Sir Denis Pereira Gray, OBE, is a consultant at St Leonard’s Research Practice, Exeter, and Emeritus Professor at the University of Exeter in the United Kingdom
A few weeks ago a blog by Domhnall MacAuley picked up on an article that I had written in the British Journal of General Practice, entitled “Academic general practice: a viewpoint on achievements and challenges.” The article was written to ask some big questions and to stimulate debate about academic general practice and Domhnall’s blog followed it up interestingly and extended the issues.
I am still optimistic about academic general practice. General practice is the key branch of the medical profession and there are still many aspects of it to be discovered. Yes of course “big data” are a new resource and need new techniques, but a place remains for clinical research in general practice and in single research active general practices too. However, the relationships and the support for research in clinical settings need clarification and funding. The prime role of single practice research is to study new clinical developments, to scope their potential, and pave the way for bigger definitive studies. Single practices do have the numbers for statistical significance if they choose their subject— for example, most group practices now have 1,000 patients who are seniors,
In one single practice, Sweeney and colleagues found that patients who did not receive continuity of care with their GP had more problems and used the A & E department significantly more often. This initiated discontinuity research which was later extended in the USA and pointed the way to big surveys which confirmed the finding 19 years later.
Is more research is needed on continuity of care?
“Yes”, say patients who simply hate repeating their story and seeing strange doctors. As the President of the Patients’ Association once said to a meeting at the Royal College of General Practitioners: “God preserves us from your locums!” “Yes”, say good family doctors who know that they can do a better job and gain more professional satisfaction when they tailor their advice to a patient. General practitioners, when giving tailored care, described this as providing “higher quality” care.
“Yes”, says the research literature, which now reveals that continuity of care is significantly associated with better adherence to medication; better take up of preventive medicine; significantly fewer admissions to hospital for children; for the elderly with ambulatory care problems; and even significantly fewer emergency admissions to hospital. “Yes”, said the English Department of Health (in 2013), which has introduced a form of personal list called the “named doctor” which makes research on this system important.
Clinical opportunistic screening in general practice led to the majority of patients with Type 2 Diabetes being diagnosed before they reported a single symptom of diabetes. Then it was found these patients had a significantly lower HbA1c at diagnosis. This was done at lower cost per new diagnosis than other screening programmes.
A key feature of the postmodern world is flexibility. Whilst general practice research in universities is very important, research in the clinical setting of general practice is as well. This means training programmes, and opportunities to obtain higher university degrees so that generalist physicians and community nurses can gain the necessary skills to do research. In the 1990s the Department of Health in England in the South West, supported about 1% of general practices in the national health system as ‘research active practices’ with about £15,000 ( ̴ CAD 30,000) each. This worked well and should be reinstated.
Academic skills in general practice are greatly needed and should be available in the same proportion as is usual in specialist medicine. This means leadership by the institutions and Colleges of general practice and their equivalents, to mobilize the necessary resources.
I happened to pick up the April Edition of the CMAJ today and was incensed by an excerpt of a blog written by a Sir Denis Pereira Gray OBE printed on the back page “Digestif“. The article was titled “The importance of knowing your physician”. The gist of the article was that “may God preserve us from a locum”.
As a permanent locum of some 4 years now, I travel the length and breadth of Canada to do locum services (British Columbia, Northwest Territories and Prince Edward Island), giving what I consider reasonably high quality care to patients who mostly I have never set eyes on before.
The insinuation by Dr. Perreira that one has to ‘know” the patient to be able to deliver quality care I take personal exception to – he quotes better adherence to medication, lesser admissions to hospital, and not having to repeat the medical history over and over again. I see none of this. I am sure the hundreds of locums who work for the BC Rural Locum Program (the RGPLP, one of the many excellent locum programs in Canada) which is run by the BC Government feel much the same way as I do. The locum program incidentally provides locum services all over BC at a fixed daily stipend In response to this article, I actually asked 10 patients today at my present locum site what their past and present diagnoses were, an not one of them got it all right and in fact many did not have a clue! The computer did!
The opening page of all Electronic Medical Records (EMR’s) these days provide one with an instant patient profile of past and present medical and surgical history, current and past medication profile, drug allergies, immunizations, family histories etc etc. I do not need to ask the patient a single question and “no” he doesn’t need to tell me his story over and over again! I already have it all in front of me instantaneously and far more accurate that what the patient could ever provide to me verbally.
I have numerous patients who access my services as a locum in order to get, amongst others, a second opinion. This is something that most of them freely admit to. It is also my experience that patients will often tell me stories, especially in smaller communities, that they would never tell their family doctor, this all for reasons unknown.
So “no” Dr Perreira my experience is directly opposite to what your statistics are telling you. My numbers tell me that I inevitably find that I am seeing more patients per day than what the regular physician does and they all appear to be reasonably to highly satisfied. Perhaps Dr Pereira’s locums do not have access to EMR’s!
David v B Smith MD.CCFP FCFP.
PO Box 640,
V0X 1W0 Canada.
I agree with Sir Denis Pereira Gray about the need to promote academic skills amongst GPs. At Imperial College London, the academic department of primary care hosts the Imperial GP Specialist Training Scheme. This is the only GP training scheme in England that is managed by an academic department. Hosting the scheme allows us to integrate postgraduate training of GPs with undergraduate teaching of medical students. We have created a number of innovative training posts that allow our GP trainees to acquire research skills. As well as posts in the primary care department at Imperial College, there are also posts in organisations such as the BMJ, BJGP and King’s Fund. Our GP Trainees are encouraged to publish and present their work, and there are now an increasing number of academic outputs from the members of the Imperial GP Training Scheme.