Nick Summerton On the limitations of specialists

Published: 02/09/2004, Volume II4, No. 5921 Page

Some of my consultant colleagues are moonlighting. They may well bear the title cardiologist, colorectal surgeon or chest physician but a proportion are also undertaking primary care medicine. I have encountered patients with ENT problems treated by a dermatologist, eye problems managed by an orthopaedic surgeon and skin problems dealt with by a gynaecologist. In the US the situation has developed further, with specialists now serving as primary physicians for almost one fifth of the population.

In its drive to create a new category of generalists - GPs with special interests - the government seems to be ignoring the training requirements of surgeons or physicians who wish to undertake primary care medicine.

At the same time, the new PMS regulations for general practice say the provider can 'choose to contract for the provision of primary medical services from an appropriate medical clinician who could be a GP, geriatrician or other appropriate medical professional'.

Primary care medicine is distinct from specialist medicine.

Clinicans in primary care do not only see patients with the same problems as their specialist colleagues, they also encounter these conditions at all stages from screening, through diagnosis and initial management into continuing and, if necessary, palliative and terminal care. In addition, GPs have to cope with a much broader range of conditions and treat them more holistically.

But the broader and more long-term nature of primary care is frequently ignored when clinical research questions are formulated by hospital-based specialists or when new drugs are weighed against existing treatment.Much of what a GP does is about continuous treatment over many years. For example, preventing cardiovascular disease. GPs have to weigh up the initial benefits of prescribing drugs - such as warfarin, anti-hypertensives or diuretics - against the risks of long-term treatment. Do the risks for the patient eventually outweigh the benefits and at what point does this switch occur?

For many patients the GP's most fundamental role is being able to act appropriately when they have concerns about their health.

However, specialists have a very different diagnostic approach: the link between symptoms and organic disease is much tighter in their setting. For example, if a patient goes to secondary care with rectal bleeding they are more likely to be diagnosed as having colorectal cancer. The GP would need to eliminate other less serious conditions before referring the patient. Diagnostic differences between GPs and specialists also arise because patients present to GPs with early/evolving symptoms, so that GPs have to be able to cope with a higher degree of diagnostic uncertainty.

The role of the traditional specialist is changing. In areas such as cancer care, constraints have already been placed on general surgical practice. Perhaps specialists should become more comfortable with their limitations and not simply assume that they are up to anything.

Nick Summerton is a GP and reader in public health and primary care at Hull University.