Declan writes:

>Let us cast our  minds back to one of the few truly brilliant thinkers of
>the second half of this century---Ivan Illich.  Ivan would say that the
>college is a classical example of an institution which pays more attention
>to its own need to grow, to survive, to control its environment than to its
>supposed reason for existing. Likewise its senior members----the needs of
>the college as a socio-cultural organism and source of power use up a lot
>of their time and energy.    The college has passed the point of doing more
>good than harm; 

This is surely the most important point. The college has ceased to be at
the forefront of advances in general practice. Instead it defends an
increasingly outdated tradition. The ideas of Balint, the notion that
anything is the GPs business as long as patients bring it to the
surgery, above all the implicit assumption that the job of vocational
training is to *teach* doctors what is *known* to be required for good
general practice all belong to the 60's and 70's.

When I was a vocational trainee I was struck by how the VTS teachers
assumed that our hospital jobs would teach us about medicine but that
the VTS would teach us about patients. It was Jack Norell in the early
80s who expressed his embarrassment at discovering that material for the
MRCGP exam was validated by "looking it up in the appropriate specialist
textbook".

The result is a generation of GPs who have been taught how to be touchy-
feely towards their patients but not taught much about the practice of
medicine in primary care. This is something they have to find out about
for themselves. 

Just as the exploration of the consultation led to a paradigm shift in
GP expectations about their role, so we now need a new paradigm shift.
Personally I believe that evidence-based practice (and especially
clinical epidemiology) are the way forward both in GP training and
practice, since they give the practitioner exceptional clarity in
defining clinical problems. The fact that many of the more traditional
college types have expressed scepticism about EBP ("it will detract from
the holistic approach" they wail, "it will lead to a biomedical
approach" they complain, "RCTs can't answer all our questions" they
assert without bothering to find out that EBP is about much more than
RCTs) only confirms my view that it is really useful for us!

There is a need for GPs to practice medicine in the community for two
reasons. First there is no longer any such animal as a general physician
in most hospitals, second modern advances in diagnosis and therapeutics
enable us to investigate and treat conditions that would once have
required hospital admission, never mind an outpatient appointment.

We really shouldn't be doing surgeries full of people with coughs and
colds - nurses are more than capable of telling them to take
paracetamol! Nor should we spend hours "counselling" people with
hopeless social or personal problems. We should, on the other hand, be
capable of early diagnosis of serious illness (especially if it is
treatable), and of treating it with the most effective and up to date
tools.

When I have spoken to GP educationalists I have often had the feeling
that they were:
1) incredibly smug and
2) incredibly ignorant of the world outside the holy writ of vocational
training and
3) unwilling to listen to anything that did not fit in with their
established world view

Cheers

Toby  
-- 
Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel
0191-2811060 (home), 0191-2437000 (surgery)


%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%