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Forgive, pray, a little nostalgic self-congratulation. I've just come back from the annual meeting of the Society for Academic Primary Care in St Andrews. When Samuel Johnson visited St Andrews in 1773 he found it in decline: ‘Had the university been destroyed two centuries ago, we should not have regretted it; but to see it pining in decay and struggling for life, fills the mind with mournful images and ineffectual wishes.’ Now both town and university (to say nothing of the golf courses) are flourishing, and the architecture seems to have avoided any modern invasion, like stepping back 50 years. At the meeting John Spencer quoted a 1991 paper of mine where I had foolishly agreed to predict what I thought was going to happen in the next 20 years.1 I had forgotten writing this piece, so it was encouraging to see how much I had got right: the importance of planning continuing education to one's own needs, now represented by personal development plans; the very detailed MRCGP curriculum (not wholly approved of by the educational establishment);2 the MRCGP exam being the entry point for independent practice; the tendency of doctors not to take on permanent jobs immediately after finishing formal training; and revalidation (though that predicted for a 7, rather than a 5-year cycle).
However, I spectacularly failed to predict the explosion of electronic media as the means by which so much education would be accessed and undertaken. I can perhaps be forgiven. Tim Berners-Lee had proposed the world wide web only 2 years before in 1989; a fact ascertained, appropriately enough, via the web. Now, it seems, nothing happens except through electronic media, and it's exciting to join in the launch of an electronic programme to support GPs' continuing development (page 616). Some readers will already be familiar with this resource, since those in charge have wisely delayed the official launch until they were quite sure all the initial bugs had been removed. Newcomers like Faye McCleery will be surprised and impressed by the quality (page 617). But take care: as Murray Lough warns on page 564, we are still unsure that e-learning really scores over other ways of learning, and everyone should take pains to maintain a balance of educational methods in their portfolio.
Another subject discussed in the 1991 piece was the difficulty of finding a path between greater specialisation and remaining a generalist family doctor. Paul Morrish, who now works as a specialist, puts in a vigorous argument in favour of GPs being more involved in neurology (page 599). The reasons he gives are familiar. There has been a big increase in the number of referrals from primary care to specialist neurologists that is threatening to overwhelm the service, and many of those referred turn out to have the kind of common functional conditions that ought to be more appropriately, and better, managed in primary care. Leone Ridsdale feels that the answer lies in much better undergraduate teaching, supplemented by proper resourcing of the GPwSI grade (page 567) but systematic application of the MRCGP curriculum should help.
And who, 20 years ago, would have predicted some of the other changes that have overtaken us? Adrian Elliot-Smith, from an Australian perspective, echoes some of our own dissatisfaction in deploring the growing numbers of salaried doctors, the current out-of-hours arrangements, and the impersonal communication between GPs and specialists (page 618). The paper on page 584 provides a little more ammunition to those who deplore the advent of QOF targets, with evidence that one set of payments is too blunt an instrument to reward the behaviour intended. Nor did I guess how embattled it would feel. Readers feeling unloved, unwanted, underachieving, or simply overwhelmed should turn to Martin Marshall's article on page 605, based on his James Mackenzie lecture from last November. He is clear that we need to be certain of our core values, and then suggests how we should set about doing so. One solution is to concentrate on telling stories (for his own you will have to turn to the electronic version: doi.10.3399/bjgp09X420266), and as it happens we're publishing two such pieces on page 595 and 597. This takes us to the world of qualitative research, which Kath Checkland, in the editorial on page 565 (linked to articles on pages 571 and 578 concerned with receptionists), thinks we have deprecated in comparison with RCTs. Mea culpa, but when you read about the Bells palsy RCT described on page 569 I might be forgiven for that too.