MANY years ago I was strongly influenced by an idea of David Metcalfe's, illustrated with a simple line diagram, showing how GPs occupy the space and form an essential link between the hard edged world of hospitals, governments, and authority in general, and the more ill-defined world of our patients, with its fuzzy edges indeterminate size, and protean, ever-changing shape.
This month we have a paper on the experiences of teenage mothers (page 813). The official world sees teenage pregnancy as a major problem, and we are exhorted to play our part in bringing down the scandalously high United Kingdom (UK) rates. But this paper shows that, for the mothers themselves, there were lots of positive feelings and experiences, and there is a strong sense that their lives have been enriched by motherhood, despite their young age.
The familiar example of our position is as the gatekeeper between primary and secondary care. The Dutch study on page 848 reports on the pattern of paediatric referrals between 1987 and 2001. Despite the changing pattern beneath the overall steady state, the Dutch GPs show themselves to be responding to society's apparent needs accordingly, such as the increase in the referrals for psychological problems.
Or take guidelines, (sorry, but the subject simply won't go away). Guidelines make the position clear: simple, clear instructions from some authoritative source, that we try to fit to our patients' much more complex needs. On page 858 Ian Hill-Smith discusses the dilemma posed by a guideline telling him to stop recommending something he had been advising his patients to do for many years, and which they seemed to welcome doing. The leader on page 810 agrees with him. Not only that we shouldn't follow guidelines blindly, but that this particular piece of advice is open to question.
On page 832 guidelines are treated in another way. For patients with mental health problems the preliminary step was to adapt them to individual patients' needs, before passing them to GPs. This didn't seem to improve the outcome for the patients significantly, but it was striking that both groups improved in the first 6 weeks after entry to the trial, and equally striking that there was little improvement between 6 weeks and 6 months. But the picture of GPs' handling of mental health problems is as confusing as ever. The paper from New Zealand on page 838 wonders if we are quite as bad at diagnosing the problems, as we have been led to believe for the last 20 years. In this study, the rate of recognition improved with an increasing number of consultations. This might be another argument for better continuity, or it might not.
The position we occupy, between society and our patients, also gives us the opportunity to inform and lobby for what we know will help them. The leader on page 811 tells the story of the Republic of Ireland's ban on smoking in public places. This sounds like a model of such activity: informed by sound research, with doctors working to help the government and public understand the arguments for the ban. The ban has been very successful, even welcomed by many smokers who appreciate both the improved atmosphere in pubs, and the extra encouragement they get to give up the habit. Normally our position on smoking is as a conduit in the other direction, passing on to our patients the official world's disapproval of the behaviour for which they are entirely to blame. Of course we should be helping patients give up smoking, but the endless instructions, enshrined in the new UK contract for primary care, to discuss it every time we see them, aligns us much more with the official world where, as one colleague has said, smoking becomes the only sin in the modern world.
On the subject of sin, I have recently completed the annual season of penitence, of thinking about the sins of the past year. The tradition is that I may ask for God's forgiveness, but only after asking for (and being granted) forgiveness from all the people against whom I have sinned. This is difficult: not the asking but the effort of memory is taxing. In any case, the largest group of people I have sinned against are the numerous authors who have received offensive or hurtful letters in the last year. I try to soften them, but I don't always succeed. So, to all of you, whoever you are, I sincerely apologise, and shall keep up the efforts to mollify the rejections that are a permanent feature of the Editor's job.
- © British Journal of General Practice, 2004.
