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A short history of general practice: The changing gaze

Stephen Gillam is a semi-retired GP and public health specialist who has written extensively in both fields. He is the author of ‘Of Patient Bearing – A History of General Practice in Eight Generations‘ and winner of the RCGP and Society of Apothecaries Rose Prize in the history of British general practice.

Introduction

Over time, new scientific discourses have shaped the way doctors view their patients.1,2 Movements in epidemiology, social and behavioural sciences, management theory, political and moral philosophy change doctors’ perception of ‘what is wrong’ and ‘how we know it’.3 These disciplines have left their own distinct sedimentary stains of language, values and practice. What my forebears ‘saw’ changed down the generations.

The apothecary William Skrimshire (1739-1814) received no formal training. He practised in the marshy hamlets and villages around Wisbech where malaria and other marsh fevers were a scourge. He studied texts still imbued with miasmatic theory and humoralism. The emphasis on prevention and behavioural change was stronger then and many of his recommendations regarding the ‘non-naturals’ would resonate today. His son, also William (1766-1829), was the first to attend medical school, in Edinburgh. Natural sciences were central to medical education and he developed a lifelong passion for botany, bequeathing an extensive herbarium on his death.

Nowadays, it is regarded as a lapse of taste to refer to patients as ‘cases’, as though they were the receptacle inside which the doctor’s true object (the name of the disease) is concealed.

Over the next generations, medical discourse became recognizably biomedical. As doctors are still wont to do, my great great grandfather John Truscott Skrimshire (1835-1912) and his sons discussed their ‘cases’. As a boy, I watched my father and grandfather, with clinking whiskies to hand, standing either side of the sitting room fire doing the same. Nowadays, it is regarded as a lapse of taste to refer to patients as ‘cases’, as though they were the receptacle inside which the doctor’s true object (the name of the disease) is concealed.

The second article in this series described the emergence of the ‘family doctor’, a stereotype which proved enormously powerful in shaping public and professional perceptions of contemporary practice.4  This coincided with rise of laboratory medicine during the second half of the nineteenth century. The term ‘laboratory’ refers not just to physical space but to associated attitudes and methodologies. In the advancement of basic medical sciences, German universities led the scientific research community. The advent of medical microscopy gave rise to competing epistemologies of disease. Traditional diagnosis based on histories and observation was displaced by a new ‘rational medicine’ based on histology. Medical authority shifted to the pathologist as the final diagnostic arbiter and the laboratory came to be regarded as the source of most fundamental, reliable information on the workings of the body.

Major developments in the public funding of health care were to take place over the next two generations. The National Health Insurance (NHI) Act of 1911 established a system of free health care financed from employers and the state. My great uncle Henry Skrimshire (1874-1953) cared for workers but not their wives and families, whose demands were curtailed by the need to pay. NHI provided doctors with some financial security and, like many others, Harry operated his own welfare system waiving fees for the indigent. My grandfather Geoffrey Gillam (1905-1970) worked either side of the establishment of the NHS; general practice was reorganised but not transformed.

Till half a century ago, the psychological was regarded as the antithesis of the physical – a distraction that seduced the doctor from fidelity to the clinical task. ‘I make it an absolute rule never, under any circumstances, to tell a patient what his blood pressure is. Instead I say ‘not bad for your age’, or ‘quite reasonably satisfactory’. Once a patient knows he or she has hypertension, symptoms multiply enormously, and misery grows…’5 Practitioners such as Stephen Taylor disdained psychologizing; the diagnostic prizes were the diseases he first encountered at medical school.

Psychodynamic approaches to consulting gathered momentum in the 1960s onwards, in tune with the individualistic spirit of the period.6 Michael Balint readjusted practitioners’ clinical focus: first from disease diagnosis to the meaning of the illness, secondly from the illness to the patient, thirdly from the patient to the doctor-patient relationship.7Biopsychosocial approaches to teaching moved centre-stage in 1970s.8 They framed diagnosis in physical, psychological and social terms. This represented a major break from the established instrumental, hospital-centred orientation but general practitioners’ preferred default remained biomedical for that is the basis on which they are schooled, selected and trained.

‘A profound problem is that the map of biomedical science only roughly matches the territory of human suffering.’ 9 My uncle Pat (for whom I undertook locums) was a single-handed general practitioner working round the clock on the Pembrokeshire coast. He resembled no-one so much as John Sassall, the subject of John Berger’s acclaimed meditation on humanity, society and the value of healing.10 A Fortunate Man is a memorial to a way of practising medicine – for many a high watermark – that is nowadays impossible to sustain.

The 1980s saw a steady resurgence of the preventive agenda.11 ‘Illness became a prediction, a variable probability, a genetic weakness or a human frailty in behaviour, in which treatment must be invested now, in the expectation of benefit later.’3 Julian Tudor Hart, most notably, sought the fusion of epidemiology with primary care.12 Illness was once more re-located from ‘in here’ (the body-mind) to ‘out there’ in the socio-economic characteristics of the community.

General practitioners’ public health role was further extended from the 1990s onwards. My generation engaged in commissioning on behalf of practice populations. This inevitably shifted our ethical compass away from one-person clinical medicine. Ironically, there were intriguing similarities in the language of Tudor Hart and proponents of the health care markets he so abhorred. The authors of Working for Patients talked of producers and consumers.13 For Tudor Hart, the consultation was the point of ‘co-production’ of important health-related consumptions.12

Whither now the ‘family doctor’? We remain attached to the idea for the connotations of intimacy and extended biography it suggests.

The evangelists of Evidence Based Medicine were unwitting foot soldiers in this brave new world. Quantification as an aid to decision-making fostered a growth industry in the production of guidelines, protocols and algorithms. Criteria for diagnosis, investigation and treatment were henceforth determined by combing the world literature for evidence. The randomised controlled trial came to exercise a tyrannical domination over other intelligence. Economists refined a calculus of cost and benefit in the search for a morally neutral basis for rationing decisions. This reached its apogee in the Quality and Outcomes Framework with its unitary measure of quality.

Whither now the ‘family doctor’? We remain attached to the idea for the connotations of intimacy and extended biography it suggests. It is hard to ignore the influence of family on presentation, diagnosis and management. Huygen14demonstrated how new generations learn how to be ill from their parents. However, critics have drawn attention to the inherent conflicts of interest and confidentiality between different members of the family and household.15

Other changes have continued to erode family practice: the end of round the clock responsibility; the growth of part-time salaried practice; declining rates of home visiting, the source of so much intimate knowledge. The associated administrative demands of pay-for-performance, commissioning and regulation have crowded out the style of practice upon which the popularity of the discipline was founded. Less personal care is the consequence. My working life has seen a steady decline in the status of generalists, despite impressive therapeutic advances.

A new cosmology

Over forty years ago, Nicholas Jewson coined the term ‘medical cosmology’ as shorthand for the prevailing theories and practices that defined the nature of medical discourse at that time. He argued that, until the late eighteenth century, a system of ‘bedside medicine’ had prevailed in the western world. An individual’s psychological and social circumstances, behaviours and life history were central to diagnosis and treatment. A new cosmology emerged from post-Revolutionary France in the form of ‘hospital medicine’. It employed concepts and technical language that were increasingly alien to lay understandings. This, in turn, was supplanted by ‘laboratory medicine’ which sought disease at the cellular level and intensified the reductionist tendencies of the preceding stage.16

Arguably, we are now grappling with a new cosmology, that of ‘virtual medicine’, which will once more shift what Jewson called the ‘locus of epistemological authority’. The medical gaze is nowadays refracted through computerised protocols and algorithms; first we check the template, then we listen to the patient. The screen has replaced the body as the emblem of contemporary medicine. Actual practice is no longer tactile. We scan before we undertake physical examinations. If we lay on hands at all, we do so for largely symbolic reasons. The subjective sense of illness and bodily unease arising from disease, tiredness and unhappiness has been invalidated by scientific medicine with its emphasis on disease.

Personalized medicine is taking a paradoxical turn, redefined by its very antithesis: polygenic risk scores linked to the mass of real time information collected by tech companies.17 Artificial intelligence and quantum computing will yield transformational benefits. Whether they will help us, as optimists believe, once more ‘learn how to be human’ remains to be seen.18

Covid-19 has further altered the practitioner’s gaze. The rapid transformation of practice to remote consulting has been astonishing. The limited evidence base suggests that the acceptability and effectiveness of video-consultations compare with that of traditional clinic-based care19 but few studies have been carried out in general practice.  Whether the employment of new communication technologies can be employed in ways that sustain meaningful continuity of care will determine the discipline’s future.

The song remains the same

So what would George Burrows, a founding father, make of UK general practice today? He always rued the loss of independence that would have been enshrined in a new College for GPs and would be gratified by its Royal appellation. He would approve developments in training but be surprised by the disappearance of most surgery from practice. He might be permitted some schadenfreude in respect of the other Colleges and their desire to keep upstart GPs at bay. In that early disunity, he would discern the roots of the ‘independent contractor’ status that divides the NHS to this day.20 He might note wryly how little has changed in the volumes of physic that GPs prescribe and their dependence on dispensing. On the other hand, he would be astounded by the complexity of a modern practice. He would observe how their origins as tradesmen have equipped them as entrepreneurs and commissioners. Finally, he would note that doctors have always grumbled about their lot.

The main business of front-line work is, as it always was, managing mental health and acute as well as chronic illness.

Constant advance characterizes biomedicine and the range of treatments available today would bemuse Burrows. Yet while many aspects of practice have greatly changed, it is more striking how little this is reflected in the day-to-day dynamics of general practice. The main business of front-line work is, as it always was, managing mental health and acute as well as chronic illness. The patients encountered by all those Drs Skrimshire and Gillam suffered from the same problems as those visiting my surgery this morning – depression, cardiac problems, minor injuries – but the landscape of health care is very different. Try to imagine practising without agreed qualifications and training standards, extended teams and purpose-built premises, managers and regulation, let alone guaranteed pay and effective remedies.

The first William Skrimshire would wonder at the strange, technological complexity of general practice today. In many respects, it is more efficient and effective. It is not obviously more responsive or personal. He would, on the other hand, recognize many of the patient-centred rhythms and rituals of practice. True, GPs now have many more complex decisions to make – which diagnostic tests to request, which medicines to prescribe, which fellow professionals to involve or refer to. The job is supposedly more stressful and demanding. Against that, fewer house calls or protracted bedside vigils are required and good pay is guaranteed. Though the cliché is well worn, clinical decision-making – the whether and how to intervene – remains art as well as science. What William’s descendants and their patients prized was continuity of care with someone they knew, a relationship of trust and dependability – always the basis of our effectiveness. We forfeit such relationships at our peril.

References

  1. Foucault M. The Birth of the Clinic: An Archaeology of Medical Perception. New York: Random House, 1963.
  2. Jordanova L. The Social Construction of Medical Knowledge. Social History of Medicine 1995; 8: 361-81.
  3. Marinker M. In Loudon I, Horder J, Webster C eds. General Practice under the National Health Service, 1948-1997. Chapter 3. ‘What is wrong’ and ‘How we know it’: Changing Concepts of Illness in General Practice. London: Clarendon Press, 1998, pp 88-9.
  4. Loudon I. The Concept of the Family Doctor. Bulletin of the History of Medicine 1984; 58, No. 3: 347-362.
  5. Taylor S. Good General Practice. A Report of a Survey. Oxford: Nuffield Provincial Hospitals Trust, 1954.
  6. Royal College of General Practitioners. The Future General Practitioner: Learning and Teaching. London: RCGP, 1972.
  7. Balint M. The doctor, his patient and the illness. London: Pitman, 1957.
  8. Pereira Gray D, ed. Forty Years On. The Story of the First Forty Years of the Royal College of General Practitioners. London: RCGP, Atalink, 1992.
  9. Heath I. Medicine needs an injection of humanity. BMJ 2016; 355: i5705.
  10. Berger J. A Fortunate Man. London: Pantheon, 1967.
  11. RCGP. Health and prevention in primary care. Report from general practice no. 18. (Chairman: J Horder.) London: Royal College of General Practitioners, 1981.
  12. Tudor Hart J. A New Kind Of Doctor. London: Merlin Press, 1985.
  13. Secretaries of State for Health. Working for Patients. Cm 555. London: HMSO, 1989.
  14. Huygen F. Family Medicine: The Medical Life History of Families. Nijmegen: Dekker & Van De Vegt, 1978.
  15. Marinker M. The Family in Medicine. Proc Royal Soc Med 1976; 69: 115-24.
  16. Jewson N. The disappearance of the sick-man from medical cosmology, 1770-1870. Sociology 1976; 10: 225-44.
  17. 17. The Economist. Technology Quarterly. Personalised medicine. The coming of the datome. March 14th, 2020, pp 11-12. https://www.economist.com/technology-quarterly/2020/03/12/medicine-is-getting-to-grips-with-individuality
  18. Russell, S. Reith Lecture: What will AI mean for the future of work? BBC Radio 4 – The Reith Lectures, Stuart Russell – Living With Artificial Intelligence, AI in the economy
  19. Greenhalgh T, Wherton J, Shaw S et al. Video consultations for covid-19 BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m998
  20. Majeed A. Should all GPs become NHS employees? BMJ 2016; 355: i5064.

Featured image by Petri Heiskanen on Unsplash

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