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As often, Helen Salisbury's article (1) is very interesting for addressing issues that, although local, have clear general conceptual repercussions.
General medicine plays a fundamental role in effective and cost-effective healthcare. The general practitioner (GP) enjoys a strong position: each resident is registered with a GP who is accessible to all, who treats most health problems and coordinates referrals to specialist care. However, utilization rates are increasing, as are costs, which may indicate inefficient use of health services. The typical response is an increase in the supply of resources, causing a "black hole" or "boomerang" effect.
My experience as a GP in Spain over the last 40 years is that the increase in demand and consultation frequency in general medicine cannot be resolved by increasing the supply of resources (in fact, it worsens them). Rather, the organizational characteristics of practice and mainly medical technical actions are the main causes of the ineffective, costly, and iatrogenic increase in healthcare demand (2). It is the existing trends of medicalization that increase the prevalence of the disease and its treatment, when, for example, from the beginning the treatment is carried out with drug associations, with the use of higher doses of drugs, with screenings and preventive advice that are not based on scientific evidence, etc. I put forward the hypothesis (difficult to achieve, when the GP is so "small" compared to such large multinational powers) that achieving a more reflective and critical GP can be an authentic filter to avoid the introduction of medical measures that are poorly contrasted at the individual level and clearly pathological at the population level, from a clinical, ethical, quality, epidemiological and economic point of view.
Escaping from a "black hole"
Dear Editor
As often, Helen Salisbury's article (1) is very interesting for addressing issues that, although local, have clear general conceptual repercussions.
General medicine plays a fundamental role in effective and cost-effective healthcare. The general practitioner (GP) enjoys a strong position: each resident is registered with a GP who is accessible to all, who treats most health problems and coordinates referrals to specialist care. However, utilization rates are increasing, as are costs, which may indicate inefficient use of health services. The typical response is an increase in the supply of resources, causing a "black hole" or "boomerang" effect.
My experience as a GP in Spain over the last 40 years is that the increase in demand and consultation frequency in general medicine cannot be resolved by increasing the supply of resources (in fact, it worsens them). Rather, the organizational characteristics of practice and mainly medical technical actions are the main causes of the ineffective, costly, and iatrogenic increase in healthcare demand (2). It is the existing trends of medicalization that increase the prevalence of the disease and its treatment, when, for example, from the beginning the treatment is carried out with drug associations, with the use of higher doses of drugs, with screenings and preventive advice that are not based on scientific evidence, etc. I put forward the hypothesis (difficult to achieve, when the GP is so "small" compared to such large multinational powers) that achieving a more reflective and critical GP can be an authentic filter to avoid the introduction of medical measures that are poorly contrasted at the individual level and clearly pathological at the population level, from a clinical, ethical, quality, epidemiological and economic point of view.
REFERENCES
1.-Salisbury H. Helen Salisbury: Improved access is meaningless without increased capacity BMJ 2025; 389 :r641 doi:10.1136/bmj.r641. https://www.bmj.com/content/389/bmj.r641?utm_source=etoc&utm_medium=emai...
2.-Turabian JL. Suggestions to Address the Increase in Demand and Costs in General Medicine: Escaping From a "Black Hole" and from Boomerang Effect. J Qual Healthcare Eco 2019, 2(3): 000119. https://medwinpublishers.com/JQHE/JQHE16000120.pdf
Competing interests: No competing interests