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Annotations

HOW BUSY IS THE FAMILY DOCTOR ?

." Busy " is now an almost automatic adjective for" family doctor " or

" general practitioner." The bondbetween them amounts almost to hyphenation, so vividlydoes the public and the profession think of the generalpractitioner as a man bowed down by days and nightsof ceaseless activity. He is credited thus, and perhapsaccepts the implied compliment to his powers of endur-ance. Seldom does he deny that he is busy (at leastpublicly) for perhaps to him " being busy" hasbecome something of a habit or a kind of defensivereaction.

Statistical studies of general practice have not so farshown in detail how the family doctor disposes of hisworking-time. This information could be obtained onlyfrom a general practitioner who was prepared to undergoa time-and-motion study of the kind more usually usedas a guide to personnel management in industry. Thishas now been done, and Crombie and Cross record thefindings of a general practitioner who timed his ownactivities, stop-watch in hand, for a period of a year.The background to the figures might perhaps have beenclearer, and no precise evidence is offered of how the esti-mate of the population at risk (4200 patients) was made.The time spent in the care of those patients was, however,analysed by season, age-group, and condition for whichthe patient was seen. Separate record was made of timein actual contact with patients, time spent travelling, andtime consumed by the administrative tasks which are anoften unacknowledged part of the efficient managementand conduct of a practice. The practice was in a better-class suburban area with a relatively static population,and the figures may not be directly applicable elsewhere,but they show, perhaps for the first time, how busy afamily doctor, practising under these circumstances,can be.The time spent in contact with patients, travelling

between them, and administration, was slightly over 30hours a week throughout the year, varying from about,35 hours a week in the winter months, to a low level of20 hours in August, when many of the patients of thepractice were, no doubt, away on their summer holidays.Most time was spent on children and on old people, andmost of the children in the practice were seen at sometime during the year. There were some sex differences,particularly at older ages, which would repay closer

study, though they reflect recognised differences in

susceptibility to degenerative diseases.This analysis, drawn first-hand from an efficient general

practice, may suggest that the family doctor is less hardpressed than is often supposed. Since his skill is appliedpiecemeal, in long or short contacts with patients, hewill often seem very busy to those who consult him. Butmore information could usefully be extracted beforeconclusions are drawn. How much time, for example, isconsumed in one year by attendances for the ritual bottleof medicine ’? How busy is the doctor in a mining area,in consultations arising from bonus-shift certificationrather than medical necessity? How far, in fact, couldadministrative and technical improvements in themanner and method of his practice, save him time andenable him to widen his vision and scope ’? This know-

ledge can come only from inquiries in other generalpractices.Though some may be afraid of administrative efficiency

in general practice on the false grounds that it detractsfrom humanity in some mysterious way, all must assumethat a moral obligation rests on every family doctor toarrange and conduct his practice so that he may serve

1. Crombie, D. L., Cross, K. W. Brit. J. prev. Soc. Med. 1956, 10,141.

his patients best. For long visiting lists, overcrowdedsurgeries, and long weary hours of hurried work the

practitioner can have himself to blame. Hours savedby proper organisation might enable the family doctor toplay a fuller part in preventive medicine, the success ofwhich would progressively relieve him of further burdens.

1. Spence, J., Walton, W. S., Miller, F. J. W., Court, S. D. M.,A Thousand Families in Newcastle upon Tyne. London, 1954.

2. Pemberton, J. Brit. med. J. 1949, i, 306.3. Shaw, A. B., Fry, J. Ibid, 1955, ii, 1577.4. Registrar-General’s Statistical Review of England and Wales

for 1954. H.M. Stationery Office, 1955.5. James, U., Brimblecombe, F. S. W., Wells, J. W. Quart. J.

Med. 1956, 25, 137.6. See Lancet, Oct. 13, 1956, p. 770.

PULMONARY COLLAPSE IN CHILDREN

THE Newcastle survey 1 showed that few children

escape a more or less severe respiratory infection at leastonce a year; and figures from family practices 2 3illustrate that respiratory disease accounts for a largeproportion of visits, many of them to children. Themortality of respiratory diseases in early life is still

considerable ; 2373 children under 2 years were certifiedas dying of respiratory disease in 1954.4 Our knowledgeof these diseases is surprisingly inadequate and thesedisturbing figures are a stimulus to further efforts inprevention, investigation, and treatment.Now that the pressure on hospital beds for children

has been reduced, it is possible to look more closely at.some common psediatric problems. Such an investi-gation which throws much light on the common respira-tory infections has been carried out by James and hercolleagues 5 at the Princess Louise (Kensington) Hospitalfor Children. This hospital, serving a rootless and ill-housed population, admits each year a great manychildren who, except for bad living conditions, would betreated at home. James et al. have taken the oppor-tunity to review the natural history of pulmonary collapsein childhood in a reasonably unselected group of cases.Of the chest films of some 5000 children, 854 showedevidence of pulmonary collapse as assessed by radio-logical diminution in size of one or more broncho-

pulmonary segments. 55% of the children were availablealso for follow-up examination.The results show that the most common antecedents

of collapse were pertussis, upper respiratory infections,sinobronchitis (chronic paranasal sinusitis with recurrentepisodes of bronchitis or collapse), pneumonia, and lowerrespiratory infections in that order. Asthma, tuberculosis,and measles figured much less frequently. Collapse dueto measles, sinobronchitis, pertussis, and lower respiratoryinfection was often multilobular, whereas isolated lobarcollapse tended to follow asthma, tuberculosis, and upperrespiratory infections. The deflation of the lung in allthese conditions was usually benign and transient. Bron-chiectasis was proven in only 1-7%, but it was notlooked for in the whole series. Persistent collapse wasobserved most often in tuberculosis, sinobronchitis, andpertussis. These differences may reflect different causesfor the collapse (for example, aspiration, retention of viscidsecretion, or obstruction by enlarged lymph-glands; butthat is not certain. James et al. do not discuss theresponse to treatment.

It is important to realise that the common upperrespiratory infections of childhood may be followed bycollapse-consolidation in the lungs. This complicationmay explain the long convalescence and persistent wintercough of some children, and is an argument in favour ofusing X rays more freely. The lung apparently re-expandsreadily in most cases, but it would be valuable to havemore information on what physiotherapy and antibioticscan do to hasten resolution. Bronchoscopy and broncho-graphy are seldom indicated in the absence of strikingsymptoms or radiological changes 6 and they should bereserved for children in whom collapse has persisted for

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more than three months or who are thought to havebronchiectasis. Children with recurrent respiratorydisease, such as asthma or sinobronchitis, are liable toboth recurrent and persistent collapse, which representsa real threat to their lungs and calls for adequatetreatment of the primary condition.The experience of James and her colleagues strengthens

the view that sinobronchitis is a clinical entity ; but abetter name should be devised before " sinobronchitis "

passes into acceptance through ’continued misuse.

1. Gear, H. S., Deutschman, Z. Chron. World Hlth Org. 1956,10, 275.

ON GUARD AGAINST PLAGUES

WHEN the Fourth World Health Assembly adoptedthe International Sanitary Regulations in 1951 it was a

legal rather than a hygienic innovation. From thatdate all nations who were members of the Assemblybecame bound by the regulations, and such membernations that wished to deviate from them in part or inwhole had to submit their reservations to the Assembly.It may be a sign of the times that so little fuss was madeover this victory for common sense over national

prejudices. Since then the regulations have beenmodified in detail and will, no doubt, be modified againto meet new dangers or to remove useless impedimentsto commerce and travel. They are concerned with the"

quarantinable diseases " only—plague, cholera, yellowfever, smallpox, typhus, and relapsing fever. In generalthey do no more than codify the many existing agree-ments, but in the process many obsolete procedures havebeen abandoned and the recommendations limited towhat now appears sound and efficacious.Even fifty years ago the medical officer of every port

in the world knew that he was sitting on an epidemio-logical volcano. His first news of plague in Surabaya orsmallpox in Bahia Blanca might be a ship in the roadswith the yellow jack in her rigging or a dying man in hisisolation hospital. Today patient clerks in Geneva sortand distribute a weekly return of infectious diseasesfrom almost every country. The- advances in the pre-vention and treatment of the pestilent diseases are asgreat as those in any branch of medicine. Activeimmunisation is effective not only against smallpox butagainst yellow fever and typhus, and (perhaps) againstcholera and plague. Thanks to the newer insecticides thelocal extermination of mosquitoes is now a reality andthe louse a very rare animal indeed. The rat survives,but new ships and more subtle poisons have drawn histeeth. That travel by air might bring with it the riskof spreading disease was readily appreciated, and notraveller can doubt that every care is now taken to avoid

introducing undesirable aliens-with 2, 4, or 6 legs.All these technical improvements have been accom-

panied by a remarkable and world-wide decline in thequarantinable diseases which goes a long way to justifythe optimism of a recent review of the subject from theWorld Health 0 rganisation. 1 Nevertheless a carefreefaith in the certainty of continual and inevitable progresshas led mankind into trouble before now and it wouldbe foolish to forget that these diseases remain a dangerso long as they are endemic in any part of this contractingworld. Cholera today is almost confined to India, China,and the intervening countries. (It is hard to knowwhether India’s place at the top of -the table is a meriteddisgrace or the penalty of conscientious diagnosis andnotification.) Cholera is a " simple " disease of whichthe cause and method of spread are well known ; and yet,in spite of much thought and toil, the stimulus whichconverts endemic to epidemic infection is still a matterfor surmise. In the future we may be able to confine theinfection more closely than in the past, but the threatremains. No-one knows the origin of the outbreak inEgypt in 1947 and very few are certain why it ended

when it did. Much the same is true of plague. The majorepidemics have been more widely spaced than those ofcholera, but they lasted far longer. It is still a sporadicdisease in many parts of the world and endemic foci inwild animals are known in three continents. If we knewthe chain of infection from a marmot in Turkestan to amillion rats in the slums of Bombay we would be betterplaced to forecast our immunity from the pestilence.Vaccination against yellow fever gives a lifelongimmunity. This by itself should be enough, but vaccina-tion is a costly business and it is hard to justify theexpense in a poor country where antibodies in the inhabi-tants’ blood are the only evidence of the disease. In

populous places it seems almost as effective to eradicateAëdes cegypti (as has been done in parts of Brazil), but" jungle yellow fever " in monkeys and marmosetsremains a threat of unknown potency. It is not entirelyclear if the " wild " disease can give rise to the urbanepidemic form : some slight evidence from Trinidad

suggests that it might. At any rate, during the last fewyears jungle yellow fever has been advancing rapidlynorthward along the Central American isthmus : it mayinvade Mexico at any time and the U.S.A. is not outsidethe zone of danger if the disease is transmitted to Aëdes

œgypti in the coastal belt.2 Typhus and relapsing feverare diseases of war and at the moment we enjoy peace ofa sort : in any case, the experience in Naples in 1943suggests that louse-borne infection can be checked evenin the middle of a war. Smallpox is everywhere lesscommon than it was, and yet where doctors are few andmoney is scarce it is seldom absent. No doctor anywherein the world can be quite certain that the next patientmay not show a pustular rash which will cause him somehard thinking. This seems the disease most likely to bespread by air travel, but accurate diagnosis and sufficientvaccine should ward off a major epidemic.

It is equally a cause for thanksgiving that the combinedwisdom of experts of all nations could be used in draftingthese regulations and that the nations of the world

accepted them with so little demur. At the moment

they are sufficient, but the problems of disease are

dynamic. Old diseases may assume new forms or newdiseases appear to threaten us. The laws of the Medesand Persians are a poor model for medical legislation.

2. Elton, N. W. Amer. J. publ. Hlth, 1956, 46, 1259.

MEDICAL REFUGEES

SOME of the Hungarian doctors in this country needpersonal hospitality, as we said last week ; but some nowneed-perhaps more than anything else-a little money.In supplying the physical wants of the thousands of

refugees in their care, the British Council for Aid to

Refugees provides pocket-money for all ; but it cannotdiscriminate and give larger amounts to any particulargroup. To the professional people among them the smallallowance they receive must seem almost negligible ; andsupplementary help is required to enable them at least tomake small purchases of clothes, or to make necessaryjourneys. For such help towards restoring their sense ofindependence they should look particularly to their pro-fessional colleagues, and we are therefore opening a smallfund to supply it. We ask other contributors to leave usdiscretion in the disbursement of what they send, merelyassuring them that it will all be given to Hungariandoctors and their families as and when we ascertain theirneed for this kind of temporary support. Contributionsmay be sent to the Editor of THE LANCET at 7, AdamStreet, London, W.C.2 (cheques being crossed " Hun-garian Doctors Account ").

Dr. W. G. BARNARD, professor of pathology in theUniversity of London, dean of St. Thomas’s HospitalMedical School, and treasurer of the Royal College ofPhysicians of London, died on Dec. 20.