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Medical books tend to follow a ‘rule of thirds’—one-third of the content above expectation, one-third below and the remainder at par. With the Oxford Textbook series we expect a better performance, and the Oxford Textbook of Primary Medical Care1 does not disappoint. It is scholarly and authoritative yet thoroughly entertaining.
The editorial team, headed by Roger Jones, included Chris Silagy, now sadly lost to us; and under this team were the worldwide section editors who helped to blend some 270 essays into a logical and readable whole. The spread of subject matter is vast—from rural primary care to adult sexual abuse; from jaundice to hearing loss; from end-of-life decisions to normal pregnancy. The book comes in two volumes, each over 600 pages. Volume 1, subtitled Principles and Concepts, deals with the nature of general practice and primary care around the world, moving on to analysis of the consultation and ending with sections on research, education, ethics and the law. Volume 2, Clinical Management, adopts a system-specific approach to covering most of the clinical conditions encountered in primary care with additional sections on child health, old age and palliative care. The book also comes with a CD-ROM, of which more later.
The concept of this work strikes me as excellent. How does it perform as a day-to-day reference? I invited members of my practice to try it, and the feedback was positive. Here, for instance, are some comments from David Ward:
‘Welcome source of up-to-date description of the craft of general practice with references. Reflects current high quality practice. Concise digest of the issues featured in editorials and reviews of recent years with regard to modern organization and evaluation of practice. The references provide a starting point for more in-depth study when entering new areas. Relevant documents can be obtained quickly rather than as a confusing mass of references from a “literature search”. References and statistics provided for “the useful and well known facts” of everyday practice, the things that people are always talking about without necessarily knowing where they came from.’
From my own reading I was drawn into the history of British general practice described by Irvine Loudon, which makes a striking contrast with Gordon Duff's essay on genomic medicine. Having a research interest in respiratory disease I also paid special attention to the essays on asthma and chronic cough. The former gave a concise well-written description of the epidemiology and diagnosis of asthma, ideal for medical/nursing students and general practice registrars wishing to get started on their ‘asthma assignment’. There follow illustrations of asthma action plans and a description of beliefs that underlie the behaviour of people with asthma. The chronic cough section is a practical way of leading a practitioner from a common symptom to a reasonable differential diagnosis, with most attention being paid to chronic obstructive pulmonary disease. The importance of smoking cessation is appropriately emphasized and I then turned to a short essay by Tim Lancaster on smoking and changing behaviour. In the space of three pages he explores why people smoke, the benefits of stopping and what primary care clinicians can do to help, as well as offering an excellent list of references for further consultation.
So, what of the ‘rule of thirds’? This textbook confounds the rule by being very largely above par, but a few negatives do need to be expressed. With my professional interest in community hospitals I was disappointed that there is no mention of the role of general-practitioner clinicians in these hospitals. Many of my compatriots will share my dismay on this score since one in five British GPs has admitting rights to community hospital beds. Polymyalgia rheumatica is a common complaint usually managed within general practice but is dealt with in a cursory manner under the heading of ‘non-specific presentations of illness’. No mention of the value of the erythrocyte sedimentation rate in confirming the diagnosis and no guidance on treatment and follow-up—oddly, since a ‘key point’ in this section is that ‘careful follow-up is necessary’. Inevitably, some aspects of a text of this sort will be out of date even before publication, and such is the case with the advice on emergency contraception. The CD-ROM that came with the book proved useful at my desk during the working day, but the search facilities are inferior to those for the disk of the Oxford Textbook of Medicine; perhaps the next edition will provide links that give access to references in online libraries.
As an account of the evolution and craft of primary health care this work has no serious rivals: it is an extraordinary repository of scholarship from the various disciplines that contribute to practice. If it becomes widely used by students and practitioners, the discipline can only benefit. How could any modern quality-oriented practice not wish to possess a copy?