General Practice as an
essential part of a
socially responsible
health care system
Iona Heath
“Primary Care and Family Medicine:
Practical Implementation Challenges”
8th June 2009
Holiday Inn, Silom, Bangkok
gift of history
specialist/generalist
divide
Apothecaries Act
1815
Medical Act
1858
The physician and
surgeon retained the
hospital but the general
practitioner retained
the patient.
Stevens R.
Medical Practice in Modern England.
Yale University Press, 1966
In hospitals, the
diseases stay and the
people come and go; in
general practice, the
people stay and the
diseases come and go.
Power of scientific
medicine for both
good and harm
•A human being is both a
subject and an object;
•Illness is different from
disease;
•Demand is different
from need.
•A human being is both a
subject and an object;
•Illness is different from
disease;
•Demand is different
from need.
- the prevailing commitment to accurate
diagnosis of disease - which is the hallmark
of the modern physician - turns on the
notion that there is a pure disease state
which is, ideally, distinct from the patient.
Thus, the patient is seen as a kind of
“translucent screen” on which the disease
is projected. In consequence, ... the
patient's subjective experiencing of illness
is ignored in favor of an objective,
quantitative account of a disease state.
S. Kay Toombs
The meaning of illness: a phenomenological account of the different perspectives
of physician and patient., 1993
- individual and
closely intimate
recognition is required
on both a physical and
psychological level.
John Berger
A Fortunate Man, 1967
- the mystery of the
individual is precisely
what must be put into
the facts to make
them meaningful.
Boris Pasternak
Dr Zhivago, 1958
The body as object: gaze of biomedical science;
what this patient has in common with other
patients (normative monological)
Object
Doctor
Patient
Subject
The body as subject: what is unique for this
person; life context, story and meaning
systems (dialogical)
Theory … grows out of
particular circumstances and,
however abstract, is validated
by its power to order them in
their full particularity, not by
stripping that particularity
away.
Clifford Geertz
Available Light - Anthropological reflections on
philosophical topics, 2000
uncertainty
None of us - generalists all,
working in an open system
of human interaction can
afford the luxury of
certainty, or even near
certainty.
Stevens J.
Brief encounter.
J Roy Coll Gen Pract 1974; 24: 5-22.
•A human being is both a
subject and an object;
•Illness is different from
disease;
•Demand is different
from need.
Stressful life
experience
Illness
Disease
Disease
requiring
hospital
treatment
Power of scientific
medicine for both
good and harm
The strength of a country's primary
care system was negatively
associated with (a) all-cause
mortality, (b) all-cause premature
mortality, and (c) cause-specific
premature mortality from asthma
and bronchitis, emphysema and
pneumonia, cardiovascular disease,
and heart disease.
Macinko J, Starfield B, Shi L.
Health Services Research 2003; 38: 831-865.
•A human being is both a
subject and an object;
•Illness is different from
disease;
•Demand is different
from need.
social solidarity
fear
Schwartz LM, Woloshin S. Changing disease definitions:
implications for disease prevalence analysis of the Third
National Health and Nutrition Examination Survey, 1988–
1994. Effective Clinical Practice 1999;2:76–85.
32 million more patients
Three quarters of the
total adult population
need
needs of the
individual
needs of the
population
GP
•caution
•doubt
•frugality
Contemporaneous and timelagged primary care physician-topopulation ratios were
significantly associated with lower
all-cause mortality, whereas
specialty care measures were
associated with higher mortality.
Shi L, Macinko J, Starfield B, et al.
The relationship between primary care, income
inequality, and mortality in US States, 1980-1995.
J Am Board Fam Pract 2003;16:412-22.
illness
disease
Sustaining
generalism:
•College
•Teamwork
College:
•identity and self-confidence
•equivalent status
•mutual respect
•training, education, standards
•examination set and assessed
by generalists
Teamwork:
•a seamed service
•interprofessionalism
Primary Care Team
• general practitioners
• nurses
–
–
–
–
practice
home
older people
children and babies
• midwife
• pharmacist
• interpreters
• social worker
• money, benefit,
employment adviser
• administrator
• reception and
clerical staff
• secretaries
• trainee professionals
- the
most fascinating
and absorbing and
rewarding job in the
world.
S Taylor
Good general practice
1954