I was interested by Dr Peter Davies’ article on controlling difficult asthma and in particular by the ‘GP rule of threes’, which I had not come across before (GP, 27 April).
The idea that the first time you see a patient you treat them, the second time you try something different and the third time you refer them seems a useful rule of thumb if you don’t know what you are doing or the patient is dissatisfied, but at the same time it represents a reactive style of practice that responds to the immediate problem and gets the patient out of the room quickly.
As our understanding of the science of general practice, and, in particular, the management of chronic disease, progresses I would hope that the GPs of the future increasingly master the art of making a management plan at the first encounter that outlines a sequence of future steps, which might lead to referral on consultation number three, but which might equally well include a number of other interventions and trials in pursuit of a solution.
In asthma, certainly, there should be more than two attempts before the average GP feels obliged to refer the patient for specialist care.
Dr James Heathcote
Catford, south-east London