paediatric general practice

Archives ofDisease in Childhood 1991; 66: 894-899

PERSONAL PAPER

Paediatric care in general practice

Stuart Carne

I qualified in 1950 and, before I did my nationalservice in the Royal Air Force, I was fortunateenough to get an additional year's experience asa rotating house officer at the Queen ElizabethHospital for Children in Hackney.

I was appointed medical officer to the RAFMedical Training Establishment where newlycommissioned medical officers (like me, mainlynational service) were taught how to be RAFofficers and new airmen recruits were taught tobe nursing orderlies. My main task was to takethe early morning sick parade: 7.30 am onordinary mornings; 6-30 am when the command-ing officer had his parade.Once a week I had to examine each new batch

of recruits. They had all been examined at leasttwice previously: once before they were calledup and then again when they arrived at the ini-tial training centre at Padgate. Nevertheless, afew of them had quite severe disabilities-mainly orthopaedic or cardiac-and wereclearly unfit for service duties.As they were going to work as nursing order-

lies, I also had to give them all a Mantoux test.Most were positive, to varying degrees. (Themost violent reaction was in the son of a thoracicsurgeon who, it transpired, had watched hisfather at work on many occasions.) Havingalready done two hospital ear, nose, and throatappointments (one adult, one paediatric) I hadseen a lot of tonsillectomies-and even tried myhand at it, not very successfully! Cervical adeni-tis, much of it tuberculous, was not uncommonin those days and so, too, was tuberculousmesenteric adenitis. I wondered whether theMantoux reaction was in any way related to aprevious tonsillectomy or appendicectomy. Apilot study revealed no obvious connection butthere did seem to be a connection between thefrequency of these operations and the recruit'ssocial class-though not between social classand the Mantoux reaction. Both operationswere performed more frequently in recruits whocame from a higher social background.

I therefore rewrote my protocol and decidedto look at the incidence of tonsillectomy andappendicectomy. For good measure I added cir-cumcision to my data. (As there was no nationalservice for women, there were very few femalenursing orderly recruits.) The RAF were ex-tremely cooperative and provided me with sta-tistical assistance. My hypothesis was confirmedand the editor of the British Medical,Journal sawfit to publish my paper,' though he 'invited' meto change the title from 'Three popular opera-

tions' to 'The incidence of tonsillectomy, cir-cumcision and appendicectomy among RAFrecruits'.My time in the RAF coincided with the eva-

cuation by the British forces from the SuezCanal Zone. The wives and children were senton ahead. Those without their own homes in theUK were housed in a camp outside Blackpool orlodged during the winter in boarding houses inthe town. In addition to my duties as medicalofficer at the Medical Training Establishment, Iwas posted as medical officer to these families,presumably because of my paediatric interestand experience.My experience with these families taught me

a lot: dare I say, more than most ofmy previoushospital experience. The mothers were con-stantly seeking medical help for their problems,yet pathology as I had been taught it was scant.More often than not it was a child who wasbrought to me, not the mother; and very oftenthe child or a sibling was brought back at fairlyfrequent intervals.At first I thought that my clinical skills had

failed me, probably because I was usually deal-ing only with the presenting symptom-whichis what we tended to do in those days in primarycare. I therefore arranged to see the more persis-tent attenders at special sessions in order to givemyself time to carry out a proper hospital typeassessment. Instead of taking a superficial his-tory of the more physical aspects of the prob-lem, I probed extensively into the family historyand its social aspects. I discovered two things:the presenting medical problem of the child wasrarely the mother's major worry; and secondly,at the end of a consultation, many mothersthanked me 'for listening'. Later I read MichaelBalint's seminal textbook: The Doctor, HisPatient and The Illness and, for the first time,found in print an answer to the conundrum that

2we call general practice.My first proper job in general practice was in

All Saints Road in North Kensington where Ispent three years as an assistant. In 1957 I gotan Executive Council vacancy in ShepherdsBush-about a mile south of the Royal Postgra-duate Medical School at Hammersmith Hospi-tal and half a mile east of Queen Charlotte'sHospital. The previous general practitioner(GP) in the practice was age 75+ and terminallyill. His wife-an ex-nurse-had been runningthe practice for the previous year or so! Recordswere scanty as were the equipment and facilitiesfor clinical examination. Now that I had my

The Royal Coilege ofGeneral Practitioners,14 Princes Gate,Hyde Park,London SW7 IPUCorrespondence to:Dr Carne, president.

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own practice, I could organise it in the way Ibelieved best to improve the quality of care. Ihad shelves put in a corridor to store recordsand purchased an examination couch. I alsobought a typewriter and my wife became my(unp5aid) secretary/receptionist. All hospital let-ters were typed so that they were at least legible.By keeping a copy of all my letters, I was able tocompare the outcome with my thoughts when Ireferred the patient: a sort of audit.For the first five years in Shepherds Bush I

lived above the surgery. I introduced a wellbaby clinic, which was held once a week onWednesday mornings. I announced the fact onthe plate in my front garden. The local BMAsecretary wrote me a stern warning about adver-tising and I had to remove the notice of myclinic!

I met the local London County Councildivisional medical officer and she offered tosend one of her health visitors to my weeklybaby clinic. So began a 16 year relationship withthe same health visitor. The time she spent inmy practice steadily increased till she becamefull time. Indeed, as the practice expanded wefound it necessary to have two health visitorsattached full time. The practice itself has grownfrom the original list of 1400 which I took overin 1957 to 14 000 patients with seven GP part-ners, four of whom had been trainees in thepractice. In 1967 we moved into the GroveHealth Centre, which was only the second pur-pose built health centre in London. We are nowin the process of planning a new building, aboutthree times the size of the present one. Such isprogress: though I believe that small can also bebeautiful.

In the early years of undergraduate trainingin general practice, almost half the St Mary'sHospital Medical School students came to theGrove Health Centre. Among that group weretwo who are now consultants at HammersmithHospital: one is a neonatologist, the other ageriatrician (which must, surely, say somethingfor the generality of general practice!).For many years I was a GP trainer. Later I

became the first course organiser at the RoyalPostgraduate Medical School, with the title of'Senior tutor in general practice'. (The only pri-vilege which went with that appointment wasparking rights in the front of the hospital!) Thepost of course organiser is now filled by one ofmy partners who, himself, had been the first GPtrainee at Hammersmith Hospital. In fact, thepractice now has such a heavy teaching commit-ment elsewhere, and space is so limited in thehealth centre, we can no longer have a trainee inthe practice and have to look outside for thestimulus that postgraduate students bring tomedical practice.

I have a special interest in paediatrics,whether it is dealing with the children whenthey are sick or dealing with children when theyare well, such as at a child health clinic (which Istill prefer to call a well baby clinic). Indeed, asI frequently tell the mothers (and now, also, thefathers): 'How can I look after your child prop-erly when he is sick if I do not know what he islike when he is well?'

Until my presidential duties restricted my

time, I ran the well baby clinic in the practice.We have three sessions a week devoted specifi-cally to children under 5 years. The first is forroutine child health surveillance and is runjointly by one or two of the GPs together withthe health visitors. The second session is organ-ised by the health visitors. Parents always havedirect access to the health visitors wheneverthey are there (that is, office hours). Because weare in the same building, referral from doctor tohealth visitors-and vice versa-is uncompli-cated.

Immunisations are done at a separate session.I am often asked why immunisations are notgiven at the child health surveillance or healthvisitors' sessions. Would it not save mothers'(and doctors') time? My answer is that healthsurveillance clinics should be conducted in ahappy relaxed atmosphere. Mothers are comingto be reassured that their baby is normal andthat they are doing a good job as mothers. (Truedisabilities are rare-as opposed to the numberof normal children referred from clinics to aspecialist, which reflects not a need for treat-ment of the baby but better education of theclinician conducting the clinic.) Immunisationsessions are often traumatic. Waiting mothersare anxious: 'Is it going to hurt my baby?'; andthe baby, seeing other infants leaving theroom crying, is also likely to be upset.

Nevertheless, if a baby attending a surveill-ance clinic is overdue an immunisation, we willoffer it on the spot but-probably because ofclose health visitor and GP collaboration-attendance rates for immunisation are, by innercity standards, good.Though I have a special interest in child

health, I do not see all, or even the majority ofsick children in the practice. I am not a GPpaediatrician who-when we think about it-isneither GP nor paediatrician. Occasionally I amasked by a partner to comment on a child healthproblem but I am as likely to be asked my viewson clinical problems not related to children. Ifand when we want another opinion, it is from aspecialist that we want it (which is why we willsometimes complain that a child referred for aconsultant opinion in outpatients is seen by aregistrar or even a senior house officer).

Expertise is a combination of knowledge andexperience. Knowledge we can all acquire,either by reading the literature or attending(didactic) lectures. We have to wait for experi-ence to be available. In Britain there are,roughly speaking, 100 GPs for every paediatri-cian. A British paediatrician is therefore 100times more likely to have had to deal with a rareproblem than a GP. Similarly, for every paed-iatric specialist in the UK there are-proportionate to the population-almost 50paediatricians in the United States, most ofthem delivering primary care paediatrics.The British specialist paediatrician can thus

justify his claim to expertise because far more ofhis time is devoted to the less common prob-lems. Either we dilute his experience or weretain the present division between GP andspecialist.

It is no loss of status in the eyes ofmy patientsfor me as a GP to seek a second opinion. Were I

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called a paediatrician, I would have to explainwhy I need another paediatrician to advise me.A GP referring a patient to a specialist is no dif-ferent from one specialist referring to anotherspecialist.Thus I believe that the British system of hav-

ing a generalist deliver primary care and leav-ing specialists to concentrate on secondary (andtertiary) care has much to commend it.There are a number of diseases I almost cer-

tainly see more often than my hospital basedcolleagues-for example, upper respiratorytract infections and all the associated complica-tions such as otitis media and tonsillectomy.(Yes, I do mean the complication of tonsillec-tomy, not the indications for that operation,which I believe to be very rare.)The ritual sacrifice of parts of Waldeyer's

ring has remained a special interest ever sincemy RAF study. What are the criteria for sayingthat surgery is necessary? There are very fewabsolute indications, now that tuberculosis ofthis part of the respiratory tract has virtuallydisappeared; malignant disease is equally as rareand quinsy in children is also uncommon.(Perhaps GPs were right, after all, to prescribepenicillin for 'ordinary' sore throats!) Probablythe most frequent indication is recurrent tonsil-litis but, in my experience, recurrent true ton-sillitis is also not a common problem. What isseen frequently can best be described in the fol-lowing scenario: the child has a cold, the nose isblocked, and the child mouth breathes. Mouthbreathing causes a sore throat, which may thenbecome the symptom presented to the doctor. Ifthe doctor fails to appreciate what is happening,he may fall into the trap of making the diagnosisof 'tonsillitis'. Subsequently, every recurrenceof nasal catarrh is honoured with the samediagnostic label. Sooner or later-often depend-ing on the frequency of visits from relatives orcomments from 'helpful' friends-somebody isgoing to 'want something to be done'. If thestory were correct, what else can be done forrecurrent tonsillitis other than remove thetonsils? Indeed, I would agree with thatapproach-if the story were correct. But doesthe child have recurrent tonsillitis? or is he justone of the many children known in inner cityareas as 'snotty nosed little brats'. Mouthbreathing is not an indication for tonsillectomy;nor does adenoidectomy help in most cases,especially if-as is now so often the case-thereis an underlying allergic rhinitis.

If we look at the bridge of the nose of thesechildren, we will see that it is still flat. In fact, itdoes not start to acquire the adult shape (and anairway inside which is adequate enough to letthe child blow his nose) until the child is 7-9years old; which, by some coincidence, is theage when tonsillectomy seems to be less neces-sary.

Eczema, dermatitis, and seborrhoea-callthem what you will, the terms are ofteninterchangeable3 4-are also a common prob-lem. What interests me is the effect of the atti-tude of the patient (and/or the parents) on theskin eruption. To some, one spot off the facewhich almost requires a magnifying glass to beseen, becomes 'this disfiguring rash'; while,

to others, limbs or trunk covered with a sebor-rhoeic eruption are accepted as part of life. Alsorelevant may be the attitude of the doctor. Theauthoritarian physician who would expunge allpathology off the skin is likely to prescribemedication that is both more potent and moreexpensive, though this does not necessarily leadto an improved dermis.Young children who have frequent spells of

coughing, especially at night, are seen fre-quently both in hospital and general practice.Inquiries of other mothers reveal that there areeven more children who cough frequently andare not brought to the doctor. Often asthma liesat the root cause but, in infants, treatment ofthe bronchospasm is not very satisfactory ineliminating the troublesome cough. I alwaysask the mother how much the child's nighttime cough worries her and how much it dis-turbs the baby.Not infrequently the child is also feverish.

We know that antibiotics are frequently pre-scribed by GPs for these feverish coughs: and,regrettably, even in the absence of a fever. Howwrong is this approach? It would be easy to con-demn it, yet I have to say that I know few ofmycolleagues in general pratice who-faced by acoughing child with a persistent temperature of38°C or higher-would not prescribe an antibio-tic. I know that my hospital colleagues do nottake this view but, equally, I have to say thatquite often the only justification for the diagno-sis of a lower respiratory tract infection on a dis-charge summary is the prescription of an anti-biotic in hospital.What do I myself do? In a coughing child

who is well-feverish or not-and in whom sig-nificant signs relevant to the lower respiratorytract are absent, I temporise. If the fever per-sists I may write out a prescription for an anti-biotic, instructing the mother not to 'cash' ituntil the next day, by which time the child isusually much better. I find this technique parti-cularly useful when mothers bring their childthe day before they are going away on holiday.Most of these postdated antibiotic prescriptionsare not taken to a pharmacist.Some families believe that antibiotics are a

'cure all' and expect a prescription every timetheir children are feverish and also for everyexacerbation of nasal catarrh, with or without afever. In feverish infants in whom I can find nosignificant physical signs, a ploy I sometimesuse is to say: 'Let us see if this is the start ofroseola?'. By the third day the child is invari-ably better or, occasionally, the rash will haveappeared. Either way I can justify to the familymy not having prescribed an antibiotic.One of the problems of inner city practice is

the close proximity of teaching hospitals and themagnet effect of a walk-in clinic staffed by'paediatricians', the average experience of someof whom is only three months (that is, half theirsix month appointment as a senior houseofficer). That many of these young doctors will,in a year or two, themselves be GPs, seems notto be acknowledged by those who organise theservice.Nor am I enamoured with case conferences,

especially those which start: 'I am Mary Jones:

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I am deputising for Mollie Smith, the districtnurse who cannot be here today'. 'I am DrBloggs: I am standing in for Dr Snooks, thepaediatrician who is away at a conference thisweek'. Nor do I regard it as reasonable to expecta GP to attend a case conference at what is, forhim, a particularly busy time in the practice,such as 10 am on a Monday morning.

Furthermore, I cannot automatically bebound by conference decisions. As a GP I haveto make up my own mind. I am personallyresponsible, both within the NHS and in law,for all my actions. It is no defence for me to say:'I acted on the advice of X, a specialist in thatfield'. (I was recently at a Department of Healthmeeting when a consultant paediatrician wassurprised to learn that GPs do not have to com-ply with hospital recommended prescriptionsunless they themselves are in agreement withthe decision. The choice of medication is that ofthe paediatrician or the GP who actually writesthe prescription: neither can order the otherwhat to do.)

'Emergency' housecalls to children loomlarge in the traditions of general practice; manyof my hospital colleagues always assume thisto be a major part ofmy work. Parents do worryabout their children, some more than others,and especially with their first child. The prob-lem for many is aggravated by the absence notonly of a nuclear family but also of an extendedfamily. I suspect-though I cannot prove it-that close collaboration in my practice with thehealth visitors adds to the feeling of protectionwe can offer these mothers. I long ago realisedthat if good quality care is available 'in hours',the number of 'out of hours' calls fallsconsiderably.5We run an appointment system which is

valued as much by working class mothers as it isby the 'yuppies' who now live in ShepherdsBush. It is resented by an equal proportion inboth groups. But we also accept 'walk-in'consultations-without (I hope) the patient hav-ing to justify the request with a receptionist.

Occasionally there are unnecessary requestsfor emergency house calls. A common varietybelongs to the 'dad's home from the pub syn-drome'. Father comes home late for his supper,rather more inebriated than is good for him.'Where is my meal?' he demands. 'There isn'tany meal'. 'Why isn't there a meal?' he asks hiswife, now herself becoming a bit defensive.'Because the kid's been ill all day'. At this pointhusband and wife (or wife and 'partner') recog-nise an opportunity for reconciliation. 'Let'scall the doctor'. On my arrival at the home, thehealthiest person I see is often the child; but thisis not the occasion for berating the parents forcalling me out unnecessarily.Having examined the child I say: 'Fortun-

ately baby is not very ill. If you are still worriedabout him in the morning, why not bring himround to the surgery?' What I certainly do notdo is offer them a sachet of an antibiotic or Cal-pol, for that action would convince them thatmedication was necessary and therefore theywere right to have called me. (I always remem-ber the teaching of the great Carlisle Potter onthe subject of fractious babies: 'a large dose of

sedative is the best remedy' he would say; 'no,not for the baby but for the mother!').

In my first weeks in general practice, I sawone child with tuberculous meningitis andanother with pyloric stenosis. Since then I haveseen only one other baby with pyloric stenosis:and that was about 25 years ago. I have not seenanother case of tuberculous meningitis. I haveseen three cases of meningitis and-by the graceof God-I diagnosed all three. In one, I recog-nised the high pitched cry-and had an argu-ment over the phone with 'the duty paediatri-cian' about its significance. I hope that if, andwhen, I see my first child with epiglottitis I willremember not to try and examine the throatwith a tongue depressor.

Appendicitis seems to be getting much rarer. Ihave not seen a case for over two years, thoughone of my younger partners sent a child to hos-pital with that diagnosis a few weeks ago.We have always to remember that, in the

NHS, if a GP does miss a diagnosis, sooner orlater the hospital discharge summary-howeverthe child got to hospital-will bring the error tolight.

Acute attacks of asthma are distressing to thedoctor as well as to the patient and the parents;they can also be life threatening. I am not infavour of the current vogue for nebulisers,which seem to me to be underused by some andabused by others. I believe that if nebulisation isnecessary, a course of oral steroids is almostalways also needed. The various 'spacer' deviceswhich can be attached to an ordinary inhalerare, anyway, almost as effective as a nebuliser-and far less dramatic. My own preference (goingback to my days at Queen Elizabeth Hospitalalmost 40 years ago) remains a short, sharpcourse of oral prednisolone, followed a few dayslater (when the child and the family are morerelaxed) by better education on how they shouldmanage the disease with ordinary inhalers. Inmost cases I find it quite safe to leave the familywith a small supply of prednisolone for use in afuture emergency. In my practice we do notissue repeat prescriptions without seeing thepatients each time. We then issue enough medi-cation to last until the next time it is clinicallynecessary to see the patient. Therefore it is easyto monitor the frequency and the quantity ofsteroids consumed and, hence, to recognisewhen to introduce inhaled steroids on a regularprophylactic basis.From a general practice point of view diabe-

tes in children is rare. The majority of us willhave, at most, only one diabetic child on our listduring the whole of our 30-35 years as a GP,and many will never have that responsibility.However, for 15 years I had the privilege ofbeing medical officer to Palingswick House hos-tel for diabetic children, which was situated lessthan a mile from my surgery. At any one timethere were 40-50 children with diabetes resi-dent at the hostel, including some of the mostdifficult cases from all over the country. Beforecoming to Palingswick House, most of themhad been absent from school for frequent andprolonged periods and in and out of hospitals.In most of the children the main problem wasemotional: they and/or their family had not yet

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come to terms with the illness.6 Without realis-ing it was offering the service, what PalingswickHouse did was provide group therapy. The chil-dren supported each other. All of those who hadnot yet learned how to do it, including those ofpreschool age, were taught to administer theirown insulin injections (but a nurse alwayschecked the quantity loaded into the syringe).We taught them how to manage their owndiabetes. In particular, we taught them how toreduce the frequency of 'hypo' attacks byunderstanding what was likely to bring one onand what preventive action to take. We reliedon oral glucose or, in the early stages of anattack, any carbohydrate. It was rarely neces-sary to use glucagon; it was used less than fivetimes in all the 15 years I was there. We neverused intravenous glucose. Palingswick Houseclosed for financial reasons. I hope its lessonshave not been completely forgotten.

Urinary tract infections in children are alsorarely seen in general practice. (Before my cri-tics berate me for my ignorance of this problemand failure to diagnose it correctly, let meagain remind them that the average paediatricunit in Britain covers the practice areas of aboutone hundred GPs. For the average GP to see onecase a year, the hospital would have to see two aweek.) I cannot recollect ever having seen a pre-pubertal child with a urinary tract infection pre-sent with the classical symptoms of frequencyand/or dysuria. Dysuria in young girls-when itdoes present-is usually associated with a vagi-nitis, often accompanied by oxyuriasis infesta-tion. In boys the most frequent cause of dysuriais balanitis.

Secondary enuresis always arouses my suspi-cion of a possible infection; but in primaryenuresis investigation of the urine is usually awaste of time. I cannot estimate how muchmoney I have wasted in confirming the normal-ity of the urine in children who have never beendry at night. My preference for the treatment ofprimary enuresis remains imipramine: why Icannot explain, but in my patients it usuallyworks!

Diarrhoea-in patients of all ages-is a verycommon presenting symptom in general prac-tice. There are significant differences in themanagement, both in the diagnosis and treat-ment, of acute and chronic diarrhoea. Chronicdiarrhoea is not seen frequently in children. It isthe acute, and generally short lived, varietywhich causes the most problems. The 'illness'could be dismissed as little more than a nuisancewere it not for the risk of dehydration, espe-cially in infants. Much literature has appearedon the subject, all too often by hospital doctorswho are critical of the management by generalpractitioners.6 It is therefore worthy of com-ment by someone from general practice.The diagnosis of diarrhoea should be obvious

but, in fact, much of what is presented to theprimary care physician as 'diarrhoea' in infants,as much as in older children, is only a minor andtemporary upset of gastrointestinal motility.Assessment of the consistency of the stool is asimportant as an assessment of the frequencyand, certainly in the early stages, more impor-tant than an examination in a pathology labora-

tory for infectious contaminating organisms(the result of which tests, anyway, will not beavailable in most cases until after the child hasrecovered).

In some cases, diarrhoea is attributed to a sys-temic infection, in particular of the respiratorytract (23% in the series of Conway et al7). Otitismedia (generally classified with respiratory tractinfections) is one of the most frequently blamedsystemic infections for the cause of diarrhoea.The treatment is often an antibiotic. (Views dif-fer as to the appropriateness of this treatment.Nevertheless, there are many doctors both ingeneral and hospital practice who regard anantibiotic as the first line treatment of otitismedia.) Conway et al showed that 7% in theirseries of children admitted to hospital with adiagnosis of gastroenteritis had been given anantibiotic before getting to hospital.7 However,the authors do not indicate how many of thesechildren were being treated for an associatedsystemic infection.By now it should be universally recognised

that fluid replacement, plus electrolytes wherethere is any risk of a salt imbalance, is the main-stay of treatment. Nevertheless, there is still adifference of opinion as to whether ordinarymilk feeds-in particular breast milk-shouldbe continued. Indeed, Conway et al were givingbottled milk to some of the infants in theirseries.7 My own practice is to continue milkfeeds in mild cases, but usually weakening thestrength of bottled feeds. In those cases wherethe consistency of the stool is unaltered, I do notusually recommend any alteration in the feed.Most children with diarrhoea-and that

includes infants-are being treated, and beingtreated successfully, by GPs outside hospital. Ibelieve that this should continue: if anythingthe proportion being treated by GPs should beincreased. It is equally my view, however, thatall infants with a gut upset require careful andfairly close follow up. How frequently they needto be seen, by whom (GP, health visitor, ornurse) and whether telephone contact is adequ-ate will depend on the circumstances of the caseand the individual family. If there are to be dis-trict policies on this (and other clinical problemsthat are dealt with mainly in general practice)the policies can only be effective if they are writ-ten by GPs, albeit with comments from theirhospital colleagues.

Emotional problems are seen very frequently.Indeed it is an axiom in general practice thatevery problem we see has a clinical, a psycholo-gical, and a social component; the proportion ofeach varies from case to case, with the clinicalelement being the most significant in some, thesocial or the psychological in others. Majorpsychopathology is relatively uncommon. Mostof the disorders seen in children are intrafami-lial and therefore it is not unreasonable toexpect that the family doctor should be able todeal with a large proportion of these.Most families are well known to their general

practitioners. A family of four will, on average,consult 16 times every year-and even more fre-quently if the mother is pregnant and/or thereare infants in the family. The home circumst-ances are also usually known to the doctor from

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Paediatric care in general practice 899

his house calls.8 Stress can, therefore, often bedetected in more subtle ways than it might be ina family seen for the first time.Not infrequently, an acute emotional break-

down in the family will be presented as an appa-rently medical illness in one of the children. Ihave described elsewhere puerperal depressionin the mother presenting as vomiting in thebaby,9 to which clinical picture I later gave thename of the 'Azazel syndrome' after the biblicalstory of the scapegoat who was sent into the wil-derness of Azazel. 10 Equally, we always have toremember that, because there is emotional ill-ness in a family, it does not mean that we canexclude a physical cause for the current present-ing problem.The care of children is a fundamental compo-

nent of general practice. It is virtually imposs-ible to do proper general practice-familymedicine-without being involved in the treat-ment of sick children. It logically follows that ifproperly trained GPs are able to look after child-ren when they are ill, they are also able toexamine children when they are well. I there-fore anticipate that the additional knowledgerequired for child health surveillance will beaccepted as part of the core content of goodgeneral practice.

I have left to the last the issues that surroundreferral of children to hospital. Regrettably thisis, all too often-especially in an inner cityarea-the only interface between GP andspecialist.The reasons why patients are referred for a

specialist opinion are complex.'1 It is oftenassumed that the GP is passing a problem hecannot manage to a more senior member of themedical hierarchy, but that view is incorrect.Very often the specialist is being asked for hissupport in the management of a chronic condi-tion for which there is no cure, such as catarrhor eczema. It is also to reassure the family thatthere is no need for active medical or surgicaltreatment, for example, most children withrecurrent abdominal pain. If referral is tobecome rational and, hence, more cost effectiveit will be necessary for all three partners in theprocess-GP, specialist, and patient (orparents)-to understand the process more fullyand its nuances.

We need to understand the differencebetween a 'consultation' and a 'referral'. A'referral' is the handing over of the managementof that illness by the GP to a specialist and hishospital based team. A 'consultation' impliesthe seeking of an opinion from a specialist withthe intent that the ongoing management of theproblem will be left in the hands of the GP.(The word 'consultation' is also used to describewhat happens when a patient seeks the opinionof a doctor, whether it is GP or specialist.)A 'second opinion' is, strictly speaking, not

synonymous with either referral or consultationwith a specialist. It was originally used to indi-cate the obtaining of another (and possibly dif-ferent) opinion from a second specialist in thesame field. If the term 'second opinion' is to beused to denote an ordinary referral or consulta-tion, then it is important to remember that it isnot possible to have a second opinion withouthaving a 'first opinion', which should be pro-vided by the general practitioner.

Early in my career I realised that, if I wantedto help sick children, I needed to know a lotmore about their families. Furthermore, thiswas a field in which-to use the American ex-pression-I felt comfortable. So I chose generalpractice, and I have never regretted it.

I would like to thank Professor Denis Pereira Gray and Dr ColinWaine for their helpful comments.

1 Carne S. Incidence of tonsillectomy, circumcision andappendicectomy among RAF recruits. BMJ' 1956;ii:19-23.

2 Balint M. The doctor, his patient and the illness. London:Pitman Medical, 1957.

3 Mackie RM. Clinical dermatolog-an illustrated textbook.Oxford: Oxford University Press, 1981:61.

4 Carne S. Some common skin disorders. In: Hart C, Bain J,eds. Child care in general practice. 3rd Ed. Edinburgh:Churchill Livingstone, 1989.

S Working group of the Children's Committee. Out of hourssocial and health care. Health Services Journal 1980;90(suppl):759.

6 Carne S. Diabetes in children. Proceedings of the Royal Societyof Medicine 1975;68:277-80.

7 Conway SP, Phillips PR, Panday S. Admission to hospitalwith gastroenteritis. Arch Dis Child 1990;65:579-84.

8 Pereira Gray DJ. Feeling at home. J R Coll Gen Pract 1978;28:6-17.

9 Came S. The influence of the mother's health on her child.Proceedings ofthe Royal Society ofMedicine 1966;59:1013-4.

10 Came S. The Azazel syndrome: the child as scapegoat for afamily illness. Modern Medicine 1989;34:595-6.

11 Came S. A problem halved? J R Coll Gen Pract 1982;32:10-31.



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