Apr 12, 1992 - Wensleydale; medicine, and with it general practice, has altered. But there is one similarity between the Pickles' era and today: the answer to ...
WILLIAM PICKLES LECTURE 1992
What our practices teach us C VAN WEEL
Introduction WILLIAM PICKLES will be particularly remembered for his book on his research, Epidemiology in country prac-. tice. I It is a comforting thought that among the thousands of biomedical publications each year, this book still stands out for its quality more than 50 years after its first publication. It offers the reader of 1992 an insight into Pickles' reasoning behind the collection and analysis of data on his patients. Pemberton's biography describes the favourable circumstances which allowed Pickles' exceptional potential as a researcher to be realized.2 It was reading Mackenzie's book The principles of diagnosis and treatment in heart affections3 at an appropriate time in his career that stimulated him to carry out research in his own practice. In one of his first pieces of research in 1928, Pickles studied an epidemic of infectious hepatitis, at that time known as catarrhal jaundice.2 The epidemic was unusually severe and, as a consequence, many cases could be traced and analysed. Researchers will appreciate the importance of this stroke of luck: it offered plenty of opportunities to revise and adapt his data collection, an experience that prepared him well for later studies. William Pickles was an outstailding man. The tools he used for his work, on the other hand, were fascinatingly simple: a chart, a map of the practice area, a pocket diary and a pencil enabled him to unravel the nature of infectious diseases and their spread in the population - prime clinical challenges at that time. There is an additional feature of Pickles' method of research I would like to emphasize: he studied patients in the context of his practice, the practice population. The theme for this lecture will be long term morbidity and practice oriented research. In the light of the European dimension of Royal College of General Practitioners' spring meeting, I shall be drawing on European research, mainly from the Netherlands. The concept of the practice population as the target of study has been fundamental in the development of general practice research in the United Kingdom4 and in the Netherlands.5'6 In other countries, the organization of health care is different, and the practice population is a less obvious entity. For many years this has obstructed the exchange of general practice experience. C van Weel, RCGP, professor of general- practice, University of Nijmegen, The Netherlands. This is an abridged version of the 1992 William Pickles lecture, which was delivered at the spring meeting of the Royal College of General Practitioners in Nottingham on 12 April 1992. © British Journal of General Practice, 1992, 42, 206-209.
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However, the episode-oriented analysis7 enables international comparison in general practice. It is encouraging that recent majorgeneral practice studies have emphasized the similarities in European primary care. An analysis of morbidity in Belgian general practices8 produced a diagnostic and therapeutic picture almost identical to that in the Netherlands despite the differences in the structure of health care beween the two countries. In the care of elderly people general practitioners in Germany9 have been facing clinical problems in prevention, prognosis and psychosocial impact of disease identical to those in the UK'° and the Netherlands." The findings of a European study exploring the reasons why patients consult their general practitioners underline the essential concurrence between most countries in patients' reasons for consulting. Therefore, when Dutch practice research is presented here, it is in the belief that it is relevant to most family doctors throughout Europe. In the following examples of longitudinal research on morbidity, I shall focus on respiratory illness (asthma and chronic bronchitis) in children and adults. Hasler described the challenge of long term care as the very stuff of general practice.'3 The relationship between the epidemiological aspects of general practice morbidity and pathophysiological features of illness was an important aspect of Pickles' research, a point highlighted in the studies concerning long term outcome reviewed here.
Trends in morbidity Many of the clinical challenges in general practice have changed since the days of Pickles. Studies of morbidity trends in general practice give a frame of reference for general practitioners and represent the clinical challenges of general practice today and in the future. A number of long term studies of trends in morbidity have been undertaken. Fleming and colleagues demonstrated changes in morbidity in general practice in England and Wales between 1971 and 1981.1" The Nijmegen continuous morbidity registration has been recording all episodes of morbidity presented to the general practitioner since 1967.1 116 TWo of the four practices involved in the continuous morbidity registration took part in an earlier study by Huygen when he analysed family morbidity between 1945 and 1965.5 Linking these two data sets enabled a survey of trends in presented childhood morbidity between 1945 and 1990 (Van den Bosch, et al. Unpublished results). Van den Bosch and colleagues found that as expected, substantial changes in morbidity took place over that period. Childhood diseases such as pertussis, diphtheia and measles virtually disappeared. The prevalence of bacterial skin infections greatly reduced while the prevalence of asthma and fungal skin infections increased. Many more episodes of non-serious morbidity are treated today than shortly after the second world war. Interestingly, there has not been a steady increase in mnorbidity over the years: since the late 1970s the total number of illness episodes diagnosed, including psychosocial problems has been gradually declining. Chronic morbidity, however, has shown a steady increase during this period. This puts chronic disease at the top of the general practice agenda. Essential for proper care is information on the long term perspective: the natural course of an illness and its prognosis. Outcome should be measured not only in terms of survival but in quality of this survival. This information is vital today, just as information on epidemic catarrhal jaundice, its early signs and its spread in the population were important in the days of Pickles.
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Chronic respiratory problems in children The childhood morbidity data presented here are based on a series of cohort studies using the Nijmegen continuous morbidity registration records,'5"6 and data from Huygen's study.5 Early childhood is associated with a high level of morbidity.'5"7"8 Illness episodes are not evenly distributed among the children in the practice (Kolnaar, et at. Unpublished results). There are many factors influencing the recording of illness episodes at this age including' biological, social and economic factors. The nmost important of these appears to be the child's parents and their inclination to consult the general practitioner.'9 But what are the consequences for the longer term perspective? In a study of 109 patients whose medical history could be followed for up to 40 years we found a continuity in presented morbidity (Van den Bosch, et al. Unpublished results). The number of illness episodes presented by a patient in any five year period correlated significantly with the number of episodes presented in the following five years. However, the morbidity pattern of early life did not predict health status in early adulthood. This was confirmed in an extensive investigation which took into account pre-symptomatic morbidity.20 It did not reveal any differences in health withiit the group aged between 21 and 40 years that could be related to morbidity in early life. Respiratory illnesses are of particular importance in early childhood.'5 These infections may play a role in the development of bronchial hypersensitivity, which in turn may trigger the development of asthma.2'-24 The failure to control established persistent hypersensitivity has been implicated in poor outcome of asthma.24 The high number of respiratory infections suffered in the first two years of life remained a characteristic of the patients for some years, but at eight years old the pattern seemed to have normalized.'5 A later survey of the same population of approximately 900 patients in their adolescence (10-20 years old) found a 21% prevalence of asthma symptoms (Kolnaat, et al. Unpublished results). On the basis of additional spirometric data, 14%o were classified as suffering from asthma. Their early childhood medical history pointed to an increased prevalence of acute bronchitis and early asthma, compared with the non-asthmatic adolescents. Asthma is the principal chronic illness of adolescence. Respiratory illnesses in early childhood are related to the prevalence of asthma and represent a potential area for general practitioners for early recognition and intervention, particularly when the illnesses are acute bronchitis and pneumonia. General practitioners who have made a diagnosis of asthma in a young child should be reluctant to drop this label later, even when the patient may have been free of symptoms for a long time. As a guideline for management, it should be accepted that only a minority of children grow out of asthma. In general, early childhood morbidity predicts the levels of morbidity in later years (between the ages of 10 and 30 years). Parental illness behaviour (parents' behaviour when the child is ill and, more importantly, parents' behaviour when they themselves are ill) seems to affect the patient's subjective health status during the first 15 to 20 years of life. Intervention should concentrate op counselling parents to cope with a sick child.25 The findings of a recent drop in the number of episodes of nonserious morbidity treated in general practice may be an indication of the effectiveness of this parental counselling strategy.5'25 Encouraging long term management is essential for a child's future.
Chronic respiratory problems in adults Asthma and chronic bronchitis are two of the most common chronic diseases in adults. The joint prevalence is 30 ppr 1000, both in the UK26 and in the Netherlands;27 the majority of these patients are treated by general practitioners. Long term British Journal of General Practice, May 19922
William Pickles lecture 1992 management includes drug therapy, advice, avoidance of irritants and other non-pharmacological interventions. Drug therapy and other interventions will be used by patients for many years. Therefore, evidence of the long term effects is essential. Long term objectives should be defined: the lasting control of symptoms, the safeguarding of the patient's functional status28 and the preservation of respiratory capacity. The latter must be considered in relation to the physiological decline that occurs from the age of 20 years onwards.29 For the control of symptoms, preventive treatment and bronchodilator drugs can be prescribed.30 Bronchodilators can be easily administered by the patient, who is able to assess their effect quickly. Therefore, patients can take these drugs when required, as an early intervention for symptoms, or as a way of preventing symptoms. In one study, the long term effects of a regular, fixed daily dose of bronchodilator therapy were compared with use when the patient felt it was necessary (ondemand).3' A group of 223 adult patients with mild or moderately severe asthma or chronic bronchitis were studied over four years. No patients were taking steroids at the commencement of the study and all were being treated in general practice. During the first two years, only bronchodilator therapy was prescribed, with patients having been randomly allocated between the on-demand therapy group or the regular therapy group. After two years, approximately 300o of patients showed a decline in their respiratory capacity of a mean of 160 ml yrin excess of the physiological declixie, as measured by the forced expiratory volume.32 This finding was true for both patients with asthma and those with chronic bronchitis. Decline in respiratory capacity was not related to the frequency or severity of symptoms and it could not be predicted from the sociodemographic, clinical or spirometric information available at the start of the study.33 Of particular interest was the effect of regular and on-denand use of bronchodilators: patients on a regimen of regular bronchodilator therapy showed a decline in their respiratory capacity of 72 ml yr-' compared with those only using their drug. when they felt the need to do so, who showed a decline in their respiratory capacity of 20 ml yr-1.32 In the second part of the study, inhaled corticosteroid treatment (beclomethasone diproprionate) was offered to all 57 patients with a fast decline in their respiratory capacity. During the first six months of this additional treatment, the mean forced expiratory volume increased by 226 ml yr -'. Between six months and 12 months of therapy, the mean forced expiratory volume declined by 41 ml yr-1. However, this decline was less than the decline experienced when patients were on bronchodilator therapy alone.34 Restoration of the respiratory capacity was achieved for patients with asthma. Patients with chronic bronchitis improved to a lesser extent but there was still a downward trend in their respiratory capacity. Control of bronchial hypersensitivity could be related to this outcome; The study teaches general practitioners of the importance of managing chronic respiratory disease: asthma and chronic bronchitis are progressive diseases with a long term development. This progression will be seen in general practice but so far cannot be inferred from symptoms or from other clinical data. As a consequence, there is a case for the systematic monitoring of lung function in patients with asthma and chronic bronchitis. This study contributes to a better understanding of the essentials of airflow obstruction, and particularly of the role of hypersensitivity and inflammation. Effective long term intervention depends on the control of the process of inflammation 24 Elimination of irritants and the use of inhaled corticosteroids may be essential elements of treatment. Bronchodilators are important tools in controlling symptoms, but should be'restricted to short term, on-demand use. These drugs have no role in the long term prevention of symptoms and might, when used over a long period and as the sole therapy, do more harm than good.
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William Pickles lecture 1992
C van Weel It is vital to explore further the mechanisms of airflow obstruction. Clinical research in general practice can make a valuable contribution.
Lessons from the practice The challenge of general practice is to provide comprehensive primary medical care over many years for patients in their social and family environment: this is its accepted role in most countries. The challenges change over time as a result of the changes in the prevalence of diseases and the diagnostic and therapeutic possibilities of medicine, but also as a result of changes in patients' demands and expectations. It is a long time since Pickles studied his patients in Wensleydale; medicine, and with it general practice, has altered. But there is one similarity between the Pickles' era and today: the answer to most challenges can be found in general practitioners' clinical experiences - the practice. This paper has concentrated on examples of the long term perspective of primary care. This was a deliberate choice because long term care is essential in the treatment of chronic diseases and general practice is the correct place for such care to be provided. From this position, it is a logical consequence to build a case for longitudinal research in general practice. In studying patient outcomes, it is essential to use patient oriented outcomes together with a disease specific frame of reference, an area of development where much remains to be done. However, international cooperation in general practice has been remarkably successful in classification, 735 in defining a glossary of general practice36 and in exploring patients' functional status as a relevant outcome37 for general practice research and patient care. Research has to be thorough and needs specific expertise: this requires concentration and specialization. The programme of longitudinal research in Nijmegen was a deliberate choice, but chance also played a part. The stability of a practice population'5"6 enhances longitudinal research. In this respect, it is important that the clinical content of general practice care is essentially the same in many European countries. In other words, as it will be possible to exchange clinical lessons from practice, general practice researchers should be encouraged to concentrate on the type of research at which they are particularly good. This is an incentive for focused primary care research programmes and for more exchange in international general practice research. The results of long term studies have important consequences for the definition of adequate primary care. The field of quality assurance was reviewed by Boland in the 1991 William Pickles lecture.38 The study of the long term outcome of the treatment of airflow obstruction is a useful example. It pointed to the unfavourable outcome in a substantial part of what were, at first sight, mild cases. It also pointed to the need to focus the treatment in this group on airway inflammation. This experience will be used by the Dutch college of general practitioners in its current standard-setting strategy39 to set a standard for the diagnosis and treatment of asthma and chronic bronchitis. It illustrates the close relationship between patient oriented research and quality assurance. This close relationship was the reason for introducing a working party on quality assurance into our patient oriented research.40 This working party works together with members of the Maastricht department of general practice and exemplifles the possibilities of structural cooperation in research. The impact of -what the practice can teach us is essentially even broader. Long term outcomes, understood in a patient oriented frame of reference, is what all of medicine is about. This should, therefore, be included in the clinical teaching of all medical students. There is a growing concern about the changing role of the teaching hospital in academic patient care. 208
Teaching at the patient's bedside has been fundamental in medical education since its introduction by Boerhaave in Leyden University in the 18th century and has been important for the development of medical schools throughout Europe.4' Bedside teaching is now under pressure, time and financial constraints having resulted in an increasing number of technological interventions in teaching hospitals having to be performed on an increasingly select group of patients. Medical faculties are becoming the place 'where ever more is taught about less and less'.42 This development should be seen as an extra stimulus for general practice to contribute its share in medical undergraduate teaching. So far, the emphasis of general practice teaching has been on vocational training at the expense of the teaching of medical students. General practitioners must take up that task and we should teach what we in our practices are good at: the lessons from our practices. Long term care is but one of the excellent examples of what general practitioners are able to contribute to medical education. There is also a vast teaching culture we have to offer: the teacher-learner approach used in vocational training43 offers a direct student centred, patient oriented approach so relevant for today's medical students. In this way, the teaching of knowledge can easily be combined with supervision of skills. It is our obligation to organize our teaching and teaching practices" in such a way that all future doctors are actively included in the lessons from our practices.
Conclusion This paper has concentrated on the long term perspective of general practice. Much has changed since Pickles enriched medicine with the magnificent observations from his patients. What should not be forgotten is Pickles' overall lesson: it is from our practices that we learn the essentials of medical practice. In the first chapter of his book,' he acknowledged the inspiring words of Mackenzie, stating 'that it was the family doctor who alone saw disease in its true perspective, as he had the advantage of observing early symptoms and following an illness from beginning to end. Years later this statement has lost none of its value. Pickles summarized the obligation of general practice at the close of his first chapter: 'We are in a position to supply facts from our observation of nature, and it is, I feel most strongly, our plain duty to make use of this unique opportunity.' I am convinced Pickles had medical research in mind when writing his message. With Pickles' help we have come a long way in research. The message, however, is still as true today as it was in 1939. It is probably even more important today to add medical education to Pickles' message and to live up to it. It is our duty to supply our unique observations to the education of medical students. Essential fields of medical education will be left unexplored unless the general practitioner takes up the position of a teacher for medicine generally. The general practitioner has lessons to offer from the practice, including long term care of patients and their families. Here, research and teaching combine the knowledge, wisdom and skills vital to provide what has always been the hallmark of the Royal College of General Practitioners, and what must be the hallmark of every doctor practising in whatever field of medicine: cum scientia caritas.
References 1. Pickles W. Epidemiology in country practice. Bristol: John
Wright, 1939. Republished, London: Royal College of General Practitioners, 1984. 2. Pemberton J. Will Pickles of Wensleydale. London: Royal College of General Practitioners, 1984. 3. Mackenzie J. The principles of diagnosis and treatment in heart affections. London: Henry Frowde, Hodder and Stoughton, 1916.
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C van Weel 4. Hart JT. The marriage of primary care and epidemiology. J Coll Physicians Lond 1974; 8: 299-314. 5. Huygen FJA. Family medicine. London: Royal College of General Practitioners, 1990. 6. Lamberts H. Morbidity in general practice. Utrecht: Huisartsenpers, 1984. 7. Lamberts H, Wood M (eds). ICPC. International classification of primary care. Oxford University Press, 1987. 8. De Maeseneer J. Huisartsgeneeskunde: een verkenning. Dissertation [English summary]. University of Ghent, Belgium, 1989. 9. Fischer G, Kerek-Bodden HE, Schach E, et al. Care of elderly patients by the general practitioner. Allgemeinmedizin 1985; 14: 111-118. 10. Taylor RC, Buckley EG (eds). Preventive care of the elderly. Occasional paper 35. London: Royal College of General Practitioners, 1987. 11. Mayboom-de BJ. Bejaarde patienten. Een onderzoek in twaalf husiartspraktijken. Dissertation [English summary]. University of Groningen, The Netherlands, 1989. 12. Hofmans-Okkes IM. An international study into the concept and the validity of the reason for encounter. In: Lamberts H, Wood M, Hofmans-Okkes IM (eds). The ICPC in the European Community. Oxford University Press, 1992 (in press). 13. Hasler JC. The very stuff of general practice. James Mackenzie lecture 1984. J R Coll Gen Pract 1985; 35: 121-127. 14. Fleming DM, Cross KW, Olmos LG, Crombie DL. Changes in practice morbidity between the 1970 and 1981 national morbidity surveys. Br J Gen Pract 1991; 41: 202-206. 15. van Weel C, van den Bosch WJHM, van den Hoogen HJM, Smits AJA. Development of respiratory illness in childhood a longitudinal study in general practice. J R Coll Gen Pract 1987; 37: 404-408. 16. van den Bogaard C, van den Hoogen HJM, Huygen FJA, van Weel C. The relationship between breast feeding and early childhood morbidity in a general population. Fam Med 1991; 23: 510-515. 17. Butler NR, Goulding J. From birth to five; a study of a national cohort. Oxford: Pergamon Press, 1986. 18. van den Bosch WJHM, van den Hoogen HJM, Huygen FJA, van Weel C. Morbidity in early childhood: the difference between boys and girls. Br J Gen Pract 1992 (in press). 19. van den Bosch WJHM, van den Hoogen HJM, Huygen FJA, van Weel C. Early childhood morbidity: differences in sex, birth order and social class. Scand J Prim Health Care 1992 (in press). 20. van Weel C, van den Bosch WJHM, Smits AJA. Studies using the Nottingham health profile in general practice. In: Classification committee of WONCA (ed). Functional status measurement in primary care. New York: Springer, 1990. 21. Sluiter HJ, Koeter GH, de Monchy JGR, et al. The Dutch hypothesis (chronic non-specific lung disease) revisited. Eur Respir J 1991; 4: 479-489. 22. Vermeire PA, Pride NB. A 'splitting' look at chronic nonspecific lung disease. Eur Respir J 1991; 4: 490-496. 23. Hopp RJ, Townley RG, Biven RE, et al. The presence of airway reactivity before the development of asthma. Am Rev Respir Dis 1990; 141: 2-8. 24. Sears MR, Taylor DR, Print CG, et al. Regular inhaled betaagonist treatment in bronchial asthma. Lancet 1990; 336:
1391-1396.
25. Wyke S, Hewison J, Russell IT. Respiratory illness in children: what makes parents decide to consult?' Br J Gen Pract 1990; 40: 226-229. 26. Royal College of General Practitioners, Office of Population Censuses and Surveys and Department of Health and Social Security. Morbidity statistics from general practice - third national study. London: HMSO, 1986. 27. van den Hoogan HJM, Huygen FJA, Schelekens JWG, et al. 28. 29.
30. 31.
Morbidity figures from general practice. Nijmegen: Department of General Pracitce, University of Nijmegen, 1985. van Weel C, Rosser WW. Functional status assessment. Fam Pract 1991; 8: 394-395. Pato R, Speizer FE, Cochrane AL, et al. The relevance in adults of airflow obstruction, but not of mucus hypersecretion, to mortality from chronic lung disease. Am Rev Respir Dis 1983; 128: 491-500. British Thoracic Society. Guidelines for.management of asthma in adults. I Chronic persistent asthma. BMJ 1990; 301: 651-653. van Schayck CP, van Weel C, Folgering H, et al. Treatment
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32. 33. 34.
35.
of patients with airflow obstruction by general practitioners and chest physicians. Scand J Prim Health Care 1989; 7: 137-142. van Schayck CP, Dompeling E, van Herwaarden CLA, et al. Bronchodilator treatment in moderate asthma or chronic bronchitis: continuous or on demand? BMJ 1991; 303: 1426-1431. Dompeling E, van Grunsven PM, Molema J, et al. Early detection of patients with fast progressive asthma or chronic bronchitis in general practice. Scand J Prim Health Care 1992 (in press). Dompeling E, van Schayck CP, Molema J, et al. Inhaled beclomethasone improves the long-term course of asthma and COPD in comparison with only bronchodilator therapy. Eur Respir J 1992 (in press). Classification Committee of WONCA. The international classification of health problems in primary care. ICHPPC-2
defined. Oxford University Press, 1983.
36. Classification Committee of WONCA. International glossary for primary care. J Fam Pract 1981; 13: 671-681. 37. Scholten JHG, van Weel C. Functional status assessment in family practice. Lelgstad: Meditekst, 1992. 38. Boland M. My brother's keeper. William Pickles lecture 1991. Br J Gen Pract 1991; 41: 295-300. 39. Grol R. National standard setting for quality of care in general practice: attitudes of general practitioners and response to a set of standards. Br J Gen Pract 1990; 40: 361-364. 40. Grol R, van Beurden W, Binkhorst T, Toemen T. Patient education in family practice: the consensus reached by patients, doctors and experts. Fam Pract 1991; 8: 133-139. 41. Underwood EA. Boerhaave's man at Leyden and after. Edinburgh University Press, 1977. 42. Gray DJP. A system of training for general practice. Occasional paper 4. London: Royal College of General Practitioners, 1977. 43. Savage R. Continuing education for general practice: a life long journey. Br J een Pract 1991; 41: 311-314. 44. Department of General Practice. A manual for undergraduate teaching in the general practice environment. Nijmegen: University of Nijmegen, 1992.
Address for correspondence Professor C van Weel, Department of General Practice, University of Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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