A paper Dr Cook delivered to a medical conference in 1954
In order to correct any misapprehension and to prevent any subsequent sense of disillusionment let me say at the outset that my talk today will have no clinical interest or value, will announce no new achievement of medical research and will have no pretension to being instructive. This period of your proceeding you had purposely devoted to sort of symposium upon the position after the practising profession in the National Health Service. This unfortunately and unavoidably has had to be abandoned but I have assumed that you would wish my talk, which takes its place, should be concerned, if not with precisely the same subject, at least with one akin to it.
I have therefore chosen to speak briefly to you upon the place of general practitioner in the field of medical research and preventive medicine. In these days when most publicity research seems to have been conducted in an environment of the mathematical tables, abstruse physical and chemical formulae and fantastically costly and elaborate laboratory equipment the general practitioner might well feel that he has no place in medical research. Similarly, the design and application of measures for the prevention of disease seem to be exclusively the responsibility of the Local Authority administering an Act under the direction of the Public Health Department and it might be supposed that opportunities for the general practitioner in this field must be negligible.
Yet consider for a moment the basic realities of preventive medicine. The existence of a disease must first be recognised and its nature understood before any effectual action can be taken to control it. Remediable factors contributing to its prevalence and to its dissemination must be identified and made publicly known. Large-scale preventive measures may be practicable and useful under some conditions but for most self discipline in the patient, every patient, will be necessary before complete control can be obtained. For all these purposes the assistance of the general practitioner is required to supplement the efforts of the Central Health Authority and the Local Health Authority. Indeed for some of them only the general practitioner can be of service. For of all persons concerned in the detection, treatment and control of disease the practitioner of medicine is the only one who is at all times and in all places in actual contact with the patient. He it is who first sees the patient and has the earliest opportunity to recognise the disease. He alone seeing the patient in his own environment and all stages of the disease, is in a position to study and interpret this significance of its clinical manifestations to ascertain the circumstances preceding onset, and to determine how, if at all, these relate to its subsequent course in different patients. He can observe the effect of treatment not only in the relief of immediate clinical condition but also in cure or in the prevention of transmission to other persons. When the therapeutic or sanitary measures necessary to control the disease or prevent its dissemination have been identified the practitioner alone is in that relationship to the patient which will permit him, as the agent of the Health Authority, first to instruct the patient in the necessary prophylaxis which he must practise and subsequently to supervise and ensure his compliance.
That the general practitioner as clinician has always been in the forefront of research throughout the history of medicine will be conceded by all who reflect for a moment and recall the contributions made to its advance through the centuries by the great physicians. In our own land, too, the history of general medical practice has included a chronicle of keen observers, gift with the tenacity of purpose to study the clinical and aetrological detail of their cases, endowed with the perception to descry the significant features and possessing the ability accurately to assess the relative importance of each in causation and prevention.
For your interest and to emphasise this point let us briefly refer to a number of general practitioners in this country, indeed in this very belt of tropical and sub-tropical Queensland who have themselves undertaken laboratory researcher who have prepared the ground for the laboratory worker by identifying clinical entities and correctly indicated lines of further research likely to prove profitable to the bacteriologist or other technical specialist.
Joseph Bancroft, a busy and much sought medical practitioner of Brisbane, where he practised from 1864 – 1894, found time to conduct an astonishing number and variety of biological studies. These included such diverse subjects as the evolution of a rust-proof wheat, the identification of the diseases of bananas and sugar cane and the culture of grape and oysters. Of special medical interest were his demonstration of the transmission of filaria by the mosquito in 1876, and the mydriatic properties of duboisia in 1877.
Frederick Goldsmith in the Northern Territory of South Australia, in practice in a township which was little more than a hamlet having but poor communication with the outside world, provided with a rudimentary hospital and lacking bacteriological facilities of any sort, in 1897 described finally the instruction of his colleagues in the Australian tropics then differential diagnosis of tropical fevers. In addition he gave a careful clinical description of Granuloma venereum and recorded the endemicity of leprosy. He discussed the occurrence of beriberi and ascribed it to a dietary factor even before Eijkman had yet demonstrated the role of polished rice in the production of polyneuritis in fowls.
G.V. White of Thursday Island in 1902 reported 200 cases of beriberi. At a time when in text books available to the profession in Australia the cause of this avitaminosis was not known but still the subject of wide dispute and varied theory he attributed it to the lack of fresh food and noted the clinical similarity of alcoholic neuritis.
Graham Brown at Charters Towers, 1882-1892 noted and reported the association of a high incidence of typhoid with low rainfall and related this observation to the unhygienic disposal of night soil in cess pits alongside wells on the river banks and to the reliance of more and more of the population upon a few polluted sources as water became scarcer during dry weather. He emphasised the necessity for improved sanitation and advocated education of the people in and out of school as the best means of securing it.
T. L. Bancroft, son of Joseph, and medical practitioner in Brisbane and at Eidsvold, was the first to discover trypanosomes in certain small animals. In 1902 he demonstrated the hookworm larva penetrating the human skin and three years later showed Aedes aegypti to be the carrier of dengue fever.
Of special interest to the profession in Queensland and in particular to practitioners in tropical coastal Queensland is the story of Scrub Typhus.
In 1907 there were reported at Port Douglas 31 cases of an illness with slight glandular enlargement is somewhat suggestive of bubonic plague. The Government Bacteriologist in a special investigation report that finding B. pestis in specimens from ten of the patients but in retrospect the apparent mildness of the condition and the law mortality rate makes in doubtful whether this observation was correct.
In 1910 Oliver Smithson of Port Douglas gave a detailed clinical account of “Mossman Fever” and emphasised certain epidemiological features which established it is a definite clinical entity associated with exposure in certain localities in the vicinity of Mossman.
In 1913 P. S. Clarke of Cairns prepared for the Queensland Commissioner of Public Health a full clinical description of this disease based upon his study of 1500 cases over a period of five years. The report, which included advice upon differential diagnosis and treatment, was printed for professional and general information in the Commissioner’s Annual Report for that year.
Between 1915 and 1922, 100 cases of a similar febrile condition were reported in the Sarina Area. Of these cases 19 died. Stewart Kay, medical officer for Health for the area, established that this pyrexia was not as had been suggested, typhoid.
Nye and Payne at Atherton in 1923 diagnosed cases of a similar fever as endemic typhus but laboratory confirmation was not available. 10 years later, Matthew at the Commonwealth Health Laboratory, Cairns, in collaboration with Langan of Cairns and Unwin of Tully was able to demonstrate serologically that these fevers were as earlier practitioners had claimed separate clinical entities and to support the diagnosis of typhus made by Nye and Payne in 1923 and by Langan and Unwin more recently. Matthew in his report gave full credit to his practising colleagues and explained that serological confirmation of the local medical diagnosis in earlier years had been delayed by technical difficulties in the Health Laboratory.
General practitioners in the endemic area also played major part in the elucidation of the identity of Leptospirosis another pyrexial condition and endemic in parts of the North and formerly linked with scrub typhus as one of North Queensland’s unidentified fevers.
In 1933 – 1934, Gordon Morrissey of Ingham observed during an influenza epidemic a pyrexial syndrome new to his experience and to that of his colleagues in that area. His critical and careful study established this condition as a definite clinical entity. He observed too that the cases occurred in groups at irregular intervals and that the reappearance of cases was associated with heavy rainfall and with the rat infestation in the cane fields. Cotter and Sawers of the Commonwealth Department of Health Laboratory Service were able to establish the disease as Leptospirosis, thus confirming an opinion held for some time by Morrissey and Leckie.
Three years later Clayton of Pomona in South Queensland called attention to the prevalence of Leptospirosis of a different type and this as in due course shown by serological studies to be caused by a different strain of Leptospirosis.
I think there is ample evidence here that the general practitioner plays a most important part in the initiation of medical research. After all it is he and he alone who can recognise the existence of a clinical problem, identify its component and bring it to the notice of special technical investigators. He too will provide and check the suitability of the human material for their investigation.
Let us pass then to the second point made earlier in this talk, namely that the general practitioner also has an important role to play as the agent of the Public Health Authority in the prevention of disease. What shall we recognise as the feel of preventive medicine? An attempt may be made to summarise this briefly thus –
- the recognition of the causes of morbidity and mortality in the community and the assessment of the incidents of each,
- the identification of the epidemiological factors which are remediable and the development and general application of measures to correct these,
- the discovery of methods of therapy best suited to shorten the period of illness, to avert or fatal outcome are to prevent transmission and to take measures necessary to ensure the general use of these.
The first of these purposes requires prompt and accurate diagnosis and faithful reporting. Who but the general practitioner is available for these purposes? He first and he perhaps alone sees the patient, has sufficient clinical knowledge to make an accurate diagnosis and responsibility to report his findings.
If he should feel to make a correct diagnosis or if he omits or neglects to report a notifiable diseases the value of morbidity statistics kept by the Central Health Authority will be to that extent impaired. If the majority, indeed if a significant number of general practitioners, are unable to make a correct diagnosis or are too negligent to provide the Central Authority with the information sought concerning any disease measures for control are to that extent frustrated and rendered futile.
Two responsibilities are apparent here, one affecting the Central Health Authority and the other the general practitioner. Clearly the general practitioner must be provided with facilities for the diagnostic procedures required to supplement his clinical knowledge and skill. These for the most part in a community such ours would be provided by the Health Authority and in their absence responsibility for any failure in the programme of disease prevention arising from incorrect diagnosis lies at the door of that authority.
Notification of identified notifiable diseases is in turn the responsibility of the practitioner. It may be remarked here and now that there has developed amongst general practitioners throughout Australia attitude of resistance and hostility to notification. A number of factors have contributed to this regrettable development. First, though possibly only indirectly, there has been the influence of that very unhealthy spirit of non-cooperation engendered by the reluctance of members of heavily taxed profession to perform any duty for a Government Department for which they consider an adequate re-imbursement or fee is not paid. Superimposed is the suspicion, not always unjustified, that much of the information required to be supplied as a routine serves no useful purpose and indeed is not used all for any purpose. The suspicion has, of course, received some appearance of confirmation by the circumstance that for many notifiable diseases the original purpose of their notification no longer obtains. In the days before mass immunisation and effectual therapy the control of epidemics of infectious diseases was attempted chiefly by notification and home isolation. Meticulous notification was required of the practitioner in order that these measures could be promptly applied by the Local Authority. Now-a- days, of course, the methods have fallen largely into disuse and the modern medical practitioner can see no tangible purpose to be served by notification. It must, of course, be frankly admitted that unless the Health Authority has a use for the information supplied actually puts it to that use he may be right. On the other hand, refusal to notify in notifiable disease may stem from a very different reason. Notification today is required for more purposes of epidemiological and statistical study than for local attempts at prophylaxis. When therefore, acute rheumatism and chorea were made notifiable in a certain State for study purposes it was not contemplated that any Local Authority would concern itself with attempts at prophylactic routine. However, it was soon discovered medical practitioners were refusing to notify these conditions on account of the indignant reactions of patients’ families to the unwelcome and unexpected intrusion of Local Health Authority officers armed with sulphur candles, formalin sprays and similar disinfecting equipment.
Here then is a matter upon which the two partners in epidemiological study and in preventive medicine must reach clear understanding and full agreement. The Central Health Authority should state without reserve what information it requires and for what purposes it is intended to be used. The profession is acknowledging the value of the purpose should agree meticulously to supply the information and in return should be provided with evidence that it has indeed been used as intended.
It may be thought that identification of it its remediable epidemiological factors and the development of a system of prophylaxis for a disease would be exclusively the function of the Central Health Authority without much practical assistance from the general practitioner or even without his co-operation at all. On the contrary an essential ingredient of any comprehensive study of the aetiology of a disease and of the oecology of its parasite is very critical and enlightened observation of the patient at all stages of disease in his own environment. It is true that an investigation on these sought could be undertaken by a qualified special research student devoting his attention specifically to a group of cases as they occur in one or more areas. It is nevertheless equally true that these cases must be discovered and presented to him for this purpose by one or a group of competent medical practitioners and that much more is to be expected much more rapidly and economically from a concerted study over a wide range of circumstances and environments by a number of co-operating practitioners trained as observers.
There can, of course, be no question of the role of the general practitioner in the study of new methods of therapy. In this field the medical practitioner alone is competent to prescribe the treatment, to watch its effects and to assess its value and hazards. It would be the function of the Central Authority to see that therapeutic agents of proved value are generally available and that the medical profession is fully and accurately informed upon their use in preliminary therapeutic trials.
The importance of therapy as a means of prevention means of may not at first sight be fully apparent. Consider however two conditions with which you personally are likely to be concerned; the treatment of leprosy end the cure of malaria. Since the introduction of the sulphones in the treatment of leprosy more and more patients are being discharged under surveillance. Maintenance therapy is necessary for these. Although suitable arrangements for the supervision of treatment and review will doubtless be made in each case by the Central Health Authority it must be expected that proportion of cases will, from time to time, seek medical attention privately, automatically bringing the practitioner consulted into the relationship of agent for the Central Health Authority.
In most of the potentially malarious areas of North Australia anopheline control is impossible and of the question. Control of malaria if it is to be achieved must be attempted by prompt diagnosis and proper treatment for the complete eradication of infection and prevention of relapse. The patient must be warned to report immediately any recurrence of fever in to submit himself for review to confirm eradication of infection. This method of control which depends entirely upon diagnosis treatment and on a good doctor-patient relationship can be discharged only by practising medical profession. The Central Health Authority would be wholly dependent upon the medical profession for its successful application.
Conceding that general practitioners in the past contributed substantially to medical research you may ask what opportunities offer today, I think these are legion. To mention but a few I suggest amongst other activities in which the general practitioner can engage in co-operation with the Central Health Authority you might consider –
(a) The collection of clinical and statistical information required by special research institutes such as for example the Institute of Child Health;
(b) The furnishing to the Central Health Authority of detailed information required for the study of foetal and neonatal deaths;
(c) The assumption by the general practitioner of much of the work at present undertaken by medical officers of Schools Medical Service relieving the latter of much of the examination routine and freeing him to be trained as and elevated to the position of consulting paediatrician co-operating with, existing and guiding the general practitioner in the improvement of the health of the school child;
(d) Immunisation: The assistance after the general practitioner is also required in the devising of methods by which the adequate immunization of all children against certain diseases maybe confidently assured and the effect of immunisation satisfactory, permanently and accessibly recorded.
(e) Health Education: The medical practitioner has a place, an important place in health education of the public. To derive the best value from his services it would be necessary to evolve an organisation to guide his activities in concert with the policy of the Central Health Authority and to supply him with educative material.
(f) Health and medical authorities throughout Australia have, on many occasions, emphasised the need for measures to conserve the value of antibiotics and to prevent misuse and unnecessary use. Only with the co-operation of the medical profession can any effectual measure be applied for this purpose.
The problem, as I see it, is not so much how these several discipline and others similar to them maybe willingly assumed by the practising profession as how a satisfactory liaison organisation can be established between the central health authority and general practitioner in the field so that practicable routine in the procedures in this and other matters may be devised and ordered to the manual satisfaction of both parties and so that the goodwill and active co-operation of the practitioner may not only be assured but fostered. It may be found necessary to provide some form of clerical assistance to the medical practitioner for some of these purposes. Whatever the problems I believe there should be no further delay in commencing a study of them and I am glad of and grateful for this opportunity to suggest that you give careful thought to the possibilities of closer co-operation in these fields so that no future reformer in health administration will consider it desirable or necessary to achieve the same purpose by regimentation.