Common Dilemmas in Family Medicine

401 Pages·1982·14.596 MB·English

by  Daniel M. Barr, Eric Gambrill, John Fry (auth.), Dr John Fry (eds.)

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