Consent is fascinating. It seems to different things to different people. Some patients want to make choices. Some want me to make the choice. Many never seems to have even considered it. Colleagues often find it threatening, a challenge to their self perceived clinical autonomy. Personally I find it a challenge to my personal knowledge and time, but when it is done well it seems to aid patient compliance with medication, testing etc.

But more interesting is taking a wider, universal look at informed consent and the issue of different cultural attitudes on informed consent as an individual's decision. A recent article reviewed on Global Family Doctor (http://www.globalfamilydoctor.com/search/GFDSearch.asp?itemNum=10115) found a distinctive North/South and East/West gradient (northern hemisphere that is) on whether prenatal testing (screening) was a matter of individual right.
If you have access to the full text of the article, the researchers felt that the burden of disease and attitudes towards disability are major drivers of the difference between cultures. Certainly the attitude towards disability varies from culture to culture and fits nicely with this research finding. One only has to look at the way different societies aid disabled persons to understand why this should be so..

But wait, there's more. What about the place of a pregnant woman in the society hierarchy? In many cultures women in such positions often subjugated their views to those of others, something that was hinted at in the study but not discussed.  Wider family, especially in matriarchial societies will take responsibility for such decision. In patriarchial societies obvious men will hold sway and in paternalistic societies it sometimes will be the medical profession. Which example is right and which is wrong?

Such matters really get to the philosophical basis of medicine. Who should make the decisions about such matters? The persons most affected by any such decision,  those who will suffer the most? Antenatal testing is a real problem in detremining this. A disabled person requires significantly more societal resources and parenting. But why then is the decision passed to others rather than a mathers in those socieities where disability support is less?

I suspect that whoever makes the decision will do so with the best interests of their position in their society in mind, be it nuclear family, matriachial, patriaichial or whatever. And if medicine makes the decision, especially a very hierarchially orientated medicine, then it will be to medicine's advantage. Just look at things like breast cancer screening. Think about whether such screening would actually have occurred if women were given proper information on the harms and benefits of screening. Jorgensen/Gotzsche's article in BMJ 2006;332;538-541 identifies the significant deficits of breast screening program “informed consent”. 

So what exactly is informed consent? (watch this spot)

We tend to identify generalism in medicine as being the realm of primary care physicians..namely GPs and Family Practitioners. Us. But maybe primary care nurses are more generalist than doctors. After all we have gone down the path of a far more biomedical understanding of health than nurses who I suspect are more psychosocial, ignoring of course those who have chosen to specialise in primary care areas such as wound dressing. Nurses seem to branch out more into the society issues, contextual things like being more focuses on family support for patients, social welfare provision etc. These are the sorts of things that I know a lot of doctors find frustrating and not something that we need to know about. After all doctors are professionals who do the important things like diagnose disease and conditions, all the while we quietly dig ourselves into another specialised ditch.

A case of seeing the trees, not the forest, for we have defined our world as medicine.

Interestingly I recently observed the benefit of being able to cover, in a generalist manner, realms outside of medicine. Over a medical career I have personally been fortunate to acquire two additional realms of experience, namely business governance and IT systems knowledge. Both have been experienced within the realm of health care, but combining all three was recently very useful in an analysis of the IT requirements of several large health organisations. I don’t profess to be an expert (specialist) in these two non medical realms, but knowing a little allows one to formulate a great overview of the issues and synthesise an understanding of how things work that you cannot do, even as a generalist doctor. 

Now the problem is that medical training provides nothing outside of medicine, well in this country at least. In primary care, GPs tend to own the businesses but it seems none are trained in business governance anywhere in the training programs. No one trains in IT systems. A result has been one of often poor business practice and that other fascinating observation that doctors are to computer salepersons what doctors are car salesmen. I even know a practice that was sold one computer and network software in the days when networks were not integral with the operating system.

Now somewhere out there in this world, does anyone know of a doctor training program, be it undergraduate or post graduate that provides governance training, or even some business training ?

A good colleague of mine many years ago coined the term “partialist”. Probably plagerised but nevertheless the imagery conjured up by this desription of a specialsist has a particular appeal for family physicians, at least down here at the end of the world. As generalists, family physicians/general practitioners can be said to know a little about everything (in medicine that is) while specialists know a lot about very little. The likes of Barbara Starfield and other researchers have demonstrated the significant benefit to health care in having generalists as the first “port of call” for patients and those of us working in health systems where FPs/GPs are the “gatekeepers” are thankful that at least there is homwbase clinician whom a patient can return as they journey through the world of health care.    

The idea of an individual clinician fulfilling that gatekeeping role is changing, moving more to the concept of the practice, not just the doctor, as the “medical home”. Family Health Care Teams and various derivative TLAs (three letter acronyms) used in different countries reflects this thinking and I must admit, it seems to work, given that your practice team operates as a team and not a collection of disparate individuals.   

So if generalism is so good, why do doctors pursue partialism? Why is it so valued? Why are specialists paid more? Is it the rarity value of capturing and owning a little niche of knowledge, the power of gnoticism? Is it because a specialists can make more money than a generalist? Perhaps it is the influence of those three humbugs of life: Power, money and fame?

When I was young (such a lovely phrase) and commenced rural GP practice, power, money and fame were for the specialists. GPs/FPs were those who couldn't hack the hospital system, those who rejected the medical hierarchy, those who were not clever enough, didn't work hard enough or were the wrong gender/ethnicity/social class. What is interesting is seeing how general practice has now become a lot more valued in health care in many nations and also seeing how primary health is now leading a lot of health system development.

But whenever you look around primary medical care in your own country, even if it has a great primary care system, you still see GPs and FPs specialising, becoming increasingly limited in their scope of practice, driven into niches of care unpopulated by other medical species, while induldging in self congratulatory reassurance that they are doing the right thing.

Maybe its something in our genes?