Roles of the general practitioner in different contexts.

Abstract

The word ¿general practice¿ denotes different contents of work as we look at different contexts. General practitioners may provide first line care, function as secondary care providers at hospital level, take responsibility for the management of health care systems. These different roles can be seen as results from historical processes of division of work in the field of health care, which gave general practice its present shapes. During the first half of the 20th century, western general practitioners were gradually excluded from hospitals as well as from public health activities. When they started to react in order to increase their legitimacy they strived--with variable success--to gain recognition as curative first line care providers, as this had become the only place in the health care system they could claim for. They gradually defined their specificity in terms of polyvalence enabling them to deal with unselected problems, and in terms of global view allowing for adequate priority setting. In developing countries, the organisation of medical care was and remains influenced by western models. As in western countries, emphasis has been put on specialisation and hospital technology. General practice was not exported to developing countries: general practitioners appear rather as cheap substitutes for specialists. The most typical workplace for general practitioners in developing countries remains the rural hospital. But their role model refers to the hospital based specialist: they tend to focus on patient care for hospital users rather than on dynamising health care delivery to the whole community in the district. In urban areas, the recent expansion of (mostly private) first line medical care is also not specific to general practice and tends to be in favour of specialists. What is the common denominator to these different roles, if any? A possible answer lies in the primary health care approach. It allows to define the specificity of general practitioners in terms of multifactorial approach and global view on health and illness, which differentiates them from specialists. Whether they provide this care themselves or organise it at district level could be less important to their professional identity than the general attitudes and knowledge they rely on.