Common Dilemmas in Family Medicine PDF
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Common Dilemmas In Family Medicine Common Dilemmas • In Family Medicine EDITED BY John Fry General Practitioner Beckenham, Kent England MT~L1MITED International Medical Publishers Published by MTP Press Limited Falcon House Lancaster, England Copyright © 1983 MTP Press Limited Softcover reprint of the hardcover 1s t edition 1983 British Library Cataloguing in Publication Data Common dilemmas in family medicine. 1. Family medicine I. Fry, John 362.1'72 R729.5.G4 ISBN 978-94-010-9194-7 ISBN 978-94-010-9192-3 (eBook) 00110.1007/978-94-010-9192-3 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the publishers. Contents list of Contributors ix Preface xiii 1 Mild-to-moderate hypertension - to treat or not to treat? The issues 1 The case for treatment (1 ) - Daniel M. Barr 1 The case for treatment (2) - Eric Gambrill 3 The case against treatment - John Fry 10 Critique by John P. Geyman 18 Commentary 21 2 Psychotropic pills or psychotherapy? The issues 23 The case for pills - Paul Freeling 23 The case 'for psychotherapy - Stanley Levenstein 32 Commentary 37 3 Alcoholism - disease or self-inflicted vice? The issues 39 The case for alcoholism as a non-disease (1) -John Fry 39 The case for alcoholism as a non-disease (2) - Benna Pollak 42 The case for alcoholism as a disease - Ken Young 44 Critique by W. E Fabb 50 Commentary 51 4 Acute myocardial infarction - home or hospital care? The issues 53 The case for home care - Brian R. McAvoy 53 The case for hospital care - Joseph H. Levenstein 64 Commentary 67 5 Is obesity worth treating? The issues 69 The case for treating obesity - Robert B. Taylor 69 The case against treating obesity - Denis Craddock 78 Commentary 87 6 Diabetes: strict control or flexibility in management? The issues 89 The case for strict control - Robert G. Russell 89 The case for realistic control-Douglas G. Garvie 95 The case for flexibility below 11.0 mmol/I - A. I. M. Bartelds 100 Commentary 107 7 Antibiotics for otitis media and sore throat? The issues 109 The case for antibiotics - Niels NrJrrelund 109 The case against antibiotics - Michael J. Whitfield 115 Commentary 120 vi COMMON DILEMMAS IN FAMILY MEDICINE 8 Premenstrual tension and the menopausal syndrome - specific treatment? The issues 123 The case for specific therapy. (1) - Gillian Strube 123 The case for specific therapy (2) - K. Gill 127 The case against specific treatment-Alistair Moulds 131 Commentary 136 9 Acute backache - active or passive treatment? The issues 139 The case for active treatment - Peter B. Martin 139 The case for conservative management - Jack Froom 145 Commentary 152 10 Terminal care - at home or in the hospital or hospice? The issues 153 The case for home care of the dying - M. Keith Thompson 153 The case for hospital/hospice care (1) - Bridget Matthews 159 The case for hospital/hospice care (2) - A. G. O. Crowther 164 Commentary 170 11 Compulsory immunization, or not? The issues 171 The case for compulsory immunization - W. O. Williams 171 Thecase against compulsory immunization - Tommy Bouchier Hayes 178 Commentary 183 12 House calls - more or less? The issues 185 The case for fewer house calls (1) - John Grabinar 185 The case for fewer house calls (2) - George Davie 191 The case for more house calls (1) - William Stewart 192 The case for more house calls (2) - Andrew Fraser 197 Commentary 200 13 Teamwork - delegated or shared? The issues 203 The case for delegation (1) - John D. Williamson 203 The case for delegation (2) - John Smith 211 The case for sharing - David Brooks 217 Commentary 226 14 Patient participation - more or less? The issues 229 The case for less patient participation (1) - Alfred O. Berg 229 The case for less patient participation (2) - Patrick Kerrigan 234 The case for more patient participation (1) - Peter Pritchard 238 The case for more patient participation (2) - G. J. Pistorius 243 The case for more patient participation (3): self-care benefits for primary care practitioners - Keith W. Sehnert 258 Commentary 268 15 Telling the truth, the whole truth, and nothing but the truth? The issues 271 The case for telling the patient the truth - Axel Engberg Pallesen 271 The case against telling the patient the truth - Robin Steel 283 Commentary 291 18 How many patients - more or less? The/'Gue, 293 The case for fewer patients (1) - Stan Schuman 293 The case for fewer patients (2) - Derek A. Coffman 298 The case for more patients - Eric Gambrill 303 Commentary 310 CONTENTS VII 17 The medical check-up - useful or useless? The issues 311 The case for a medical check-up - E. C. Gawthorn 311 The case for screening - Nils Andersen 319 The case against a medical check-up - Michael D'Souza 322 Commentary 336 18 Solo practice or group practice? The issues 337 The case for solo practice - Sus; Rottenberg 337 The case for group practice: the future practice model in family medicine - Roger A. Rosenblatt 343 Commentary 347 19 Vocational training for family medicine - useful or useless? The issues 349 The case for vocational training - Ken Young 350 The case against vocational training - John Fry 354 Critique by W. E. Fabb 357 Commentary 359 20 At least one female family physician in every group practice? The issues 361 The case for a female doctor in every group practice (1) - Elan Preston-Whyte 361 The case for a female doctor in every group practice (2) - George Strube 368 The case against a female doctor in every practice - Tommy Bouchier Hayes 370 Commentary 375 21 Prevention - realistic or not? The issues 377 The case for realistic prevention - John Fry 377 The case for more prevention - Rae West 382 Critique by John P. Geyman 390 Commentary 393 Index 395 List of Contributors Dr N.N. ANDERSEN Dr M.D. D'SOUZA Turpinsvej 2 The Can bury Medical Centre DK 2610 Rc,Jdovre, Denmark 1 Elm Road Kingston-upon-Thames DrD.M. BARR Surrey KT2 6HR, UK Department of Family Medicine Illinois Masonic Medical Center DrW.E. FABB 836 Wellington Avenue 12 Westminster Avenue Chicago, I l 60657, USA Bulleen Victoria 3105, Australia Dr A.T.M. BARTELDS OrA. FRASER Nederlands Huisartsen Institut 149 Upper Heidelberg Road Postbus 2570 Ivanhoe 3500 GN Utrecht, The Netherlands Victoria 3079, Australia Professor A.O. BERG Dr P. FREELING School of Medicine St George's Hospital Medical School Department of Family Medicine, RF-30 Cranmer Terrace University of Washigton london SW7 ORE, UK Seattle, WA 98195, USA Professor J. FROOM It Col T. BOUCHIER HAYES Department of Family Medicine Senior Medical Officer RMAS & Staff Health Sciences Center College State University of New York at Stony Camberley, Surrey, UK Brook long Island, NY 11794, USA OrO. BROOKS The Ridings DrJ. FRY 124 Manchester Road 133 Croydon Road Hopwood, Heywood Ol10 2NN, UK Beckenham Kent BR3 4DG, UK Dr D.A. COFFMAN 9 Wrottesley Road Dr E. GAMBRILL Willesden, london NW10 5UY, UK leacroft, lfield Road Crawley Dr D. CRADDOCK Sussex RH11 5BS, UK 5 Warham Road South Croydon, Surrey CR2 6lE, UK Dr D.G. GARVIE The Surgery Dr A.G.O. CROWTHER Palmerston Street 32 Kingfield Road Wolstanton Sheffield S11 9AS, UK Newcastle, Staffs, UK Dr G. DAVIE Dr E.C. GAWTHORN PO Box 27399 11 lucifer Street Sunnyside North Balwyn Pretoria 0132, South Africa Victoria 3104, Australia IX x COMMON DILEMMAS IN FAMILY MEDICINE Professor J.P. GEYMAN Professor G.J. PISTORIUS Department of Family Medicine RF-30 Department of Family Medicine University of Washington OFS University Seattle, WA 98195. USA PO Box 339 Bloemfontein 9300, South Africa Dr K. GILL Huisarts Dr B. POLLAK Zwammerdam. The Netherlands Beech Cottage, Gibson's Hill London SW16 3EX, UK Dr J. GRABINAR 31 Coniston Road Dr M.E. PRESTON-WHYTE Bromley Uppingham Road Health Centre Kent BR1 4JG. UK 131 Upping ham Road Leicester LE5 4BP. UK Dr P. KERRIGAN Dr P.M.M. PRITCHARD 9 The Hoe Monks' Corner, 31 Martin's Lane Billericay Dorchester on Thames Essex CM12 9XB. UK Oxfordshire OX9 8JF, UK Dr J. LEVENSTEIN Professor R.A. ROSENBLATT South African Acadamy of Family School of Medicine Practice/Primary Care Department of Family Medicine RF-30 24/25 Medical House University of Washington Central Square Seattle, WA 98195, USA Pinelands 7430. South Africa Dr S. ROTTENBERG Dr S. LEVENSTEIN 14 Norfolk Place 163 Koeberg Road London W2 1 OJ, UK Brooklyn Cape Town 7405. South Africa Dr R.G. RUSSELL Skinners Cottage Dr P. B. MARTIN Drayton Westley Hall, Homestead Drive Belbroughton, Worcs, UK Basildon, Essex, UK Professor S. SCHUMAN Dr B. MATTHEWS Department of Medicine 9 Royal Crescent Section of Preventive Medicine Bath BA1 2LR, UK Medical University of South Carolina 171 Ashley Avenue Charlestown, SC 29403, USA Dr B.R. McAVOY The Medical Centre Dr J.A. SMITH Byfield 2 Paterson Street Daventry Newlands Northamptonshire, UK Cape Town 7700, South Africa Dr A. MOULDS Dr K.W. SEHNERT The Health Centre 4210 Fremont Avenue South Laindon Minneapolis, MN 55409, USA Basildon Essex SS15 5TR. UK Dr R. STEEL St John's House Dr N. N(l)RRELUND 28 Bromyard Road Arhusvej 190 Worcester WR2 5BU, UK DK 8570 Trustrup, Denmark Professor W.L. STEWART Dr A.E. PALLESEN Box J-222, MSB Skovbuen 59 J Hillis Miller Health Center DK 2610 Rcildovre, Denmark Gainesville, FL 3261 0, USA LIST OF CONTRIBUTORS Xl Dr A.G. STRUBE Dr M.J. WHITFIELD 33 Goffs Park Road 24 Hanbury Road Southgate Clifton, Bristol BS8 2EP, UK Crawley, Sussex, UK Dr O.W. WILLIAMS Dr G.STRUBE Health Centre 33 Goffs Park Road Caebricks Road Southgate Cwmbwrla, Swansea SA5 8NS, UK Crawley, Sussex, UK DR J.D. WILLIAMSON Dr R.B. TAYLOR 91 Dodworth Road Wake Forest University Barnsley Bowman Gray School of Medicine South Yorkshire S70 6HB, UK 300 South Hawthorne Road Winston-Salem, NC 27103, USA Dr K.M.H. YOUNG Shell UK Ltd Dr M.K. THOMPSON Shell-Mex House 24 Fryston Avenue Strand, London WC2R ODX, UK Shirley Croydon, Surrey, UK Dr R. WEST Division of Primary Health Care Department of Community Health School of Medicine The University of Auckland Auckland, New Zealand Preface One of the eXCltmg challenges of medicine has been the reaching of decisions based on less than complete evidence. As undergraduates in teaching hospitals future physicians are taught to think in clear and absolute black and white terms. Diagnoses in teaching hospitals all are based on supportive positive findings of in vestigations. Treatment follows logically on precise diagnosis. When patients die the causes of death are confirmed at autopsy. How very different is real life in clinical practice, and particularly in family medicine. By the very nature of the common conditions that present diagnoses tend to be imprecise and based on clinical assessment and interpretation. Much of the management and treatment of patients is based on opinions of individual physicians based on their personal expenences. Because of the relative professional isolation offamily physicians within their own practices, not unexpectedly divergent views and opinions are formed. There is nothing wrong in such divergencies because there are no clear absolute black and white decisions. General family practice functions in grey areas of medicine where it is possible and quite correct to hold polarized distinct opinions. The essence of good care must be eternal flexibility and readiness to change long-held cherished opinions. To demonstrate that with many issues in family medicine it is possible to have more than one view I selected 10 clinical and II non -clinical topics and invited colleagues and fellow-practitioners to enter into a debate-in-print. Each topic has been selected because each is of some practical impor tance to family practitioners. Each chapter begins with a brief statement of the issues relating to the topic, there follow 'pro' and 'con' arguments and finally a short commentary attempts to strike a judicial balance. The prime aim of this rather unusual exercise has been to show that there can be more than one view on the common issues offamily medicine and that due attention should be given to the differing opinions. The target readership audience is all who work in, and those who are XUl
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