Chapter 1: The nature, scope and content of general practice

General practice is a traditional method of bringing primary health care to the community. It is a medical discipline in its own right, linking the vast amount of accumulated medical knowledge with the art of communication.

General practice can be defined as that medical discipline which provides ‘community-based, continuing, comprehensive, preventive primary care’, sometimes referred to as the CCCP model. It is regarded as synonymous with primary care and family practice.

The Royal Australian College of General Practitioners (RACGP) uses the following definitions of general practice and primary care:

The RACGP has defined five domains of general practice:

• communication skills and the doctor–patient relationship

• applied professional knowledge and skills

• population health and the context of general practice

• professional and ethical role

• organisational and legal dimensions

Furthermore the RACGP has identified eight core characteristics of general practice:

1. whole person care

2. person centredness

3. continuity of care

4. comprehensiveness

5. diagnostic and therapeutic skills

6. a command of complexity and uncertainty

7. coordinated clinical teamwork

8. leadership, advocacy and equity

The American Academy of Family Physicians (AAFP) has expanded on the function of delivery of primary health care.^1,2

General practice is fundamentally relational, based on the doctor having a deep understanding of the whole person, and the ability to manage complex conditions and circumstances. The general practitioner functions as a physician, counsellor, advocate and agent of change for individuals, families and their communities.³

General practice is not the summation of specialties practised at a superficial level and we must avoid the temptation to become ‘specialoids’. In the current climate, where medicine is often fragmented, there is a greater than ever need for the generalist. The patient requires a trusted focal point in the often bewildering health service jungle. Who is to do this better than the caring family doctor taking full responsibility for the welfare of the patient and intervening on his or her behalf? Specialists also need highly competent generalists to whom they can entrust ongoing care.

Anderson, Bridges-Webb and Chancellor⁴ emphasise that ‘the unique and important work of the general practitioner is to provide availability and continuity of care, competence in the realm of diagnosis, care of acute and chronic illness, prompt treatment of emergencies and a preventive approach to health care’.

The features that make general practice different from hospital- or specialist-based medical practices include:

• first contact

• compassion

• diagnostic methodology

• early diagnosis of life-threatening and serious disease

• continuity and availability of care

• personalised care

• care of acute and chronic illness

• domiciliary care

• emergency care (prompt treatment at home or in the community)

• family care

• palliative care (at home)

• preventive care

• scope for health promotion and patient education

• holistic approach to management

• health care coordination

The GP has to be prepared for any problem that comes in the door (FIG. 1.1).

Apart from these processes the GP has to manage very common problems including a whole variety of problems not normally taught in medical school or in postgraduate programs. Many of these problems are unusual yet common and can be regarded as the ‘nitty gritty’ or ‘bread and butter’ problems of primary health care.

In considering the level of care of symptoms, 25% of patients abandon self-care for a visit to the GP. Ninety per cent of these visits are managed entirely within primary care. Levels of care are represented in FIGURE 1.1.⁵

Holistic approach to management

The management of the whole person, or the holistic approach, is an important approach to patient care in general practice. Whole-person diagnosis is based on two components:

1. the disease-centred diagnosis

2. the patient-centred diagnosis

The disease-centred consultation is the traditional medical model based on the history, examination and special investigations, with the emphasis on making a diagnosis and treating the disease. The disease-centred diagnosis, which is typical of hospital-based medicine, is defined in terms of pathology and does not focus significantly on the feelings of the person suffering from the disease.

The patient-centred consultation not only takes into account the diagnosed disease and its management but also adds another dimension—that of the psychosocial hallmarks of the patient, including details about:

• the patient as a person

• emotional reactions to the illness

• the family

• the effect on relationships

• work and leisure

• lifestyle

• the environment

Taylor and colleagues, in their patient-centred model of health care, emphasise six interactive components of the patient-centred process:⁶

1. exploring both the disease and the illness experience

2. understanding the whole person

3. finding common grounds regarding management

4. incorporating prevention and health promotion

5. enhancing the doctor–patient relationship

6. being realistic regarding time and resources

Contemporary general practice focuses on patient-centred medicine, which, in alliance with evidence-based medicine, benefits both patient and doctor.

The essence of general practice is continuity of care. The doctor–patient relationship is unique in general practice in the sense that it covers a span of time that is not restricted to a specific major illness. The continuing relationship involving many separate episodes of illness provides an opportunity for the doctor to develop considerable knowledge and understanding of the patient, the family and its stresses, and the patient’s work and recreational environment.

In 2008 the World Health Organization (WHO) reaffirmed the global importance of primary health care with its landmark report Primary Health Care Now More Than Ever. WHO⁷ highlighted the evidence that continuity of care through general practice contributed to the following better outcomes:

• lower all-cause morbidity

• better access to care

• fewer rehospitalisations

• fewer consultations with specialists

• less use of emergency services

• better detection of adverse effects of medication interventions

Home visits

‘You don’t know your patient until you have seen them in their home.’ Home visits are a goldmine of information about intra-family dynamics. They should cement the doctor–patient relationship if used appropriately. We are the only doctors who practise domiciliary care.

Common presenting symptoms in Australian general practices (BEACH study, 2013) are presented in TABLE 1.1⁸ (note that the top 15 problems represent only one-third of all encounters).

To cover 75% of presenting problems, GPs must be able to diagnose and manage more than 100 different problems, and to cover 85% requires a good working knowledge of 167 problems.⁸ The breadth of knowledge required to become a proficient GP is tremendous.

The content of this book reflects what is fundamental to the nature and content of general practice—that which is common but is significant, relevant, preventable and treatable.

Most frequent presenting symptoms in the author’s practice

The most common presenting symptoms in the author’s rural practice in the 1970s⁹ were identified, with the emphasis being on pain syndromes:

• cough

• disturbance of bowel function

• pain in abdomen

• pain in back

• pain in chest

• pain in head

• pain in neck

• pain in ear

• pain in throat

• pain in joints/limbs

• rashes

• sleep problems

• tiredness/fatigue

• vaginal discomfort

Medical defence organisations have highlighted the following areas as being those most vulnerable for management mishaps:

• acute abdominal pain

• acute chest pain

• breast lumps

• children’s problems, especially the sick febrile child <2 years, groin pain and lumps

• dyspnoea ± cough (? heart failure, cancer, TB)

• headache

The most common reasons for claims against GPs are:

• diagnostic error 38%

• procedural complications 18%

• treatment issues 16%

• general duty of care 14%

• medication-related issues 9%

• legal issues 2%

• consent issues 1%

• medicolegal reports 1%

• anaesthesia 1%

Source: Bird S, MDA National

A study of international target conditions^10,11 in chronic disease management has highlighted the importance of the following (as common themes):

• ischaemic heart disease

• chronic heart failure

• cerebrovascular disease

• hypertension

• diabetes mellitus type 2

• chronic obstructive pulmonary disease

• asthma

• obesity

• epilepsy

• hypothyroidism

• chronic mental illness, especially depression

• medication monitoring

• arthritis

The World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA). <www.globalfamilydoctor.com>, accessed January 2018.