It’s something of an irony to see research papers revealing uncertainties about how best to use electronic modes of communication in general practice in the same issue of the BJGP as two articles dealing with Michael Balint, known to most GP readers for his landmark publication The Doctor, His Patient and the Illness.1 This book, among other things, placed a high premium on the quality of communication between the patient and the practitioner.
Balint was a refugee from Hungary who became a Freudian psychoanalyst, and had a profound effect on views of the consultation, the doctor–patient relationship, and the interactions between psyche and soma. Julian Tudor Hart, writing in 1988 in his wonderful book A New Kind of Doctor,2 describes Balint as someone who ‘defined a wide area of need that was currently ignored or rejected by specialists, and was not recognised as a medical task in the Osler paradigm’.
Tudor Hart goes on to say that, ‘instead of repeating futile investigations of increasing complexity and cost, and then telling people there was nothing wrong with them, Balint taught active search for causes of anxiety and unhappiness and treatment … aiming at insight, rather than tablets aiming at suppression of symptoms. He showed GPs that, far from being inferior to hospital specialists in this role, they might be more effective and less dangerous’.
Balint was also a powerful supporter of GPs, giving them confidence in their work, and also showing how inappropriate their undergraduate training was to the requirements of general practice. He also urged GPs that, again in Tudor Hart’s words, ‘to be effective they must do more than passively respond to the immediate demands of patients: active search for the hidden needs behind overt demands was essential’. Reading around Balint and Tudor Hart makes you realise how far we have come but, in so many ways, how little we have progressed.
General practice certainly hasn’t fully embraced new communication technologies. The survey by Heather Brant and colleagues of over 400 practices in England and Scotland suggests that, although telephone consultations are, unsurprisingly, pretty common, video links and the use of e-mail and other potential forms of doctor–patient communication are hardly used at all.
There appears to be a dearth of decent evidence on which to base guidance for the introduction and exploitation of communication technologies, although it may well be that there are excellent examples of these all over the country, and we haven’t heard of them. This must be an area in which innovation, exploration, and evaluation are urgently needed.
The BJGP has published a lot of primary care research on cancer in recent years, and this month there are some important messages about cancer diagnosis. Patients with cancer alarm symptoms are still reluctant to tell their GPs about them, for a variety of reasons, including being worried about wasting doctors’ time, according to the study by Katriina Whitaker and colleagues from the University of Surrey and UCL.
A well-conducted cluster-randomised trial in Spain has shown that using an electronic prompt in the electronic health record to promote participation in a population-based colorectal cancer screening programme has the potential to increase screening uptake by up to 11% in patients exposed to the intervention. The clinical utility of faecal calprotectin testing looks likely to expand as a possible means of ruling out colorectal cancer, as well as inflammatory bowel disease, in symptomatic patients, according to a diagnostic accuracy study from James Turvill and colleagues from York.
Another provocative study from Aarhus, Denmark, suggests that patients with rarer or more difficult-to-diagnose cancers, such as ovarian cancer and myeloma, may change their GPs more frequently than cancer-free patient controls in order to get their problems resolved. Finally, Jane Maher and colleagues from Macmillan Cancer Support remind us that by 2030 there will be over 4 million people in the UK living with or beyond a cancer diagnosis, and that primary care will have an increasing role in looking after them.
- © British Journal of General Practice 2016