problem solving has taken place in a variety of contexts ranging from primary to tertiary care.”(4)
Some argue that as long as the student learns about serious and advanced diseases, he will be able to transfer his diagnostic and management skills to any new range of problems. The evidence from psychology is strongly against this assumption. Elstein, Shulman & Sprafka have found that problem solving ability varies very much from case to case in the same physician. They concluded that the application of general problem solving skills is effective only if the physician has knowledge in the particular domain from which the problem arises.
A prevention orientated practice management is also essential. There is no more suitable educational setting for training in these aspects than in the general practice itself.
Medical knowledge includes information, skill and insight. Medical education has tended to emphasize the information collection and skill training. In general practice, there is always tacit knowledge which cannot be articulated. Balint suggested that the key to learning patient management is modelling or demonstration from the trainer and appropriate supervision of the learner’s interactions with patients. Anything that happens between the doctor and the patient needs to be brought to levels of awareness in a non-threatening way.(14) McWhinney suggested that “a good education should include a certain method of thinking and feeling. Insight and awareness come from human intercourse and deep reflection on the self and on experience. . . . Error in medicine arises more often from a failure of skill or insight than from a lack of information... The physician, lacking self-knowledge, cannot recognize his own failings... The personal knowledge about the patient and his family can be put to good use. He knows, for example, the kind of feelings different members of the family arouse in him, and he can use his knowledge in making hypotheses about problems he encounters in the family.”(10)
These sorts of important, tacit, personal and self knowledge are never heard of in medical school or learnt in specialty or hospital training.
Because of these distinctive values, and ways of thinking and feeling, those becoming a general practitioner must be educated in a setting in which these qualities are all-pervasive, and their teachers must be people who exemplify those qualities. Nobody is going to learn general practice from those who are not general practitioners, or in any environment that is alien to its ethos. The core and essence of his education must be the experience of general practice.
REFERENCES
(1) Stephens G.G. The intellectual basis of family practice. Tueson Arizona; Winter Publishing Co., 1982
(2) McWhinney I., General Practice as an Academic Discipline. Lancet 1966: 419-424.
(3) Dixon A.S., There’s a lot of it about: Clinical strategies in family practice, Journal of Royal College of General Practitioners, 1986; 36:468-471.
(4) McWhinney I, Textbook of Family Medicine, 2nd Edition, pg 1989.
(5) Hodgkin K. Towards earlier diagnosis: a guide to primary care. 5th ed. Edinburgh: Churchill Livingstone, 1985.
(6) Mangoine C.M. How medical school did and did not prepare me for graduate medical education. Journal of Medical Education 1 986;61 (Pt 2):3-1 0.
(7) McWhinney I., The Reform of Medical Education: A Canadian Model, Medical Education, 1980, 14:189-195
(8) Mair A: Sir James Mackenzie MD: General practitioner 1853-1925. London, Churchill and Livingstone, 1973. Quoted by McWhinney I., in Family Medicine in Perspective, New England J. Med., 1975; 293:176-181
(9) Cassell E., The healer’s art. Cambridge Massachusetts: The MTP Press, 1976 pg 20-21
(10) McWhinney I., Family Medicine in Perspective. New England J Med., 1975; 293:176-181
(11) Moore G.T., Opening the ambulatory setting: teaching medical students what they need to know. In: Gastel B, Rogers DE, eds. Clinical education and the doctor of tomorrow. Proceedings of the Josiah Macy Jr Foundation national seminar on medical education; 1988 June 15-18. New York: The New York Academy of Medicine, 1989, 89-90
(12) McWhinney I, Problem-solving and Decision-making in Family Practice, Canadian Family Physician, 1979, 25:1473-1 477
(13) Marinker M. On the boundary, Journal of Royal College of General Practitioners, 1873; 23:83-94. Quoted by Dixon A.S. There’s a lot of it about: clinical strategies in family practice, JRCGP, 1986; 36:468-471
(14) Balint M, The Doctor, His Patient and the illness, New York: International Universities Press, 1957.
(15) Balint M., The Doctor, His Patient and the Illness, New York: International Universities Press, 1957. Quoted by Stephen G. G. in The Intellectual basis of family practice. Tueson Arizona: Winter Publishing Co., 1982.
(16) Krebs, H.A. How the whole becomes more than the sum of its parts, Perspect Biol Med. 14:448, 1971.