van Lingen, S.A.

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284 S.A. MEDICAL JOURNAL 19 March 1955too good and almost always unCertain. And yet, broadly speaking,the need is for a greater measure of intensification, which meansmore rather than less farmers. Modem inventions have shownhow farm life can be made more attractive both for men and women,but these amenities are not as yet sufficiently available to competewith the attractions of urban life. That such matterS are of nationalimportance and not merely the concern of the farming communityis self-evident.Finally, it should be noted that we have confined our attentionsolely to the Union of South Africa. But obviously it is necessaryto think in terms of the food-production potential of the whole ofSouthern Africa. To do this would be to take into account thepossibilities of the Protectorates and High Commission Territories,including the great ·Okavango Delta 'where 2-3 miJlion acres ofswamp land await drainage and development', as well as theRhodesias with the vast developments that are linked with theKariba and Kafue projects. J. H. Wellington's tentative landclassification of Southern Africa, with map, (1953) 3 is a valuablecontribution to this aspect of our problem.REFERENCESI. Du Toit, M. S. (1953): Public Health (Johannesburg) 17,330.2. Food and Agriculture Organization of the United Nations.Report of 7th Conference. November-D~cember 1953.1954: Rome.3. Wellington, J. H. (1953): S. Afr. Geogr. J., 35, 16.For further reading World Population and World Food Supplies(1954) by Sir John Russell (London: AlIen and Unwin) has alengthy chapter on South Afriq and neighbouring territories.A SUGGESTION FOR A CHANGE IN THE PRESENT CLASSIFICATIO OF DOCTORSS. A. VAN LINGEN, M.B., CH.B., D.P.H., D.T.M. & H. JohannesburgDoctors are classified as general practitioners and specialists.The latter designation. is a misnomer. Specialists should morecorrectly be called 'Localists' in contrast to general practitionerswho are 'generalists'. The word 'specialist' carries an unwarrantedelement of praise,. with a reciprocal slight to his hard-pressedcolleague, the 'generalist'. Specialists and general practitionersuse the same classification of disease and similar methods ofinvestigation and treatment. The latter, however, by the nature ofhis work and experience, realizes more the fact of the inter-related-ness of organs and systems in the patient and the inter-relatednessof man and his environment. .He especially realizes the defect in the 'localist' approach ofgiving exclusive attention to one part of the body, when thecause of the disease may lie elsewhere. His greater follow-upcontact also enables him to better appraise his own work and thatof the specialists. The busy general practitioner may err in givinginadequate local investigation owing to pressur.e of work. Therefore,in order that he may be afforded the opportunity of making hisvaluable contribution to medicine, the senior 'generalist' shouldconsult only and not visit. The time-consuming home vjsitinghe can leave to his junior colleague.The 'generalist's' main concern is the treatment of his patient asa whole, and this he can best carry out by spending more time ininvestigating and treating the mind of his patient. It is he who seesand appreciates the vast amount of psychosomatic disorders ingeneral practice. (To appreciate the wide effects of emotions inprodu ing disea e of the body, see H. F. Dunbar's Emotions andBodily Changes.)NON-ACADEMIC POSTGRADUATE STUDYI h'lve personally been qualified for 16 years and for the last 5years have been doing work of this nature. The extra time I havehad to myself has enabled me, in addition to doing private researchto study journals and books on psychosomatic medicine from manyparts of the world. I am glad to report that T am not starving,and doing better work, in spite ·of the fact that I did not return toalma mater to hold her hand while I read a new book or journal.She gave me my basic training, for which I am grateful, but T amnow able to study on my own, and can readily forgo her blessingofmore academic exhibitionism. I now work in the field, and makeliving contact with my patients, where my work enjoys progressiveimprovement, but alas! not progressive remuneration.Postgraduate teaching, learning, research, practice and organi-zation of medicine must be flexible to allow freedom for individualdevelopment in diverse ways, without the stultifying encrustationsof rigid regulations and discriminations. Postgraduate academicsnobbery is harming private study and initiative which does notconfer the honour of an extra title.It is probably necessary that every doctor qualified as such shouldspend 5-10 years as a 'junior' general practitioner, the lengthof time being determined by the needs of society at the time, beforehe is peI1llltted to act as a 'consulting' general practitioner or as aspecialist. The junior 'generalist's' fees should be sufficient toprovide for future private or academic study requirements. Youngmen are better able to withstand the -arduous duties inseparablefrom a 'visiting' general practice and to benefit from them.A general practice contains features not included in giaduateteaching. The academic education carried out by specialists,instils in students the localist and not the 'generalist' approach.The integrated approach is only acquired by the general practitionerafter years of experience-it does not exist in academic education.This priceless feature must be valued, for it contains the greatestpotential for future progress in medicine. This fact is not recognizedin academic circles and not by the lay public. A doctor may callhimself a specialist after 2 years of extra study-a general prac-titioner of 20 years' experience and study remains in name ageneral practitioner when in fact he is much more. What blindnessprevails because we have not created a special title for the seniorgeneral practitioner!-ofcourse he has not returned to pay homageto alma mater; his increased skill and experience come from hiswork in the field. -Universjti~s make no provision for helping the future generalpractitioner by employing experienced general practitioners ontheir staffs. It is only the latter who can adequately apply theintegrated approach. When the medical schools wake up to therequirements of the public and employ senior general practitionerson their staffs, I hope they will not make the specialists mistakeand insist on expensive, full-time postgraduate study and a title.We need part-time courses in 'Iocalist' and 'generalist' fields whichshould be quite optional and not accompanied by special titles butonly a neuhal description of the type of work to be undertaken.The medical schools little realize that to become an effective'generalist', much more study and experience is required than tobecome an effective specialist, and that experience is mainlyacquired in practice and not in lecture rooms, where the study ofsymbols and not the man is the main concern.The medical schools can help, but they are not indispensable topostgraduate study. The many men in the field who make time forprivate study should not be penalized for not having visited themand acquired a special title. A doctor's reputation depends on theresult of his wark, which only the public can judge, and not on anyextra academic ti~le. The present belief that postgraduate study canonly take place in academic institutions may be true for men who likelectures, have aural memories, or like to be spoon-fed. There arehowever many men who, with more visual memories or preferringn ~w lines of investigation, prefer private study, individual initiative,and learning by dealing with problems in the proper context inthe field.Serfdom reminiscent of the middle ages is seen in the relationshipof organized lay bodies which demand and get from defencelessindividual doctors unlimited services at any time, anywhere, forany discomfort, medical or otherwise, and that for a fixed nominalmonthly fee or ridiculously reduced fee per treatment. This is anexample of one-way accountancy. What is happening to our muchpublicized dignity and freedom? Where is our right to some littleleisure to develop and round off our individual personality?.In modern democracy the co=on [!lan has become a lord who19 Maart 1955 S.A. TYDSKRIF VIR GENEESKUNDE 285tyrannizes over his professional brethren. Many senior generalpractitioners work in .the front line of the battle with no regularhours, for too little return, and with no chance of organizingtheir lives with a limited number of consultations per day. Whatthey need if they are to fill the invaluable role to society of 'seniorgeneralist' is time to observe, think: and study, and time to applythis 'general' approach effectively.THE WHOLE MANJulian Huxley in Evolution in Action, when discussing tools ofliving, relates generalized machanisrns to .potentially unrestrictedimprovement and progress, and specialized odocalized techniquesto potentially restricted improvement and possible stagnation.Further, the Indian teacher, J. Krishnamurti in his book The Firstand Last Freedom says: 'The truth lies in the whole, and not in theparts; in separateness lies conflict and confusion; in togethernessand wholeness lies'truth.' Sir Henheage Ogiivie, an eminent Britishmedical practitioner in General Surgery says: 'Consultant rankscontain many who are not wise men but "wise guys"':'-not men ofculture, skill or wide experience, but smart technicians who can doa number of complicated tricks·extremely well, provided that theyare not asked to go beyond them. Compared with the generalpractitioner, they are small beer indeed, and it is time they weretold so'.In conclusion, I should like to say that the most urgent problemto-day is the investigation and treatment of the whole man; the'generalist' realizes this and is most suited for the job. To turn thetables and to call him a 'specialist' instead of the 'Iocalist' becausehe deals with an urgent special problem of integration, wouldcertainly be most unfair to the 'Iocalist', who would then be leftout of the spot-light, and would probably go broke.Bertrand Russell wisely says that in order to preserve excellence,we must become more leisurely and just, less 'progressive'. I mayadd that we need less spurious verbal progress and praise in'Iocalist' medicine, which only increases the confusion in themedical Tower of Babel-that institution for the dismembermentofman without the ability to put him together again. This exclusive'Iocalist' interest probably springs from the fallacy that the studyof a part reveals the truth of the whole; it does not sufficientlyrecognise the facts of evolution and mutation. The properties ofwater are new and not accounted for by the sum of the propertiesof hydrogen alone and oxygen alone. The 'Iocalist' study of manhas its value, but the integrated study of the whole man, with itsinterrelatedness of body, mind, spirit, and environment, is the mainmeans to man's total health and happiness.I therefore propose that, in order to obviate the emotive use of apartisan classification of doctors that 'begs the question', weclassify doctors with neutral descriptive terms, such as practitionersin this or that branch of medicine, e.g. Practitioner in GeneralMedicine, Practitioner in General M,edicine (Consulting), Prac-titioner in Ear, Nose and Throat Diseases, Practitioner in GeneralSurgery, Practitioner in Internal Diseases, etc.ASSOCIATION NEWS: VERENIGINGSNUUSDR. N. L. MURRAY'S PRESIDENTIAL ADDRESS AT ANNUAL MEETING OF NORTHERN TRANSVAAL BRA CHDelivering his valedictory address as retiring President of theNorthern Transvaal Branch at the Annual General Meeting of theBranch on 8 February 1955 in Pretoria, Dr. N. L. Murraysaid:I have been a member of the Medical Association of SouthAfrica for 20 years now, and in that time many changes havecome about; it is about one of these changes that my talkrevolves. Initially, as acountry member of the NatalCoastal Branch, and living ina district in Zululand, farremoved from the cities, I wasa happy man. Young, full ofenthusiasm for my work, dayor night, and in all weathers,I regarded medical practice asa wonderful ad:venture.It is estimated that therewas, at that time, one qualifieddoctor to about 30,000 in-habitants in Zululand, and soI can assure you that therewas work in plenty for thedozen or so doctors in theterritory.I was assistant to a finecountry doctor who had takenover, after World War I; fromthe first practitioner ever tosettle in that district. InDr. N. L. Murray addition to private practiceand the District Surgeoncyand Railway Medical Officer appointments, we attended the Insti-tution for 400 lepers. Confinements and post-mortems oftennecessitated miles of trudging on foot over hilly and still malariouscountry, but it was, to me, a good life. My senior's anecdotesand discussions based on many years of hard practical ex-perience, were invaluable, and I still feel that that sort of virtualapprenticeship with an elder practitioner, well versed in all aspectsof general practice, is a most excellent grounding for all newgraduates after leaving their intern appointments.There were two Provincial hospitals (some 50 miles apart) indistricts adjoining ours and our association with the neighbouringpractitioners was excellent. There was more than enough work forall. There were no Branch Council or business meetings, and whatmeetings there were were for clinical discussion and consultation,and for social entertainment. .THE GROWING NUMBER OF MEDICAL PRACTITIONERSThat was 20 years ago and in a country practice. In the wholeof the Union at that time there. were less than 1,900 registeredpractitioners for a population of 9t million; that is about one per1,000 Europeans, or one per 4,500 of the total population. Howdifferent it is to-day!The distribution of medical practitioners in South Africa wascarefully investigated and recorded by GiJlman in 1937 and herwork served as a useful basis for comparison and review of sub-sequent statistics. Then, in September 1943, Ravenscroft of theDepartment of Census and Statistics, Pretoria, produced a Surveyof Registered Medical Practitioners in the Union of South Africaand their relationship to the Geographical Distribution ofPopulation.Shortly afterwards, in February 1944, Dr. A. Pijper wrote aninteresting article in the South African Medical Journal, entitledThe Number of Doctors.I do not intend to present you with a detailed statistical address,but I have extracted some figures which show the trend of certainevents. Although there were only 2 medical schools in the Unionuntil quite recently, now there are 5, of which 3, between them, areturning out doctors at an astounding rate. At the end of 1946,out of 4,893 practitioners on the register, 1,357 had graduated atCape Town and 1,174 at Witwatersrand; i.e. 2,531, or more thanhalf, were local graduates-a good thing I am sure, which hasbeen mainly responsible for the high standard as a whole ofmedical work in this country, and which we can justly be proud of.With the advent of medical graduates from Pretoria to swell thenumbers; with Natal for future non-European graduates; withStellenbosch in embryo, and with Bloemfontein more than atwinkle in its parent's eye, there will be doctors in abundance.This will doubtless be a good thing (or the needs of the populationat large, until saturation point is reached. In some areas it may beclaimed that this has already happened. In 1937, of 689 doctorsin the Transvaal, 506 were situated in the Reef towns or Pretoriawith an estimated 742 persons per doctor. Today Johannesburghas about 1,400 practitioners and Pretoria about 300. The popula-tion has not increased in proportion and the concentration ofIIIIIIIIIIIIIjIIII

A suggestion for a change in the present classification of doctors

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A suggestion for a change in the present classification of doctors

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