To the Editor: As much as we agree with the general sentiments of Del Mar and colleagues’ views about the malaise of general practice,1 we feel they simply listed some of the well known symptoms without elaborating on the underlying pathology or analysing the failure to provide appropriate treatment.

Their conceptualisation of general practice focused on clinical performance within a disease-centred model of medical care, which includes the issues of published and cited papers, critical appraisal and evidence-based medicine. Their analysis did not address systems issues, including the funding of general practice/practitioners, organisational change (such as amalgamation and corporatisation), and the establishment of Divisions of General Practice that have largely failed the community as well as the discipline.

We would argue that redressing the problems in general practice requires a fresh start in thinking. We need a much broader conceptualisation of general practice and its role within the healthcare system. Firstly, the specialty of general practice is patient-focused generalism — that is, a focus on patients’ bio-psychosocial healthcare needs and understanding of their illness experience. Secondly, we need to recognise the important place of general practice in healthcare delivery and population health. After all, an average 217 patients per 1000 seek medical care each month, of which only nine will be hospitalised and one will require tertiary care.2

A broader conceptualisation of general practice must embrace the discipline’s patient-centred approach to patient care and an explicit understanding of systems approaches within the context of the populations served by the discipline.

This can only be achieved if we embrace different research models and understand modes of healthcare system organisation, both of which are based on dynamic, non-linear models. Such an approach implies that we continually revise our models of clinical practice around patient and community needs. In fact, the greatest strength and the greatest opportunity of our discipline is our grassroots involvement — our ability, based on our individual experience, to advocate on behalf of our patients for a system based on their care needs and our ability to deliver such care.

We don’t underestimate the challenges inherent in reorienting our discipline away from the mechanistic disease model of the 20th century towards a dynamic, patient-focused model relevant to the 21st century.

In reply: We agree wholeheartedly with Sturmberg and Martin that it is often hard to separate cause from effect. Are the symptoms actually the cause? The old villains — amalgamation and corporatisation — are only two of the main culprits. After all, they have had influence on specialist practice too.

The point we tried to make is simply that the intellectual deficiencies in the discipline of general practice, which attracted a public flaying1 after an international conference on general practice research this year in Canada,2 are too often ignored. Addressing them in the context of biomedical research, rather than embracing a different paradigm, may be one solution.

The approach advocated by Sturmberg and Martin (ie, emphasising healthcare system organisation and using novel research methods) is fine — we need innovation in healthcare systems and new ways of improving them. Nor do we trivialise patient-focused healthcare, in which huge advances have been made based on general practice research. Patient-focused healthcare was one of the themes of the recent research conference.2

But, if general practice enquiry remains limited to health services research, and if specialists do research on disease without involving general practitioners (however old-fashioned and “mechanistic” that might appear), we will always have difficulty clawing our way out from an intellectually inferior position. A recent example to illustrate the importance of clinical research in general practice is the latest hormone replacement therapy (HRT) uproar. For many years, the benefits of HRT have been simply projected on and promoted in the general population. Now that breast cancer risks have become clearer,3,4 it is obvious that earlier research could have prevented this negative fall-out.5

As Sturmberg and Martin so rightly point out, many illnesses are principally managed in primary care. Should we not become experts (through research and teaching) in their management too?