Book review: Inside edge

Doctors on the edge: general practitioners, health and learning in the inner city Linden West London: Free Association Books; 2001 240 pp US$55 (cloth) ISBN 1-85343-522-8 US$25 (paper) ISBN 1-85343-522-8 As a topic, the work of British inner- city doctors at first seemed exotic to me. Could a book about reforms to the National Health Service and the conditions of general practice in London resonate with Canadian doctors? What about the method of inquiry, in-depth “auto/biographical” research based on interviews and discussions with 25 general practitioners in the inner city? As it turned out, Doctors on the Edge struck very close to home. Many of its themes will resonate with physicians in Canada: professional isolation, conflict with partners and employees, demanding patients, long hours of work, financial pressures, difficulty accessing community resources and working with other disciplines, poor treatment at the hands of the medical hierarchy and of health-system bureaucrats, the struggle to balance roles at work and at home, marital problems, emotional distress, difficulty asking for help and discrimination. There are also stories of dedication, overcoming obstacles, coping under harsh circumstances, reaching out and striving to improve. Indeed, remarkably little in this book is specific to inner-city London or even to general practice, while there is much that illuminates problematic issues fundamental to the modern physician's role. These issues start with the medical curriculum and its preference for linear, reductionist thinking over lateral thinking and creativity, factual learning over building relationships, and rational science over emotional expression. Once in practice, physicians are faced with vague symptoms, irrational demands for tests and therapies, uncertainty in diagnosis and prognosis and the need to establish and manage long-standing relationships with patients, colleagues and employees. None of these challenges will have been given much attention in medical school. Physicians in solo practice have autonomy but may find themselves isolated from their colleagues and at risk of falling behind in the rapid expansion of medical knowledge. Some in group practice will have to take on managerial roles for which they may be poorly prepared. Continuing education has limited appeal to many who need it, and the professional and financial pressures of daily practice militate against taking sufficient time off for new learning. The physician's role has a subtext: superiority, emotional distance, the priority of work over personal and family issues, and invincibility. In a culture of impossibly high expectations, physicians may spend inordinate time and effort trying to meet unrealistic standards. Together with the sacrifice of family and recreational time, this can lead to fatigue, despair, burnout, damaged relationships and ill health. Valuing inner strength, autonomy and the authority of physicians, the culture of medicine poses a barrier to seeking help, especially for adjustment and emotional difficulties. Physicians may be especially reluctant to take on a patient role when that role is seen as one of inferiority and submission. Women physicians are faced with the same set of work expectations as their male colleagues, but also with family and household responsibilities, setting the scene for stress, guilt and a feeling of being torn between two sets of unattainable goals. Linden West began this five-year project with an interest in educational reforms and their impact on inner-city physicians. In Britain, peer education, the formation of self-directed learning groups and audits by medical authorities held the potential to improve practice but also to further marginalize certain physicians, especially women, those from Asia, and those in solo practice. As he listened to doctors' stories, West became interested in learning more about the broad issues in their practices and in their lives. Educational reforms were one aspect of changes taking place in the National Health Service. New standards for maintaining professional certification, the encouragement of group practices and altered practice arrangements and funding formulas were having an impact on British general practitioners, just as those issues are now affecting many Canadian family doctors. Although West deals with “learning in the city,” he also includes chapters on his method of auto/biographic research, the stress and boundary issues of daily practice, transcending career and personal crises, the struggles of women physicians, dealing with changing roles and uncertain beliefs, cultures of silence, performance and underperformance, the limited options and scapegoating of physicians from minority groups and the crisis of general practice. “The edge” of his title refers both to the marginalization of general practice within medicine, a crisis in which doctors are being pushed to extremes, and the cutting edge of new forms of reflective practice. This book is a strong reminder that stories form the basis of shared human experience. Those told here are candid, sometimes tragic or redemptive, but always authentic in tone and content. Humanist psychological interpretation is provided throughout, but the narrative remains faithful to the context of the author's developing relationships with his subjects. Medical culture is portrayed as deeply flawed in the ways it prevents physicians from connecting as people with their patients, dealing with distress and emotional difficulties, seeking and receiving help and building a supportive practice environment. The focus on marginalized doctors in a marginalized setting perhaps amplifies these issues, but it is not hard to apply that emphasis more generally to our profession. Who should read this book? The many people who plan and organize primary care services and who are now considering and implementing reforms would do well to heed the messages of this book. Practising physicians, especially those early in their careers or experiencing dissatisfaction, boredom, distress or burnout might gain insight into changes they could make in their professional and personal lives. Medical educators interested in aligning the undergraduate curriculum and residency training with the realities of medical practice can also gain valuable perspectives here. West offers no prescriptive answers on how to realign medicine with a more humanistic and interpersonal approach, but the necessity of doing so is clear. His study also makes plain the need to organize care delivery in ways that support individuals, enable them to seek help, promote improvements in practice and facilitate collaboration across disciplines. Richard H. Glazier Associate Professor Family & Community Medicine University of Toronto Staff Scientist Inner City Health Research Unit St. Michael's Hospital Toronto, Ont.

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