Roger Jones, Nicky Britten, Larry Culpepper, David Gass, Richard Grol, David Mant, Chris Silagy eds) Oxford textbook of primary medical care: volume 1, Principles and concepts & volume 2, Clinical management
Oxford University Press
2003 HB 1420 pp, £295.00, 0 19 263219 1
What on earth is this book for? Is it just that we are trying to be grown-ups, like the physicians and surgeons? General practice encompasses most of medicine. Surely the ludicrous hubris of trying to encapsulate the subject in a book is matched only by the equally farcical notion that there can be any such thing as a practitioner of all medicine?
The question of whether this book can justify its existence is closely related to the question of whether there can be such a thing as a generalist in an age of modern, technological medicine. If general practice is merely second-rate medicine, then this book is necessarily superficial froth — like a strip cartoon version of War and Peace.
Fifteen years ago I made my decision to enter general practice. I told my boss of my decision. He was an elegant Italian professor of cardiology. He looked at me with the mildly perplexed air of someone who tans easily and eats guava fruit for breakfast. It was clear that, gazing down from his Olympian world of international conferences and celebrity private patients, he thought I was deranged. General practice was too far below the stars, and too close to the rugged and dusty terrain of life, to register on his radar at all. There have been plenty of times in the subsequent years, plagued by budgets and hectoring managers, when I have wondered if he was right. Consequently, it was with a flutter of mild existential doubt that I turned to review the contents page of this book.
The textbook is divided into two volumes. The first deals with the principles and concepts that, to a considerable extent, characterise general practice as a discipline. The second volume deals with the clinical problems that general practice shares with other disciplines.
When I took leave of my tanned and sculpted professor and started my trainee year I was still, I think, a bit of a hard-nosed physician. My practice was then, and is still now, rather unfashionably centred around the notion of the diagnosis. I remember being told, and accepting, that it is important to learn to live with uncertainty of diagnosis in general practice. But I considered then, and now, that the discipline of maintaining a differential diagnosis keeps that uncertainty within safe boundaries.
Because of this clinical bias I was a little surprised to realise that the areas that have really come to fascinate me in general practice were all in the first volume of this tome rather than the second. This realisation, together with the fact that I hugely enjoyed cleaning the patio this weekend with my new power hose, has forced me to acknowledge that I am now definitely middle aged and will henceforth wear sports jackets patched at the elbows.
The first volume (now, in middle age, my favourite) does have some fascinating essays if, like me, you live a very narrow life. It is possible to dip in and find chapters on illness behaviour, the communication of risk and the nature of clinical judgement. There are thoughtful pieces on everything from the principles of screening, to medicolegal standards expected in general practice. There are summaries on methods of qualitative and quantitative research. For the training practice there are chapters on all those irritating checklists beloved of video markers (although even this monolithic work does not clarify when you are, or are not, responding to a consultation cue).
This wealth of information can be found elsewhere in journals and books. But this is the only place that I have found it in one place, and, to be frank, so clearly written. There is remarkably little of the turbid jargon that one finds even in mainstream journals. In particular, there is a refreshing absence of the apparently impenetrable sociology or psychology jargon that mars so many commentaries on medicine. The editors seem to have given the authors an instruction to summarise their area of expertise clearly in 4000 words without academic obfuscation.
A lump of paper weighing several kilograms is only relevant in an electronic age in as far it deals with the eternal verities. Much of the detail of the management of chronic disease, which now makes up such a major part of general practice, will change. New trials will come along and slightly hectoring enthusiasts will flash up their endless PowerPoint bar charts showing us that we are now doing it wrong. The still points in this turning world are the principles dealt with in volume 1 of this book and the processes involved in making a diagnosis. These things do not change and are the reason why the book is not merely a collection of tidal ephemera to be swept away by the information riptide.
One of the things that is striking to me about this book is the astonishing level of thought and consideration that seems to have gone into it. When I pick up most textbooks I estimate that 80% has been regurgitated from other textbooks. In 1898 Edward G Robinson (or someone who looked terribly like him) wrote in Bailey and Love's Short Practice of Surgery that paraumbilical hernias are terribly dangerous, or that Phalen's Sign is positive in 96% of cases of carpel tunnel syndrome (on what planet?). Somehow these shibboleths are regurgitated through generations of textbooks. The nice thing about this particular one is that it is clear that every chapter has been written from scratch and, usually, with some scepticism about the conventional wisdom.
The second volume is necessarily less unique than the first. To me it is only successful insofar as it reflects those features of general practice that are not merely diluted aspects of internal medicine or other specialities. After all, there are already many excellent texts on internal medicine or dermatology. But in general practice the patient presents with a morass of undifferentiated symptoms rather than a 6-week history of dyspepsia. Many of those symptoms will be of minor disease, and even those symptoms that are signals of significant disease will often not yet have developed into the fully differentiated form that one finds in an internal medicine textbook or an outpatient clinic. This is one of the defining difficulties of general practice. At this stage over-zealous investigation can create invalidism, while too relaxed an approach can lead to missed diagnoses, missed opportunities and death. This is the tightrope that differentiates primary care from other specialities. The clinical chapters that recognise this essence, and deal explicitly with the difficulties of adeptly differentiating the wheat from the chaff, prove their worth.
I think overall this book is a titanic achievement. For the most part it is an honest and succinct distillation of the essence of general practice as considered by 400 experienced practitioners. Its approach, and its prose, is fresh. Somewhat to my surprise it is now my first reference for training matters.
I think the book also has great symbolic significance. If primary care fragments and disappears, which it might, then this book will be merely an historical anachronism. If general practice survives in Britain, then this will be its bible.
The book, of course, has many flaws. But then so does general practice. And so does everything in life (except maybe pressure hose patio cleaners).
- © British Journal of General Practice, 2004.
