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Sir,—Dr Bethell makes the valid point that the care of patients with myocardial infarction in general is poor and ascribes much of the fault to general physicians. It is equally appropriate to assign blame to general practitioners who are in the most advantageous position if they should so wish to supervise and encourage a rehabilitation programme for their patients.
As someone who has been interested in this subject for many years and has encouraged the use of thrombolysis within his own practice within the community, I would take issue with Dr Bethell’s comments that general practitioners are bound to follow protocols set by hospitals. It is such attitudes that have contributed to the problems in taking forward the appropriate acute care of patients with myocardial infarction as well as their rehabilitative care.
It is only through collaboration and discussion, not by diktat, that sensible programmes of cardiac rehabilitation can be established within the community. I would very much encourage such attitudes that might lead to improved patient care.
This letter was shown to the author, who replied as follows:
Dr Grant is right to say that general practitioners are not bound to follow hospital examples of the management of patients with myocardial infarction. However, unless the general practitioner has a particular interest in heart disease, his or her management of coronary patients is likely to be influenced heavily by the approach of the hospital physician. In hospitals where infarct patients are admitted under the care of one of several on-duty consultants this approach is likely to lack consistency and be suboptimal. If all coronary patients were to have the benefit of a cardiologist’s opinion, as is the case in some hospitals, a consistent management policy could be developed. This could then, as Dr Grant suggests, be discussed and put into practice by general agreement between hospital and community, an unlikely situation under current circumstances.
I did not “ascribe much of the fault to general physicians”; it was the system that I criticised. It is a paradox of the way we organise the care of the largest cause of death in the UK that heart attack patients may never see a doctor who is interested in their condition.