The Changing Face of General Practice

Recent Changes:
    According to BEACH¹ the following changes have occurred in general practioce in the 10 year period from 2004–05 to 2013–14.

• the proportion of GP participants who were female increased over time
• the proportion of GPs who were younger than 45 years decreased, whereas the proportion aged 55 years or more increased over the decade
• reflecting the increase in the age of GP participants, the proportion who had worked in general practice for more than 20 years also increased significantly over time
• the proportion of GPs working 21–40 hours per week on direct patient care significantly increased, and the proportion working 41–60 hours, and the proportion working more than 60 hours, significantly decreased
• the mean number of hours spent on direct patient care significantly decreased
• the proportion of participants holding the Fellowship of the RACGP increased over the decade
• the proportion of GPs in solo practice decreased over time, and the proportion in practices with 10 or more individual GPs almost doubled
• fewer practices are providing after-hours care on their own, or in cooperation with other practices, but more practices are using deputising services for after-hours care than a decade ago
• computers have become increasingly available at practices, as has their use for clinical activity.

In 2004

• About 25% of the medical workforce trained overseas¹
• Practice nurses are being increasingly used

In 2003

• 22.1% of the rural and remote general practice workforce practised in at least one procedural field¹
• 82% of a GPs billings are for a standard consultation, 9.8% long consultations¹
• 2003-2004 the bulk billing rate was 68%¹

In 2002

According to the Australian Medical Workforce Advisory Committee¹

• There were about 22,000 GPs in Australia
• 80% were vocationally registered
• 70.4% worked in major cities
• Average age of a GP was 48.6 years
• 37% were female
• The average age of a female GP was 7 years younger than the average age of a male GP
• Average hours worked per week - 41.1
• Female GPs worked 7.6 hours fewer per week than male GPs
• City GPs averaged 40 hours per week
• Remote GPs averaged 49.2 hours per week
• 40.3% of GPs worked in practices with 5 or more GPs
• 15.9% worked as solo GPs
• 78.1% work in private rooms
• 5.5% work in acute care hospitals
• 3.1% work in 24 hour clinics
• 3% work in non-residential health facilities
• 77% of the income of GPs was derived from the MBS in 2001-2002

What was it Like to Practice Medicine at the Beginning of the 20th Century?

    The general practitioner in the early 1900s would almost certainly have been male and from a well-to-do background. The younger doctors might have trained through Sydney University or Melbourne, but the older practitioner was more liklely to have trained in England (even if he had been born in Australia) and would probably have an LSA (Licenciate of the Society of Apothecaries) or be a member of the Royal College of Physicians. He would be in private practice and he would have admitting rights to a local hospital, ward rounds being typically done each morning.

    The use of the microscope had revolutionised the practice of medicine; the cause of infections had partly been elucidated (bacteria had been see, but viruses were still a mystery).

    Although he could treat a wide number of medical conditions, he could cure almost none. The surgeons were beginning to be able to cure a few more diseases. Surgery was still risky, but atleast the concept of infection was understood. The chances of surviving surgery were much improved for those surgeons employing an aseptic technique.

An idea of what practicing medicine can be obtained by looking at the medical textbooks. Tyson's Practice of Medicine, 1909 is summarized below. Curative treatments are in colour.

• Infectious disease (321 pages). There were almost no antibiotics so none of these diseases had effetive treatments except malaria was treated with quinin (25 pages). Chronic malaria was treated with arsenic. Viruses were not understood (other than being something infectious that would pass through filters) until after 1928. The management of typhoid, although not cutrative, was given 40 pages. Of interest a vaccination was available.
• Diseases of the Digestive Sytem (208 pages). Most of these were due to infections and hence could not be treated. There was no good treatment for peptic ulcers, so this tended to be a chronic condition. Most cancers were incurable. Appendicitis could be treated surgically. Most biliary disease was treated symptomatically. Surgery was a high risk.
• Diseases of the respiratory sytem (66 pages). Almost all were infections (not-treatable). Asthma was treated with morphine!, atropine, and/or amyl nitrite inhalations. Cancers were treated symptomatically.
• Heart disease (81 pages). Angina is discussed in 3 pages, hypertension is not mentioned. Most discussion relates to valvular disease, myocardial disease in pericardial disease. Valvular diseases are treated with morphine for dyspnoea, digitalis to slow and stimulate the heart and spartein sulphate as a diuretic. Mercurial purgatives were sometimes used. Angina is treated with morphine and atropine +/- amyl nitrite.
• Diseases of the blood (34 pages): "Simple anaemia" can be treated with a good diet. Pernicious anaemia, however was treated with arsenic(!), which gave a "temporary cure". Leukaemias were univerally fatal, although treatment with the "Roentgen ray" was proving useful to give some patients a remission. Hodgkin's Disease was treated with arsenic.
• Diseases of the ductless glands (21 pages). Goitre treated with topical iodine or with thyroid extract orally or surgically. Myxoedma was treate with sheep's thyroid orally. Tetany was treated with parathyroid gland taken orally. Thyroid tumours were treated surgically. Addison's disease - no effective treatment.
• Diseases of the urinary organs (96 pages) - no effective treatment. NB Cystitis was treated with leeches to the perineum
• Diseases of deranged metabolism (78 pages) - rheumatism would occasionally respond to salicylates. Gout was treated with a low nitrogenous diet. Diabetes mellitus (incidence was about 0.007%, cause not known) - no effective treatment. Diabetes insipidus - no treatment. Rickets treated with a good diet. Scurvy treated with a good diet. Haemophilia - no treatment
• Diseases of the nervous system (340 pages). Sciatica, neuropathy, CNS bleeds, the bends, myelitis, polio, tabes dorsalis, hereditary ataxia, spastic paralysis, bulbar palsy, ALS, CVA, nerve paralysis, encephalitis, meningitis, shingles - no effective treatment. Neuralgia was treated with acupuncture! Spina bifida was treated surgically as were some cerebral tumours. Migraine could be reliably treated with morphine. Epilepsy was treated with bromides with varying degrees of success.
• Diseases of the muscular system (54 pages). Muscular dystrophies, myotonia - no effective treatments
• The Intoxications (23 pages). Acute alcholism was treated with chloral hydrate!! or morphine. Morphine addiction - inpatient withdrawal. Smoking addiction was treated with apomorphine. Lead or arsenic poisoning - no effective treatments
• Effects of exposure to high temperatures (2 pages). Heat exhaustion, heat stroke treated by cooling the body
• Diseases caused by animal parasites (93 pages). Tapeworms treated with extract from the male fern or kuosso. Roundworms treated with calomel. Pediculosis treated with mercurial ointment or coal oil or turpentine
• Poisoning (14 pages)

• For sciatica:
  • ℞   The draught:
    • Ext. Cannabis ind. gr. ss . . .03gramme
    • Pulv. opii gr. ss . . .03gramme
    • Camphorae gr. ij . . 0.1gramme

• For amenorrhoea
  • ℞   Each pill (taken twice daily)
    • Pulv. Myrrhae gr. iij . . 0.2gramme
    • Aloini gr. ss . . 0.03gramme
    • Ferri Sulph. Excsicc. gr. j . . 0.06gramme

• For asthma
  • ℞   Tincture Quebracho Liquidum (taken every four hours)
    • Tincturae Quebracho mxxx . . 2c.c.
    • Caffeinae Citratus gr. iij . . 0.2gramme
    • Tinct. Stramonii mv . . 0.3c.c.
    • Aq. Chlorof. ad zss . . to 15

References

1. Britt, H. et al., General Practice Activity in Australia 2013-2014, General Practice Series no. 36, November 2014, page 36

2. Tyson, J., The Practice of Medicine, Fifth Edition, P. Blakiston's Son & Co., Philadelphia, 1909

3. Lucas, E. W., The Book of Prescriptions, J & A Churchill, London, 1906

1. The General practice Workforce of Australia - Supply and Rrequirements 2013, Australian Medical Workforce Advisory Committee, AMWAC Report 2005.2, page 5, August 2005