To the Editor: Let me congratulate the Editor and his team for their provocative issue on general practice in Australia (7 July 2003). Some of the major challenges are clearly delineated — particularly that of providing care to a chronically ill and ageing population.

While general practice in particular may be suffering from decreasing interest among young doctors, medicine in general is not seen by school leavers of today as the profession it was 30 years ago. Many bright school leavers are pursuing the “corporate world” in economics, law and business, but we can promote the overall satisfaction and variability of medicine in general and general practice in particular. The critical issues are outlined in the editorial.1

Taking a leaf from our “economically” driven society, we need to present to governments and the public the evidence that healthcare systems focusing on primary care are associated with higher patient satisfaction, lower overall health expenditure, better population health indicators and lower per capita rates of drug prescribing.2 Surely, governments (and, more importantly, treasuries) will listen to these arguments.

We also need to adopt a “whole-of-profession” approach. I am concerned that specialists (particularly in the hospital environment) continue to portray a negative image of general practitioners, particularly to young doctors.3 We can all remember, in our “resident” days, hearing negative comments from consultants: “If only the GP had done this or that or referred the patient earlier”.

Part of the problem is that there is still not enough vertical integration between undergraduate and graduate medical school education, postgraduate years 1, 2 and 3 and specialist training. A particular problem is that, after having had increasing exposure to general practice as a student, medical graduates then spend 2–3 years in a hospital environment where they have little or no contact with general practice. During this time they are influenced by hospital specialists who encourage them to pursue the “illth agenda” in hospital medicine and perpetuate negative stereo-types of general practice. Trainee doctors need exposure to positive general practice experiences in these immediate postgraduate years, including general practice terms (especially in rural general practice) along with hospital attachments. This would require significant dialogue between the federal and state health departments but would go some way towards renewing interest in general practice and continuing to provide Australians with one of the best healthcare systems in the world in terms of equity, access, cost and outcomes.

To the Editor: Like Julian White, I was deeply moved to read the final chapter in the fable of the white-tail spider.1 White comments that “The lack of strong evidence to support [the association of white-tail spider bites with necrotic ulcers] seemed to be a triviality to be ignored”.

However, I wish to take issue with the attitude to GPs reflected in his statement “General practitioners regularly and confidently diagnosed skin lesions as ‘white-tail spider bite’.” What is the evidence for this statement, or does White view it as too trivial to deserve scrutiny?

As a GP, I rarely come across a case of spider bite in which a confident diagnosis can be made. However, I am frequently asked questions such as “Could this be a white-tail spider bite?”, and frequently witness patients latching onto one of a list of possibilities, or unwilling to be dissuaded from the diagnosis they have arrived at independently of any medical advice.

Furthermore, it is only after the publication of Isbister and Gray’s evidence2 that I am able to define clearly for my patients the effects of white-tail spider bites, rather than leaving room for doubt. It is a cheap shot for a specialist in such a narrow field to malign GPs on the basis of their failure to critically appraise the evidence relating to aetiology of a rare problem for which there was said to be no treatment.

It has become common to read de-rogatory statements about GPs by specialists unsupported by evidence. Interestingly, such comments are not aimed at emergency department nurses, resident medical officers, physiotherapists or other specialists. I would argue that this may be of some importance. Denigration of the value of medical training and skills may contribute to negative attitudes towards GPs in the community. This may translate into adverse behaviours such as unwillingness to seek medical advice, reluctance to have children vaccinated, inadequate use of antenatal care services, degradation of communication between medical practitioners, and demoralisation of the medical workforce. It may also make it difficult for people to accept advice about white-tail spider bites.

Perhaps White could afford GPs the respect that he does the white-tail spider, rather than taking a random opportunity to malign the competence of GPs.

Comment: Chaffey and Brooks draw attention to the negative effects of specialists badmouthing general practitioners: undermining GPs’ self-image and community status, and discouraging medical students and young doctors from pursuing a career in general practice. Hays has made similar observations about problem-based learning exercises, written by specialists, wherein the mismanaged rural patient is “rescued by clinicians in the nearest large teaching hospital”.1

Medical badmouthing has been defined as “unwarranted, negative and denigratory comments made by doctors about other doctors in different branches of medicine”.2 It is most visible when uttered by specialists in teaching hospitals, but is almost equally as common from GPs criticising some real or imagined lack of common sense in the treatment received by one of their patients in a teaching hospital.2

The underlying psychological mechanism of badmouthing stems from a common human need for self-aggrandisement and defining of group membership by aggressively putting down people outside the “in-group”.3

So, while badmouthing is maladaptive behaviour for the medical profession as a whole, it does have some adaptive features for different subgroups.

Specialists in private practice usually have good working relationships with GPs — indeed, their practice would suffer if they didn’t. But, in my (non-evidence-based) experience (I haven’t done a study on the topic), nearly all specialists see themselves as part of a medical elite who have achieved their status through having the ambition, energy and fortitude to complete a rigorous postgraduate training and examination process beyond that required of GPs.

And we GPs are appropriately grateful for their skills, especially when one of our patients is faced with a life-threatening emergency. Also, most continuing medical education is given by specialists “teaching” GPs. Reciprocal opportunity for constructive GP feedback about patients’ hospital outcomes is rarely given or gratefully received.

Specialists and their junior staff are frequently inconvenienced by overloaded outpatient clinics and by emergency patients, referred by GPs, who arrive at 6 pm instead of 9 am. And on rare occasions they see a patient with a necrotic ulcer due to a basal cell carcinoma, referred by a GP who agreed with a patient’s diagnosis of “spider bite”. What the specialist doesn’t see is the other 100 patients bitten by an uncaptured white-tail spider who are managed solely, logically and effectively by GPs. Extrapolating from one or two cases to the whole of general practice is bad epidemiology and evidence of sloppy scientific thinking.

Badmouthing is an ingrained feature of human nature and a historically unattractive part of medical culture. It will continue until all doctors realise that they are on the same team, fighting the same war against the many facets of disease and disability. GPs and specialists need to understand and respect each other’s role and task. This requires mechanisms to enable already time-poor doctors to interact regularly with each other.

In one survey, about 10% of students admitted that negative comments by specialists about GPs had influenced their decision to reject a career in general practice.2 This was part of the rationale for setting up a medical school counterculture through rural student clubs.4

But even more harmful than badmouthing is the perception by students and young doctors that general practice is an unattractive branch of medicine, beset with governmental red tape, a divided leadership, and, after failure of the Relative Value Study initiatives,5 a guaranteed continuation of poor remuneration for heavy responsibility taken and long hours worked.