The nature, scope and content of general practice

The nature, scope and content of general practice

Medical practice is not knitting and weaving and the labour of the hands, but it must be inspired with soul and be filled with understanding and equipped with the gift of keen observation; these together with accurate scientific knowledge are the indispensable requisites for proficient medical practice.

MOSES BEN MAIMON (1135–1204)

General practice is a traditional method of bringing primary health care to the community. It is a medical discipline in its own right, linking the vast amount of accumulated medical knowledge with the art of communication. Definitions General practice can be defined as that medical discipline which provides ‘community-based, continuing, comprehensive, preventive primary care’, sometimes referred to as the CCCP model. It is regarded as synonymous with primary care and family practice.

The Royal Australian College of General Practitioners (RACGP) uses the following definitions of general practice and primary care:

General practice is that component of the health care system which provides initial, continuing, comprehensive and coordinated medical care for all individuals, families and communities and which integrates current biomedical, psychological and social understandings of health.

A general practitioner is a medical practitioner with recognised generalist training, experience and skills, who provides and co-ordinates comprehensive medical care for individuals, families and communities.

General/family practice is the point of first contact for the majority of people seeking health care. In the provision of primary care, much ill-defined illness is seen; the general/family practitioner often deals with problem complexes rather than with established diseases.

The RACGP has defined five domains of general practice:

communication skills and the doctor–patient relationship applied professional knowledge and skills population health and the context of general practice professional and ethical role organisational and legal dimensions

Furthermore the RACGP has identified eight core characteristics of general practice:

1 whole person care 2 person centredness 3 continuity of care 4 comprehensiveness 5 diagnostic and therapeutic skills 6 a command of complexity and uncertainty 7 coordinated clinical teamwork 8 leadership, advocacy and equity

The American Academy of Family Physicians (AAFP) has expanded on the function of delivery of primary health care.1,2

Primary care is a form of delivery of medical care that encompasses the following functions:

1 It is ‘first-contact’ care, serving as a point-of-entry for patients into the health care system. 2 It includes continuity by virtue of caring for patients over a period of time, both in sickness and in health. 3 It is comprehensive care, drawing from all the traditional major disciplines for its functional content. 4 It serves a coordinative function for all the health care needs of the patient. 5 It assumes continuing responsibility for individual patient follow-up and community health problems. 6 It is a highly personalised type of care.

General practice is fundamentally relational, based on the doctor having a deep understanding of the whole person, and the ability to manage complex conditions and circumstances. The general practitioner functions as a physician, counsellor, advocate and agent of change for individuals, families and their communities.3

General practice is not the summation of specialties practised at a superficial level and we must avoid the temptation to become ‘specialoids’. In the current climate, where medicine is often fragmented, there is a greater than ever need for the generalist. The patient requires a trusted focal point in the often bewildering health service jungle. Who is to do this better than the caring family doctor taking full responsibility for the welfare of the patient and intervening on his or her behalf? Specialists also need highly competent generalists to whom they can entrust ongoing care.

Unique features of general practice Anderson, Bridges-Webb and Chancellor4 emphasise that ‘the unique and important work of the general practitioner is to provide availability and continuity of care, competence in the realm of diagnosis, care of acute and chronic illness, prompt treatment of emergencies and a preventive approach to health care’.

The features that make general practice different from hospital- or specialist-based medical practices include:

first contact compassion diagnostic methodology early diagnosis of life-threatening and serious disease continuity and availability of care personalised care care of acute and chronic illness domiciliary care emergency care (prompt treatment at home or in the community) family care palliative care (at home) preventive care scope for health promotion and patient education holistic approach to management health care coordination The GP has to be prepared for any problem that comes in the door (FIG. 1.1 ).

FIGURE 1.1 Degrees of care of symptoms

Apart from these processes the GP has to manage very common problems including a whole variety of problems not normally taught in medical school or in postgraduate programs. Many of these problems are unusual yet common and can be regarded as the ‘nitty gritty’ or ‘bread and butter’ problems of primary health care.

In considering the level of care of symptoms, 25% of patients abandon self-care for a visit to the GP. Ninety per cent of these visits are managed entirely within primary care. Levels of care are represented in FIGURE 1.1 .5

Holistic approach to management The management of the whole person, or the holistic approach, is an important approach to patient care in general practice. Whole-person diagnosis is based on two components:

1 the disease-centred diagnosis 2 the patient-centred diagnosis

The disease-centred consultation is the traditional medical model based on the history, examination and special investigations, with the emphasis on making a diagnosis and treating the disease. The disease-centred diagnosis, which is typical of hospital-based medicine, is defined in terms of pathology and does not focus significantly on the feelings of the person suffering from the disease.

Whole-person care—mind and body—is the hallmark of the good GP.

The patient-centred consultation not only takes into account the diagnosed disease and its management but also adds another dimension —that of the psychosocial hallmarks of the patient, including details about:

the patient as a person emotional reactions to the illness the family the effect on relationships work and leisure lifestyle the environment

Taylor and colleagues, in their patient-centred model of health

care, emphasise six interactive components of the patient-centred process:6

1 exploring both the disease and the illness experience 2 understanding the whole person 3 finding common grounds regarding management 4 incorporating prevention and health promotion 5 enhancing the doctor–patient relationship 6 being realistic regarding time and resources

Contemporary general practice focuses on patient-centred medicine, which, in alliance with evidence-based medicine, benefits both patient and doctor. Continuing care The essence of general practice is continuity of care. The doctor–patient relationship is unique in general practice in the sense that it covers a span of time that is not restricted to a specific major illness. The continuing relationship involving many separate episodes of illness provides an opportunity for the doctor to develop considerable knowledge and understanding of the patient, the family and its stresses, and the patient’s work and recreational environment.

In 2008 the World Health Organization (WHO) reaffirmed the global importance of primary health care with its landmark report Primary Health Care Now More Than Ever. WHO7 highlighted the evidence that continuity of care through general practice contributed to the following better outcomes:

lower all-cause morbidity better access to care fewer rehospitalisations fewer consultations with specialists less use of emergency services better detection of adverse effects of medication interventions

Home visits ‘You don’t know your patient until you have seen them in their home.’ Home visits are a goldmine of information about intra-family dynamics. They should cement the doctor–patient relationship if used appropriately. We are the only doctors who practise domiciliary care. Common presenting problems Common presenting symptoms in Australian general practices (BEACH study, 2013) are presented in TABLE 1.1 8 (note that the top 15 problems represent only one-third of all encounters).

To cover 75% of presenting problems, GPs must be able to diagnose and manage more than 100 different problems, and to cover 85% requires a good working knowledge of 167 problems.8 The breadth of knowledge required to become a proficient GP is tremendous.

Most frequent presenting problems in Australian Table 1.1 general practice

Per cent of problems

1 Hypertension 5.7

2 Immunisation 4.2

3 URTI 3.3

4 Depression 2.9

5 Diabetes 2.3

6 Lipid disorders 2.1

7 General check-up 1.9

8 Osteoarthritis 1.7

9 Back pain 1.7

10 Prescription 1.6 11 Oesophageal (inc. GORD) 1.6

12 Female genital check-up 1.5

13 Acute bronchitis/bronchiolitis 1.5

14 Asthma 1.3

15 Anxiety 1.2

Cumulative top 15 34.6

Source: Cooke et al.8

The content of this book reflects what is fundamental to the nature and content of general practice—that which is common but is significant, relevant, preventable and treatable.

Most frequent presenting symptoms in the author’s practice The most common presenting symptoms in the author’s rural practice in the 1970s9 were identified, with the emphasis being on pain syndromes:

cough disturbance of bowel function pain in abdomen pain in back pain in chest pain in head pain in neck pain in ear pain in throat pain in joints/limbs rashes sleep problems tiredness/fatigue vaginal discomfort

Symptoms and conditions related to litigation Medical defence organisations have highlighted the following areas as being those most vulnerable for management mishaps:

acute abdominal pain acute chest pain breast lumps children’s problems, especially the sick febrile child <2 years, groin pain and lumps dyspnoea ± cough (? heart failure, cancer, TB) headache

The most common reasons for claims against GPs are:

diagnostic error 38% procedural complications 18% treatment issues 16% general duty of care 14% medication-related issues 9% legal issues 2% consent issues 1% medicolegal reports 1% anaesthesia 1%

Source: Bird S, MDA National Chronic disease management A study of international target conditions10,11 in chronic disease management has highlighted the importance of the following (as common themes):

ischaemic heart disease chronic heart failure cerebrovascular disease hypertension diabetes mellitus type 2 chronic obstructive pulmonary disease asthma obesity epilepsy hypothyroidism chronic mental illness, especially depression medication monitoring arthritis References 1 American Academy of Family Physicians. Official definition of Family Practice and Family Physician (AAFP Publication No. 303). Kansas City, Mo, AAFP, 1986. 2 Rakel RE. Essentials of Family Practice. Philadelphia: WB Saunders Company, 1993: 2–3. 3 RACGP. What is General Practice? Available from: www.racgp.org.au/be comingagp/what-is-a-gp/what-is-general-practice, accessed January 2018. 4 Anderson NA, Bridges-Webb C, Chancellor AHB. General Practice in Australia. Sydney: Sydney University Press, 1986: 3–4. 5 Fraser RC (ed). Clinical Method: A General Practice Approach (3rd edn). Oxford: Butterworth-Heinemann, 1999. 6 Taylor RJ, McAvoy BR, O’Dowd T. General Practice Medicine. Edinburgh: Churchill Livingstone, 2003: 6–7. 7 World Health Organization Geneva. The World Health Report 2008; Primary Health Care: Now More Than Ever. 2008. 8 Britt H, Sayer GP et al. Bettering the Evaluation and Care of Health: General Practice in Australia 1998–9. Sydney: University of Sydney & the Australian Institute of Health & Welfare, 1998–99. 9 Murtagh JE. The Anatomy of a Rural Practice. Melbourne: Monash University, Department of Community Practice Publication, 1980: 8– 13. 10 Piterman L. Chronic Disease Management OSP Report. Melbourne: Monash University, 2004. 11 Rakel RE, Rakel DP. Textbook of Family Medicine (9th edn). Philadelphia: Elsevier Saunders, 2016: 16. Resources The World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA). www .globalfamilydoctor.com, accessed January 2018.