Movsowitz, L.

English

AJOL - African Journals Online

30 January 1971 S.A. MEDICAL JOURNAL 123prescription without careful supervision, nor should hisdietary regimen be allowed to slacken.The value of the sulphonylureas has been further ex-tended by combination with the diguanides where indi-cated, but most authorities find no value in their combi-nation with insulin. They have not been found to prevent,delay or benefit vascular disease, so that they are nopanacea for the whole diabetic abnormality, any morethan is insulin. In view of their relatively physiologicalmode of action in stimulating the patient's pancreas todischarge its own insulin it is just conceivable that theymay have a place in the prevention of diabetes, but thisis quite unproven.An abridged version of much of the contents of thisarticle is contained in the 'flow sheet' in the appendix.REFERENCESL Fajans, S. S. and Conn, T. W. (1962): Diabetes, 11, suppI. 123.2. Jackson, W. P. U. (1967): S. Afr. Med. J., 41, suppl. 1 July.3. O·Donovan. C. J. (1959): Curr. Ther. Res., I, 69.4. Jop!in, G. F., Fraser, R. and ValIance-Owen, J. (1959): Lancet, 2,582.5. Patel, D. P. and Stowers, J. M. (1964): Ibid., 2, 282.6. Duncan, L. J. P. and Baird, J. D. (1957): Scot. Med. J., 2. 171.7. Lundbaek, K.. Nielsen, K. and Rafaelson, O. J. (1959): Ann. N.Y.Acad. Sci., 74, 419.8. American Diabetes Association (1970): Diabetes, 19, 527.9. Hunton, R. B., Wells, M. V. and Skipper, G. W. (1965): Lancet, 2,449.10. Hadden, D. R., Aontgomery, D. A. D. and Weaver, J. A. (1962):Diabetes, 11, 9L11. Fi12gerald, M. G., Gaddie, R., Malins, J. W. and O'Sullivan, D. J.(1962): Ibid., H, 40.12. Bauer, H. G. (1965): Metabolism, 14, 220.13. Vinik, A. 1. and Jackson, W. P. U. (1968): S. Afr. Med. J., 42, 1257.14. Katz, H. M. and Bissel, G. (1965): Diabetes. 14, 650.15. Abelove, W. A., Hills, A. G. and Echenique, R. (1962): Ibid., 11,216.16. Seftel, H. C. (1969): S. Afr. Med. J., 43. 979.17. Schneider, T. and Lopis, S. (1969): Ibid., 43, 98L18. Jackson, W. P. U. and Vinik, A. 1. (1969): Ibid .. 43, 1002.19. Conference Proceedings (1969): Tegenlsee-Kon!ere1JZ iiher das neueorale Antidiabelikw'1'l HB4/9. Frankfurt and l\.1annheim: FarbwerkeHoechst AG and Boehringer Mannheim GMBH.20. Bank, S., Herman, M. and Jackson, W. P. U. (1965): S. Afr. Med. J.,39, 1117.21. Bloom, A. (1959): Brit. Med. J., 2, 731.22. Stowers, J. M. and Helgason, T. (1965): Diabetologia, I, 128.SOME THOUGHTS ON MEDICAL TRAINING FROM A MORBIDITY SURVEY INGENERAL PRACTICE IN UPINGTON*L. MOVSOWITZ, B.SC., M.B., CH.B., General PraCliTioner, UpingTOn, CPThe general practitioner shortage, especially on our platte-land, and the general apathy on the part of medicalgraduates towards general practice, have urged me to pensome thoughts on medical training for general practice.I am in a single-handed general practice in Upington,~apital of the Gordonia district. The practice caters for allocial strata of our three major race groups. The town,tself at a population census taken during June 1968 was,hown to have a total population of 27 000, comprising7500 Whites, 14500 Coloureds and 5000 Bantu. The-ural district, which is also partly attended to by practi-ioners in the town, has a population of 18481 Whites,50 995 Coloureds and 5 462 Bantu.At the time of preparing this paper there are 8 generalJfactitioners in the town, who also staff the Gordonia-fospital of 150 beds, which is the main hospital servinghis area. We have no specialist services and administer,naesthetics and undertake surgery within our capabilities.>atients requiring specialist attention are mainly referredo Cape Town.MORBIDITY SCRVEY)uring the period 1 July 1968 to 19 August 1968 in theeart of our winter, which can be mild or fairly severe,conducted a morbidity survey in my practice using the963 classification of disease-amended version-of the:ollege of General Practitioners.'During these 50 days I was consulted by 2432 patientsf whom 665 (27'3%) were White, 1276 (52'5%) Colourednd 491 (20'2%) Bantu-a fairly representative cross-sectionE the town's population. The following interesting facts'ere noted in the patients seen:'aper preoented at the 47th South African Medical Congress (M.A.S.A.).'retoria, hly 1959.-Age IncidenceThe patients most commonly seen were aged 2 yearsand under, or over 16 years. It is of note that in the 0 - 2-year age-group the percentage of Whites seen was halfthat of the Coloured and Bantu (Table I).TABLE I. AGE INCIDENCE OF PATlE.NTS SEENAge White (%) Coloured (%) Bantu (%)0- 2 10·4 21·5 22·22 - 6 6'3 6·8 7'56 - 16 12{) 8{) 8·3Adults -1l·3 63·7 62·0Sex IncidenceAn examination of Table II shows that in the 6 - 16-yearage-group more males than females were seen amongWhites and Bantu, while among the adults there was anoticeable preponderance of Coloured females, otherwisethe sex incidence was fairly evenly distributed.TABLE It. SEX INCIDENCE OF PATIENTS SEENWhite Coloured BantuAge Male Female Male Female Male Female0- 2 35 34 109 125 59 502- 6 19 23 45 42 21 166·16 51 29 45 57 27 14Adults 242 232 358 455 158 146Disease IncidenceTable III provides a detailed picture of the incidenceof the different diseases seen. In all age-groups the commonrespiratory tract and gastro-intestinal ailments formed thebulk of diseases seen. Among the Whites they constituted217 (30'6%) of cases, among the Coloureds 424 (33'2%)124 S.-A. MEDIESE TYDSKRIF 30 Januarie 1971TABLE Ill. DISEASE INCIDENCEAge: 0-2 2-6 6-16 AdultRace: W C B W C B W C B W C BDiseasesCommunicable:Venereal .. 3 1 5 33 28Gastro-intestinal 13 65 39 2 11 6 8 1 7 14 7Others 9 19 6 7 11 4 11 15 5 5 27 9Neoplasms .. 2 3 5Allergic. endocrine, metabolic,nutritional 3 4 3 24 13 7Blood diseases 1 2 1 5 1Mental psychoneurotic, personalitydisorders 4 78 50 18Nervous system and sense organs:CNS 2 4 2 7 3 3 4 21 2Peripheral nerves 1 4 2 2Eyes 1 2 1 2 3 1 7 20 3Ears 6 3 3 4 2 2 2 3 16 11 3Circulatory system:Heart 2 35 18 9Hypertensive .. 7 12Respiratory system .. 30 144 52 17 38 15 40 34 9 97 110 51Digestive system 2 5 4 3 1 3 3 2 26 32 10Genito-urinary system 1 1 4 2 44 125 41Pregnancy and complications 1 22 144 49Skin and cellular tissue .. 2 12 5 5 7 2 1 3 4 29 30 11Bones and movement 2 5 2 35 74 30Congenital malformation 4Early infancy 5III defined .. 1 4 3Accidents, poisoning, violence 6 4 8 5 4 15 4 20 61 23Prophylactic 4 1 1 3\V = White; C = Coloured; B = Bantu.and among the Bantu 180 (36'6%). Pregnancy examinationsand the common urinary tract ailments, namely pelvicinfections and pyelocystitis, formed 67 (10·1'%) of Whites,274 (21,4%) of Coloureds and 94 (19%) of Bantu casesseen. Mental, psychoneurotic and personality disordersformed 16'4% of Whites, 6·1 % of Coloureds and 6% ofBantu cases seen, these being almost entirely in the adultage-group. Venereal disease formed 1% of White, 4% ofColoureds and 9% of Bantu cases seen-almost all beingadults. Cardiovascular disease was responsible for 6·3% ofWhites, 2·5% of Coloured and 1·9% of Bantu cases seen.Neoplastic disease, so heavily emphasized in one's under-graduate training, formed a mere 0·4% of White casesseen, 0·4% of Coloured and 0'8% of Bantu. This is inkeeping with a Canadian and Scottish practice survey doneby Noble.' In Van Biljon's Pretoria practice survey; malig-nant neoplasms constituted only 1·46% of cases seen.Accident cases accounted for 28 (4·2%) Whites, 90 (7%)Coloureds and 32 (6'5%) Bantu seen. Among the last tworace groups many were due to deliberate violence. Accidentsare becoming a major epidemic.Surgical CasesPatients requiring surgery of any sort formed only 1°{,of Whites, 2·2% of Coloureds and 1·2% of Bantu seen.This too concurs with Noble's findings of 1'8% and 1·5%of patients seen. The incidence in Van Biljon's series was7'33%.Patients Requiring HospitalizationThis was necessary among 1·6% of Whites, 9·5% ofColoureds and 11·4% of Bantu. In the Coloured and Bantumany of the admissions were as a result of neglect forpneurnonias, severe gastro-enteritis, pelvic infection andcomplications of pregnancy.Home VisitsPressure of work has forced me to cut these down to aminimum, yet among the Whites they formed 16% ofconsultations, whereas among the Coloureds they were amere 2% and among the Bantu 0·2%. The majority ofWhite patients who were visited could just as well havebeen seen at the consulting rooms.Patients Requiring Specia'ist AttentionI felt that if there were specialist facilities availablewould have referred 21 (3'3%) of Whites, 47 (3'7%) ofColoureds and 14 (3%) of Bantu for specialist attention. Inactual fact I had to manage with less.COMMENTThere is an equal demand for medical attention from allthree major race groups. The non-White has fully awakenedto the benefits of modern medicine. Excluding hospitalwork and practice administration ± 50 patients were beingseen daily at a time of the year which is not as busy asduring our summer months. With the increasing tempoof growth of the non-White community the work-load mustincrease.It is interesting that the age-group 0 - 2 years constitutedan important percentage of patients seen, stressing thnecessity of a thorough grounding in paediatrics.30 January 1971 S.A. MEDICAL JOURNAL 125Surgical cases and the rarities of hospital practice formonly a small percentage of patients seen. Diseases in allbranches of medicine are seen, emphasizing the broadmedical knowledge required by the general practitioner.Only 3 - 4% of patients seen required specialist attention.This is in keeping with the observation overseas that over80% of ailments can be dealt with by the general practi-tioner.'Although I did not include a survey of the percentageof patients who could have been seen by lesser-qualifiedmedical personnel such as nurses, social workers, midwivesand technicians, it is my opinion that a substantial per-centage need not have seen a doctor. Fry has suggestedthat one-third of the general practitioner's work can beperformed by a lesser-trained person. Krass' has found that25% of the general practitioner's time is concerned withminor duties.There is very little time for home-visiting which in myexperience plays a minor role in the evaluation of disease.Most patients can be seen at one's rooms. Unfortunatelyin the battle against the work-load one is too busy to pro-vide a high standard of social medicine so necessary forthe health of the community.All these observations point to the necessity for moregeneral practitioners and auxiliary medical services.Medical Training for General PracticeThe incentive to enter general practice can only bestimulated by correctly orientating undergraduate educa-tion, providing vocational training for general practiceand encouraging continuing education in order to keepabreast of advances in medical knowledge. It is thereforeessential that a Department of General Practice be set upin all our medical schools.In regard to undergraduate training, Scott' has said,'historically all specialities originated in general practice,differentiating as skills increased-no one can specializeuntil he has had a general medical training and for thisreason student training should be designed for generalpractice', or at least the basic training should have ageneral practice bias. The era when a doctor was expectedto know all and deal correctly with all medical eventualitieshas passed, therefore it is high time that the current 6-yearundergraduate medical course be modernized. The generalpraetitioner should be integrated into the curriculum fromthe basic sciences upward. In the first year the medicalstudent must be given a true perspective of what a careerin medicine entails in terms of dedication, integrity andcompassion and be reminded that the glamour of thelarge hospital forms but a small part of the whole. Theremust be no false ideas of what to expect in medical prac-tice so that the right students enter the course.The first-year subjects must be presented in a meaning-ful way. Basic principle rather than detail should be taughtin anatomy, physiology and pathology. The significance andretention of the details only comes after one can applythem in practice. The first 3 years could be condensedinto 2 or 2-} so that the student is brought sooner intocontact with the patient. This time gained could be betterspent in teaching the student what is normal in the living.Only after one has examined innumerable normal hearts,chests, nervous systems, etc., can one later appreciatewhat is abnormal. The further teaching of clinical subjects-done by specialists in each field should be moderated bythe general practitioner who must put the epidemiology ofeach section into its correct perspective. My fbt case inclinical medicine was one of haemochromatosis and thesecond a case of Addison's disease-I have been searchingin vain for the past 10 years for these conditions in mypractice! The same applies to the rarities of teachinghospital surgery and gynaecology. The correct attentionmust be devoted to minor medicine and surgery. Thestudent must be shown that one of the most importantfunctions of the general practitioner is to distinguishbetween disorders requiring extensive investigation andtreatment and those not, and that every patient presentsthree features for consideration: his physical complaint,social environment and emotional state.' If holidays wereshortened and modern teaching methods employed, e.g.audio-visual aids, and the teachers were enthusiastic andcompetent, the undergraduate course could well be short-ened by a year. Better use could be made of the internshipyear by eliminating the drudgery of holding retractors forhours on end as a second assistant at operations, searchingfor X-rays and running about with test-tubes of blood.Many suggestions have been made as to postgraduatetraining" for general practice involving rotating internshipsand practice apprenticeships covering periods from 2 to 5years. Five years may be in order in the United Kingdombut not in Southern Africa with its rapidly increasingpopulation and shortage of doctors. Thought must be givento making this vocational postgraduate training as short aspossible.It is unnecessary to state that medical education doesnot cease with completion of vocational training.' Medi-cine is a lifelong study requiring continuing education inall its disciplines. For the general practitioner this shouldbe the duty of the College of General Practitioners. Theconcept of continuing education must be indoctrinated inthe undergraduate years, as good general practice is asmuch an intellectual challenge, or more so, than anyspecialty. It behoves us to attract the best brains ifmedicine and health are to advance along all fronts.SUMMARYThe decrease in the number of medical graduates enteringgeneral practice is cause for concern. A morbidity survey ingeneral practice in Upington in all three racial groups showsthat over 96% of ailments can be dealt with by the generalpractitioner and that morbidity in practice is totally differentfrom that in the teaching hospital. It is essential therefore thatDepartments of General Practice be established in all our medi-cal schools, to stimulate the undergraduate's interest in generalpractice and assist with his training. If general practice is tocontinue in the future to fulfil its role as one of the keystonesof medical care, it is necessary to institute postgraduate voca-tional training and continuing education for the prospectivepractitioner.REFERE 'CES1. Classification of Disease-Amended Version (1963): J. Coli. Gen.Practit., 6, 207.2. Noblo, H. M. S. (1964): Ibid .• 8, 60.3. Van Biljon, P. J. (1968): Med. Proc., 14, 179.4. Editorial (1966): College of General Practitioners South AfricanFaculties Newsletter No. 64, 3.5. Krass. I. M. (1965): J. Coli. Gen. Practit., 10. 124.6. Scott. J. R. (1964): Ibid., 8, 244.7. Symposium on the Art and the Science of General Practice (1965):Ibid., " suppl. 2.8. Editorial (1968): South African College of General Practitioners News-letter. No. 3. 3.9. Leiman, N. C. (1967): S. Afr. Med. J.• 41, 933.

Some thoughts on medical training from a morbidity surver in general practice in Upington

https://www.ajol.info/index.php/samj/article/download/187466/176738

Some thoughts on medical training from a morbidity surver in general practice in Upington

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online