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THREE THEORIES

By Peter Davies
Contact the author via Chris Johnstone by e-mail at christopher.johnstone@ntlworld.com

A: A Cross Border Observation

• Parkinson's law states that "work expands to fulfil the time available for its completion"
• There are more GPs per head in Scotland than in England.
• Ergo as the Scottish GPs work the same hours as the English GPs they will see their patients more often each year as they have more time to do this.
• English GPs have bigger lists than Scottish GPs and are thereby richer than their Scottish counterparts.
• Scottish patients see their GP more often yet have worse health outcomes than English patients.
• The more times you see your doctor the greater the risk of iatrogenic harm.
• The English patients see their doctors less often and so have less chance of iatrogenic harm.
• This is why they are healthier than the Scots.
• English GPs deserve more pay than their Scottish counterparts as they do less harm to their populations.

Conclusion: The fewer doctors there are the healthier the patients will be and the richer the doctor will be. Good deal for both sides.

As Voltaire put it, "Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing."

Alternatively Wendell Holmes, "If all the medicine in the world were thrown into the sea, it would be bad for the fish and good for humanity."

I look forward to anyone trying to disprove this compelling, logical conclusion.

B: Demand is like cholesterol

• Blood cholesterol reflects two things, namely how much is in our diet, and how it is handled by our liver.
• Likewise demand for medical appointments depends on the incidence of symptomatology and on what doctors do with that symptomatology.
• In a GP setting the incidence of symptoms is far greater than that of pathology.
• Biomedicine occurs at the intersection of the iceberg of disease with the iceberg of symptoms.
• Most symptoms have no pathological significance.
• Many diseases have no specific symptoms. Being able to negotiate this intersection without saying "phaeochromocytoma" too often is a great ability.
• It is more important to be right about ruling out pathology than it is to be right about exactly what pathology is present. (you can get the hospital folk to do that for us (see below).
• Time will tell for most things, but if it is likely to tell you all too quickly, admit the patient acutely.
• The good doctor may refer more or less as he or she knows a lot of medicine. The bad doctor may also refer more or less as he or she knows too little medicine.
• Referral rates are no guide to the quality of the referring doctor.
• If a popular doctor leaves a surgery consultation rates often drop. If a popular doctor joins a surgery consultation rates go up.
• Demand for appointments is in part a popularity marker of the doctor.
• Demand for appointments is only partly explained by the incidence of pathology.

C: Why GPs work

GPs are crap at biomedicine. (Each week there is yet another demonstration of GP inadequacy for one severe disease or another.) We miss diagnoses, under prescribe some drugs, and give others out too much. We commit errors of omission and commission. Nunc demittis: We ask for remission of our many sins.

Yet Barbara Starfield shows that employing GPs reduces the mortality rate in an area. We actually work!

How can these facts be squared up?

GPs are not great at biomedicine, and even if we are, the successes of biomedicine are major operations, cancer treatments, MRI scanners, etc and these are all done in hospitals. That is to say that as GPs we can only be conduits to the best of biomedicine, not good biomedical scientists ourselves.

I think GPs work for an entirely different reason. Aaron Antonovsky, a medical sociologist from New York and Beersheva, turns talk about health on its head away from disease avoidance and treatment. He describes "SALUTOGENESIS", that is the positive generation of health. He says that healthy people have a "sense of coherence" which enables them to handle the slings and arrows of outrageous fortune well, without undue stress or disease development.

The sense of coherence is boosted by a good network of family, friends and other helpful contacts. At the social level this concept is commonly called, "social capital." The knowledge that there is a local doctor who can help you when needed adds to the social capital of an area. So too does good transport, jobs, clean surroundings, low crime. The presence of GPs works as it helps people develop their sense of coherence via social capital. The presence (but not necessarily the use) of GPs is salutogenic.

One consequence of this theory is that when social capital falls the incidence of both symptoms and pathology will rise and use of GP services will rise. The Polish immigrants with their "Untier Syndrome" after WW2 exemplify this relationship well. When they got settled, their sense of coherence improved and their social capital rose and so it stopped hurting quite so much here….unt here. Mrs Bibi replaced them with, "pain… pain."

There are many paradoxes in medicine that go unrecognised. Hopefully I have brought some of them to attention. I have left out the great Rose paradox, and the perpetrator-victim-caretaker triangle that creates the paradox of empowerment. There is much research in medicine, but rather less chipping away at solutions to these binding and blinding paradoxes.

Other hoolet online articles by Peter Davies can be found at:
hoolet edition 48 - Three Theories
hoolet edition 46 - Whinging
hoolet edition 44 - Cons In The Consulting Room
hoolet edition 41 - Who are we kidding on confidentiality?
hoolet edition 40 - First, let's kill the bureaucrats
hoolet edition 38 - Waking up from the medical matrix: Reality and its representation in medicine
hoolet edition 36 - Festina lente
hoolet edition 35 - Determinants or Prerequisites?
hoolet edition 34 - Propulsion Systems in Medicine
hoolet edition 32 - Time to give MRCGP away?
hoolet edition 31 - Proper work for a doctor
hoolet edition 30 - The Intruder
hoolet edition 29 - Edging towards the truth: Does it make any sense at all?
hoolet edition 28 - Thoughts from the Dark Forest
hoolet edition 27 - The Vision Splendid

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.