Ian R. McWhinney

Being a general practitioner: what it means

When I started in practice, the thing that gave me joy was the solving of clinical puzzles, the making of good diagnoses, thus impressing my colleagues. As time went on I found myself preoccupied more and more with the patients I had come to know. It was their joys and sorrows, their suffering and healing, that moved me. Of course, clinical diagnosis and management did not cease to be crucial: simply that a patients illness or disability became interwoven with a life story. I came to see medicine as more complex, more context-dependent, more poignant, more a reflection of the human condition.

Lack of impact of salt restriction advice on hypertensive patients

The response of known hypertensives to advice on sodium restriction was examined as part of a 5-year study on hypertension screening in family practice. The study comprised 34 family practices, pair-matched for location, activity level, and length of time in present practice. One practice in each matched pair was randomly allocated to an experimental or a control group. All hypertensive patients in each experimental practice were exposed to a management program which included dietary counseling to restrict sodium intake. A sample of hypertensive patients (N = 1,001) in both control and experimental groups was interviewed 3.5 years into the study. Although more subjects in experimental practices reported not adding salt (22.9%) compared with those in control practices (17.3%), the results of multivariate analysis showed that type of practice (experimental or control) was not significantly associated with salt use. Salt avoidance was strongly related to lower levels of education and to sex (men were less likely to use salt). Subjects who did not use salt also tended to avoid high-sodium foods. The response to nutritional advice was less favorable than expected. Difficulties in compliance with dietary recommendations are discussed.

The value of case studies

Case studies have played an important part in the annals of general practice and indeed of clinical medicine. Jenner’s discovery of vaccination culminated in the demonstration of its effectiveness in a boy called James Phipps.’ Jenner’s case did not stand alone. His experiment came after years of meticulous observation of the skin infections of dairy workers, enabling him to make the crucial distinction between cowpox, which conferred immunity to smallpox, and other infections, which did not. Thus, Jenner successfully integrated the concrete with the abstract, the particular with the general and lessons from individual cases with the theoretical principles derived from the collective.

Focusing on Lived Experience: The Evolution of Clinical Method in Western Medicine

The clinical method practiced by physicians is always the practical expression of a theory of medicine — a theory which embraces such concepts as the nature of health and disease, the relation of mind and body, the meaning of diagnosis, the role of the physician, and the conduct of the patient-physician relationship. In recent times, medicine has not paid much attention to philosophy. When our efforts have been crowned with such great successes as they have in the past century, why be concerned if someone questions our assumptions? Indeed, we often behave as if they are not assumptions, but simply the way things are. Crookshank (1926) marks the end of the nineteenth century as the time when medicine and philosophy became completely dissociated. Physicians began to see themselves as practitioners of a science solidly based on observed facts, without a need for inquiry into how the facts are obtained and, indeed, what a fact is (Fleck, 1979). We believe ourselves to be at last freed from metaphysics, while at the same time maintaining a belief in the theory of knowledge known as physical realism.