Q J Med 2002; 95: 337-338
© 2002 Association of Physicians
Coda |
A house divided
The Executive Editor has invited me to write this month about editorial incompetence. His penitential gesture followed a mistake he made in a previous issue of QJM, where he accidentally introduced me to readers as a psychiatrist at the Tavistock Clinic. I am in fact a general practitioner. In fairness, I should explain that his mistake was totally understandable: I am a family therapist as well as a GP, and I work as a part-time consultant in primary care at the Tavistock. So I am afraid I have little more to say on the subject of editorial incompetence—except to remark that his highly skilled remoulding of QJM in the last few months argues against it being much of a problem for this journal.
The mistake did, however, set me thinking about the way that physicians perceive other colleagues like psychiatrists and GPs. I wondered if any readers of QJM had been influenced—either adversely or positively—by the belief that the writer of this column was a psychiatrist, and how they might have to adjust their reactions when they discovered I was a ‘real’ doctor, but not a specialist.
Physicians and GPs are, of course, replete with prejudices about each other. Our mutual stereotypes include a typical mixture of idealization and denigration. Generally, GPs envy hospital physicians—especially academic ones—as important people gifted with fierce intelligence, an unflinching focus, and encyclopaedic learning. Catch us at a jaded moment, however, and we may confess a mild contempt for them, as impossibly narrow-minded folk who cannot tell their proctalgia fugax from their lateral epicondylitis. In the same way, physicians probably think on the whole that we GPs are unimportant amateurs, but nevertheless will admit at times to feeling cowed by the broadness of our competence.
In reality, the main difference between GPs and specialists like physicians probably lies in our degree of preference for conceptual boundaries—something that may be determined by personality type. Unlike specialists, GPs need to possess a facility for tracking patients' lives and narratives across wildly varying terrain, heedless of the fences we have to leap over. In any one consultation, we may have to move between orthopaedics and psychiatry, biology and biography, and even between medicine, social work and theology. Not long ago, for example, I saw a mother and her two small children in my surgery. They felt pole-axed by the sudden and unexpected departure of the father from the home. At the end of the consultation I inquired if there was any important ground that we had not covered. The mother replied: ‘Can you look in Jordan's ears to see if he's got any wax.’ Of course I said yes.
It is reassuring to think that specialists and generalists complement each other by thinking in different ways. At the same time, we should not be led into believing that the distinction between the two species is unalterable. In his classic study, The Division in British Medicine (Kogan Paul, 1979), Frank Honigsbaum traced the historical process by which successive political interventions, together with intraprofessional prejudices, intensified the divide between hospital consultants and general practitioners in Britain during the twentieth century. He argued that the division—far sharper than in many other countries—not only impeded continuity of patient care but critically limited what the National Health Service could achieve.
I met Frank Honigsbaum a few years ago, and he was astonished to learn that I was both a GP and an National Health Service consultant, since this seemed to contradict his thesis. Yet there are probably no more than a few dozen doctors like me in Britain with this dual identity. To the best of my knowledge, all our posts were created during a kind of collective panic among NHS trusts in the 1990s, after the Conservative government had offered GP practices their own budgets for purchasing secondary services. At that time, there was a marked—almost embarrassing—improvement in the way that hospital consultants spoke and wrote to GPs. Perceptions had changed.
In the event, many GPs thought that budgets were divisive, and fewer than half signed up for them. When a Labour government took over in 1997, it promised to transform the scheme into something far more equitable by bringing all GPs into commissioning agencies, in the form of primary care groups. One consequence of this was that our importance as a profession seemed assured.
Things have turned out very differently. Primary care groups have all now been ‘promoted’ to trusts as originally planned but, crucially, GPs have been assigned only minority representation on them. It is hard to know whether this was a ruse that the government intended along, or a change of plan. Or perhaps it was just a result of editorial incompetence somewhere in the Department of Health. Whatever the truth may be, most GPs now see the new organizations largely as instruments of centralized management and policing. Partly because of this, GP morale has plunged dramatically in a short space of time. Even in our own eyes, we do not seem to be very important at the moment.
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