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Benefits of Primary Care CORRESPONDENCE Benefits of primary care Record conditions SIR - In an article "Primary care is not SIR - In her diatribe against the role of the answer" (Nature 370, 501; 1994), primary care in Clinton's plans for health­ for cycling Barbara J. Culliton draws attention to care reform, Culliton demonstrates that SIR - Miguel Indurain recently broke the some "less visible provisions" in President C. Everett Koop does not have a monopo­ world 1-hour cycling record, riding 53.040 Bill Clinton's health-care plan, such as ly on patent and dangerous nonsense. She km. The previous record was held by forcing 50 per cent of physicians into misses the main point about general prac­ Graeme Obree, who rode an innovative general practice. She believes that this "50 tice: namely that well-trained generalists bicycle of his own design and manufac­ per cent solution" will fail, as modern act as vital gatekeepers for access to the ture. Subsequently, the UCI (Union Cyc­ medical practice is beyond the skills of the specialists who are thereby allowed more liste Internationale) changed its rules to general practitioner. Medicine should be time to practise their medicine on outlaw such innovations. The UCI does provided mainly by academic medical appropriate patients. not, however, regulate the atmospheric centres. To take up her argument on "Koop's pressure or composition used for the re­ Primary care has always been the pre­ elbow", what if the pain is due to angina? cord attempt. That is why both the ferred way to practise medicine. Unfortu­ Is the patient expected to know that in this Merckx (1972) and Moser (1984) hour nately, it has been abandoned by instance a cardiologist would be better records were achieved at altitude in Mex­ academic medicine. Diseases do not exist than a rheumatologist? Immediate access ico City, where the air is less dense than at as such, there are only sick people, and yet to specialist care in these circumstances is other tracks. Indeed, both Obree and our education systems produce mainly at best a waste of time and at worst lndurain have plans to attack the record in disease specialists. They may understand dangerous, as life-saving treatment may Mexico City next year. "basic biological phenomena", and know be unnecessarily delayed. The United One of us recently proposed attempting how to treat some diseases, yet the crucial Kingdom's National Health care system the hour record in a depressurized indoor question is not only how to treat but when may have many flaws , but, in the opinion track filled with -0.2 atm of pure 1 to intervene. The latter is generally of many doctors who work in it, a well oxygen • This approximates to the atmos­ ignored because withholding treatment is organized network of highly trained phere used in modern spacecraft, and has regarded as unethical, and many patients general practitioners is not one of them. the same volumetric oxygen content as therefore receive unnecessary treatment. The United States would be well advised air. At world record speeds, frictional Academic medicine turned primum non to emulate it. losses from tyres and drive train become nocere into malpractice, and palliation Cella Helllwell an insignificant fraction of total 2 into nonscience. And yet most patients do Andrew Hall resistance . not need more than that, seeking help 8 Park Avenue, We can also assume that the drag coeffi­ from alternative medicine. Hexham, Northumberland NE46 3EN, UK cient will not change, a good assumption An important objective of Clinton's for bluff bodies at high Reynolds 3 plan is to mobilize competent "academic SIR - It was disappointing to see Nature numbers . For constant power outfiut, the 11 generalists" and place them where they dismiss efforts to reform the US health­ speed will then scale as density<- ) • For a are needed most, in the community. To care system (Nature 369, 508; 1994). As a 0.2 atm 0 2 atmosphere, the speed in­ 113 restore the lost dignity of the family molecular biologist whose livelihood de­ creases by a factor of (0 .2 x 32/29)<- ) = physician who now faces new responsibili­ pends partly on continued government 1.655. The 32/29 factor accounts for the ties, and to protect his patient from spending for basic medical research, I higher molecular weight of 0 2 versus the academic medicine. Medicine has become share your concern that this source of average air molecule. extremely complex and the family physi­ revenue should not be lost. Almost any competitive cyclist could cian has to decide what is best for his However, as a parent unable to purch­ then break the current record (including patient in the same way as a lawyer does ase medical insurance to meet the cost of either one of us) within the current UCI for his client. treating a haemophiliac child, I am aware rules. Obree or Indurain could ride more The threat of academic medicine to the of severe shortcomings in our health-care than 87 km in one hour to take the title patient is real. The family physician has to system. A single dose of clotting factor definitively. protect him from unnecessary treatment, now retails for $1,300. Our health-care The hour cycling trial is one of the most experimental remedies and clinical trials dollars support large numbers of workers difficult of all sporting events, and those that study disease and ignore patient suf­ in the insurance, legal , administrative, currently contesting it are arguably the fering . pharmaceutical, marketing and other pro­ fittest of all humans. Thus the proposed Academic medicine is the main source fessions. experiment would test the absolute limits of iatrogenesis, that is, drug sensitivity In a widely quoted recent statement, of human physical performance under and antibiotic resistance (hospital strain). the former US Surgeon General, C. E. space flight conditions. It is also the main cause of rising medical­ Koop, points out that 72 per cent of Jonathan E. Snow care expenditure, as it indiscriminately Britain's physicians are primary care doc­ CNRS/CRPG, applies technological innovations, when tors, compared to 29 per cent in the BP20, in reality the patient could benefit without United States. It seems unlikely that free 54501 Vandoeuvre-les-Nancy, France them. As patient protector, the family market forces will ever reverse these MarkDrela physician will obviously also reduce trends. Unless elected officials play an Department ofAeronautics medical expenses. active, positive role in restructuring the and Astronautics, Gershon Zajicek US health-care system, the United States Massachussetts Institute of Technology, H. H. Humphrey Center for Experimental will probably never achieve what other Cambridge, Massachusetts 02139, USA Medicine and Cancer Research, developed countries have, in being able to Hebrew University, provide basic medical security for working 1. Snow,J . &Shames, P. UK Cycling Weekly, No. 5332, p. 27 Hadassah Medical School, citizens and their families. (1994). PO Box 12272, Marlana M. Goldrick 2. Whitt, F. &Wilson, D. G. Bicycling Science (MIT Press, Jerusalem 91120, 513 Pigeon Forge Road, Cambridge, 1983). 3. Hoerner, S Fluid Dynamic Drag (Hoerner Fluid Dynamics, Israel Pflugerville, Texas 78660, USA 1967). 552 NATURE · VOL371 · 130CTOBER1994 .
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