Ever wondered what general practice was like 50 years ago? I don't any more, thanks to an excellent book written in 1954 by Dr Stephen Taylor called Good General Practice.1
Here's what a (rare) practice of female GPs had to say about men: "If an unattached male between the ages of 20 and 40 appears at the surgery and asks to be registered, we usually refuse. The unattached male wanting a woman doctor is almost certainly a peculiar or a psychopath or neurotic of some kind. Equally, we refuse to take on any new elderly gentlemen, however hale and hearty they may appear. Sooner or later they develop prostates, and these are a nuisance to the woman doctor, in more than one direction."
Wise words indeed, only to be bettered by the section entitled 'Clinical Hints for the Locum':
"1. All practices have their share of neurotics. Some are born, but many are made by the medical profession. If you are not sure what is wrong, do not hint at the worst and give a really gloomy prognosis. Patients will try to live up to it.
2. Do not talk more than you must. To many a patient, your slightest word is gospel. The more you talk, the more likely you are to let fall an unguarded remark that would have been better left unsaid.
3. Naturally patients set great store on their hearts. A hint from the doctor that all is not well in the heart department will start a chain of worry which cannot be dispelled by any number of later reassurances… The anxious possessor must be reassured that the heart is "excellent for his age" or "good for another 20 years"; the result of such reassurance is a new lease of life.
4. If you can possibly avoid it, do not tell any patients they have high blood pressure. It is tantamount to telling them they are on the verge of having a stroke. A high blood pressure causes remarkably few symptoms until the patient knows he has it. Thereafter there is no end of symptoms.Once you know it is high, there is little point in taking repeated readings. It only concentrates the patient's attention to it."
Half a century ago, general practice was bathed in a warm glow of beneficent paternalism that can never be recovered. Many argue that the switch to today's mantra of patient autonomy, informed choice and better drugs is long overdue, but in doing so we seem to have lost the art of reassurance. In our target-driven world, the more tablets we treat people with, the more anxious and confused they get, and the more they fall over.
As Peter Winocour, a consultant NHS diabetologist puts it "targets are often impractical and involve taking too many drugs…up to 10% of [type 2 diabetic] patients could require two or three hypoglycaemic agents (ultimately including insulin), at least three antihypertensive agents, two hypolipidaemic agents, and aspirin. A high proportion will also require treatment for coexistent cardiovascular disease and coincidental unrelated chronic disease. It is difficult to see how we can realistically expect patients to comply for long with such a draconian regimen requiring so many separate drugs."2
I know of an elderly woman who was expected to take 20 tablets of 16 different drugs spaced out over four different time intervals. One of these was warfarin, but the INR was wildly variable and her GP couldn't get the dose right. It later transpired that instead of adhering to her absurdly complicated drug regimen, she'd tipped all 16 bottles of tablets into a basket and swallowed 20 at random each day, figuring out it would all even up in the end.
Is her quality of life better than 50 years ago? You decide.
- Taylor S. Good General Practice. Oxford: Oxford University Press, 1954.
- Winocour P. Effective diabetes care: a need for realistic targets. Br Med J 2002; 324: 1577-80.