Vancouver Institute Lectures

The horse and buggy doctor [typescript] Bates, David Oct 21, 1972

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H.’ H H  z  z  0 0•  •  •.  4J  •  U  >o *1)  ci)  C 4J  C.)  Q)  * ,  ,  0 0  .c-)  D 0 0  0  CI)  H  —  for giving thanking the Vancouver Institute I would like to begin by present the ing some thoughts with you concern me an opportunity to share ting to mp atte In to the medical profession. status and problems relating ne, sce ging e to a difficult and rapidly chan give some kind of perspectiv s s and contact as er heavily on my own experience I will have to draw rath we have met, and I take it However, we are part of all that a physicianS experience that each one of us uses his own to be more or less. nevitable lems. as a guide to contemporary prob ed in e of a remarkable book publish The title of my talk is the titl time of nt r. We can, I think, at this poi 1938 written by Arthur Hertzle the h ut 1860 and 1940 as a period in whic identify the period between abo hed was more or less self-sufficient, reac individual practitioner, who Arthur Hertzler describes the life a very high point of development. ed States practising ctitioner in the mid-west of the Unit  of a country pra houses eful and travelled to remote farm alone. He was remarkably resourc homely and dies , and brought simple reme under appalling weather conditions five of tion His book opens with a descrip wisdom to the cottage fireside. n reig g of diphtheria. He writes “the children of a fatally of eight dyin to epidemic brings out a trait common of terror during the diphtheria seek ple peo ils, per own fronted with unkn the entire human race; when con d fille ly ral lite yers for protection aid from some supreme being. Pra of nce scie the There was tic appeal to the air in those days of doom. might . No one prayed that the doctors medicine because there was none better of this possibility.” No one knew find a remedy--no one thought era how limited was his therapeutic than the country doctor of this ine aspirin, rrtd in the tropcns cuin capability. Morphine, digiLiiis, e sinc has used he else ing and everyth comprised the active pharmacopeia, gone by the wayside. which concept because it was the one in I wanted to begin with this ing ctis pra of a partnership of four doctors I grew up. My father was one a had ral area. His consulting room 30 miles from London in a semi-ru rts on es and there were eye testing cha polished cabinet containing lens ous oxide anaesthetic apparatus with a nitr the wall. He had a primitive but foot; he had a small sterilizer, tap operated by the physician’s ran a s tner par his instruments. He and enough to boil up some surgical ns ptio scri pre r d dispenser, and all thei dispensary staffed by a qualifie the of urs my life I knew the colo were filled there. Very early in e how went to medical school I was awar different medicines, and before I the act as a psychological prop for often mixtures were prescribed to had any very specific action. My patient, rather than because they built rge of a 40 bedded fever hospital father was the physician in cha the for was This d. le of an orchar about 1880 and located in the midd an Germ and les scarlet fever, meas care of children with diphtheria, ls e had developed links with hospita ctic pra measles. Over the years this l loca a in it had some responsibility and all of the physicians within hospital setting. rs as an army doctor in the Far East, When I caine back from three yea lth Service ions relat:ing to a National Hea in 1948, I found that the discuss  -2-  •  At that time my father was a local Association, and asking himself the Medical of the British representative aspects of the well-trained family question of how to preserve the good physician in the midst of radical administrative change. He never doubted that the pattern of practice and of medical administration had to change in Britain were in full swing.  and in an attempt to look at different models, he kept a keen interest in the Peckham Health Centre, which was a protorype community health centre. His own I remember he tookme to visit it when I was in medical school. for a prescribe to now fashionable it is kind the been training had not of was he one War World into I, immediately fami).y physician. Drafted College year. from University three physicians who graduated from his He Hospital out of a graduating class of about 60, who survived the war. was injured in France and, fter having been invalided at home, he spent three years working with Sir Thomas Lewis, then doing advanced cardiolo gical research. After a brief period of training in surgery, he went into general practice. His work with Sir Thomas Lewis gave him a depth interest in cardiology which he maintained for the rest of his life. He believed that no family physician or general practitioner could survive intellec tually unless he had, during his training, acquired a really strong basis in one or other aspects of internal medicine, obstetrics, or paediatrics. I have dealt, at some length, with this pattern of practice because it seems to me that many of the problems it raises are those we are still considering. In the present tangle of health services, we can identify five different components, and one of these obviously is the individual physician and the professional bodies which represent him. A second, is the hospital, which may either be a large city hospital or a sma2ler commu nity hospital. The third is government; the fourth is he medical school within the university; and the fifth are the so-called paramedical professions, namely nursing, physiotherapy, dentistry, and many others. All of the individuals who work in these different environments in different ways constitute the health professions--and I do not need to remind you that this is fast becoming one of our major industries. I believe that in two or • three years it is predicted that the health services as a whole will be the second largest industry” in the United States. •  .  In discussing the inter-relationships between these five components, I have to remind you that there are some basic propositions from which we all have to start. We are in a society based upon an ideal of freedom of choice. There are some who speak as if one segment or another of society involved in the health professions should be treated as if they were troops. They argue that doctors should be compelled to practice in different areas, overlooking the fact that such compulsion is not compa tible with our present pattern of society and its objectives. Occasionally they speak as if one could compel a medical student to choose certain professional careers for themselves after they have graduated. Admitting that we may do something to steer students and doctors into certain channels by making them especially attractive, nevertheless we have to remember that we do not accept an idea of a society run on such rigid and autocratic lines. The second feature we can identify is the obvious need for planning in the present world to ensure high standards of quality and economy of operation. During the last ten years, 27 hospitals around  -3-  This is partly to be Boston have closed out their obstetrics services. e>:plained by the reduction oC work, but it was achieved without a government directive by collaborative planning amongst all the institu tions serving a large metropolitan area. That kind of planning is clearly necessary in the future. Thirdly, we must recognize that there a process of redefinition and evolution of roles within the health is It was my predecessor, Dr. Jack McCreary, who science professions.  played a leading part in Canada in arguing that since after graduation we required health professionals to work together, it would be sensible if we had this goai. In mind during their education. As girls with a higher level of intelligence and a much better academic background are attracted into nursing, the responsibilities and roles which can be accepted by nurses will change and expand. The family physician prac tising in the urban centre hardly needs to be familiar with many of the acute medical and surgical problems that confronted the individual physician in a rural area thirty years ago, and it wouldn’t make much sense to train him as If he was going to have to operate on the kitchen table. We shouldn’t train him as a ‘Horse and Buggy Doctor’ until he has chosen that role for himself. Fourthly, we can recognize that our present society places a great deal of stress on the criteria of service •to people as the yardstick of success. Slowly, the objective of preser vation of the environment is taking precedence over immediate gain, and slowly the concept of service to people is in most of our minds becoming more important than preservation of hospital autonomy; or defence of a rigid bureaucracy; or a specialized plea of academic self-interest. Fifthly, we can identify the general point that the ucational process, whether it be of physicians or nurses, must be adapted to what we believe to be the needs of the future physician and must take as a prime task the prnviinn of continuing education for them and for all other health professionals. With these general considerations in mind let me look at each of the components which 1 have sketched, and try and understand the problems they confront and the efforts they are making to adapt to the future. The primary physician is certainly waking a valiant effort to redefine his role in relation to other health professionals, and to insist that he should be the primary reference point for most members of the public. He is confronted by the reality that one man, alone and unaided, no longer contains the potential for maximal assistance to any but a small group of patients. In my father’s day, a good physician who understood the correct use of digitalis and morphine, and possibly oxygen, could do as much for a patient who had had a coronary thrombosis, as could anyone else. Modern medicine has made this concept outdated, just as It has swept away diph theria and polio. Although the needs of continuing education for such physicians are agreed by everyone, we have made little progress in under standing how to organize this, since we do not know how to take physicians Out of their practice, let us say for one year in every ten, and provide proper economic recompense for them. We recognize that the problems of physicians in rural areas have a good deal to do with the difficulty of persuading doctors with children that their own dedication to the community should take precedence over their children’s need for high The primary physicians, and those who represent them, quality education. believe that medical schools have been training too many specialists and  -4-  neglecting the training of primary physicians; but they often forget that in a free society we allow people to choose what direction they take. Certainly the medical school must provide opportunity for students to be part of a family practice environment during their training, and our faculty at U.B.C. provides these opportunities in greater measure However, we have to recognize the than most other faculties in Canada. problem that exposure of students to a deprived environment too early in their liiieprovo.discouraging to them, since they will conclude that they can do little to ameliorate the social problems which they confront. It has. been under of different number a years for tremendous pressure during the past few educated perhaps reasons, amongst which are he fo.llowing. The public, by Dr. Kildare and his spectacular successes in the emergency room area, have used the hospital emergency department as a super sort of family physician’s office, thereby putting tremendous strain on these facilities. Furthermore, medicine has changed over the past fifteen or twenty years and new techniques are needed in the hospital setting. Suddenly the hospital has. had to find space for such things as nuclear medicine, expauded laboratories, cardiac catheterization rooms, pulmonary function laboratories, etc. and has difficulty adapting nineteen thirty space to nineteen seventy needs. As if all this were not enough, the hospitals have undergone a shift from being nineteenth century charitable institu— tions, to being major spenders of public money. Shortly after the National Health Service Act came into power in Britain, my hospital in. London was involved in a legal suit. Giving judgernent, Lord Justic Denning remarked that the hospitals must realize that it was no longer enough for them to give a basic standard of care on the basis of charity. The tact that they had become major components in government administered schemes, meant that the public was entitled to expect the highest possible standard of contem porary professional care from them. Yet the hospitals •have been handicapped by inapposite financial structures often based on yardsticks for financing much too crude for their new and changing roles. All too often the politi cian has tended to look upon them as if they were the poor law institutions they are striving hard to adapt from. I might also note in passing that an additional problem has been the composition of the Boards of Trustees established usually many years ago. The distinguished local citizens who make up these boards are generally expert in handling investments and looking at balance sheets. They are far less well trained by their back ground to judge whether the interface between the hospital and the public is satisfactory, and they are generally in no position to judge whether the quality of the operation for which they are responsible, reaches acceptable high standards. As if all this were not enough, the increasing demands of medical schools dependent on such hospitals for their educational role in clinical disciplines has bean a complicating factor. Very often the arrangements between the university and the hospital have been poorly defined. The responsibility now placed on medical schools for the quality of the education of graduate physicians to which I will refer later has added further stresses to the system. The large city hospital has problems all its own..  -  Government has made an effort to meet the rising public expectations relating to health services. They inherited, however, several difficulties,  —5--  amongst which I would place in first position the problem of dealing with a civil service which is unused to public or community input into decision making. One has a general spectacle of the politician agreeing that public participation in decision making is necessary, and the civil servant striving very hard to prevent it being effective. Furthermore, the whole system has grown at such a rate that they have had to structure large organizations involving computer programes, etc. to handle what has become a major component of public spending. The medical school, which is responsible in the final analysis for of physicians and their graduate training, has also been quality the stress. It has had to structure ways for medical students severe under to be educated within the community and by physicians miles away from It has •had to fight to preserve hard-won scientific university centres. and research excellence on which all future progress depends. Without these advances continuing, we would be condemned to pratising the kind of medicine our fathers practised. And, furthermore, it is the physi cians w’no know where the frontiers of knowledge are, who are in the best position to introduce into hospital settings new techniques and new methods of treatment. If you were to visit the twenty or thirty largest community hospitals in Canada, and inquire when they introduced a new technique of value in the management of patients, and. which physician was responsible for introducing it into the hospital, you would quickly discover that it was those physicians engaged in active medical research who brought these methods into the hospital setting. Unless you are aware of what is going on in the greater world of medicine, you are very slow to adapt to change. These stresses and strains have been compounded by serious questioning within the university community as to whether the Faculty of Medicine should exist at all, There are some university professors who regard the professional schools as somehow ancillary to the main purposes of a university, and they spend much time urging that the involvement of the university with the community through these schools is absorbing much too much of the universitys potential.  The fifth component is t.he paramedical organizations and here there have been major changes in the midst of considerable difficulties. As Charles Dickens recognized, elderly nurses are not the most radical members of society. Schools of nursing with younger faculty keen to change the role of the nurse and give her a much sounder educational basis, have often been denied educational facilities in institutions whose nursing staff is unsympathetic to such a radical change. I came across this when organizing the medical intensive care unit at the Royal Victoria Hospital in Montreal 14 years ago. As soon as we began to train nurses in managing respirators and tracheotomies and in treating patients who suffered a cardiac arrest, we found that the main opposition came from the well-entrenched senior nurses, who perhaps were jealous of so much responsibility and education being given to their juniors. Yet as we review all these organizations it should be apparent to In particular, all of us that the last ten years have seen major advances. the interface between the medical school and the community has been trarisformed. I have only been in Vancouver for three months, yet this is time enough to see the interface between the faculty and the community in some  —6—  det:ail. Not only the programs such as REACII, which bring pacdiatricians and students into contact with an urban community of chi idren, but also the faculty involvement and leadership in establishing programs for the treatment of patients with renal failure both in the hospital environment and in their homes; the pioneer work relating to the establishment of family practice units and community care centres; and the responsibility accepted by the Department of Psychiatry under its new Chairman to inte grate and improve and encourage development of psychiatric work at every These are but three of many other examples level within the community. I might have chosen and they illustrate advances made in one sector. You will remember that it was C. P. Snow who, in a famous essay, spoke of “two cultures”. He was portraying the growing division of out look which existed between a scientific rand technologically trained person on the one hand and someone working in the field of the humanities, on the His idea took fire, greatly to his surprise, because it corresponded other. to a public anxiety about the discordant objectives of these two individuals. Medicine represents one of the main interfaces between these two cultures and indeed it would not be too much to describe it, in a sense, as a third culture. One has only to look at the program of renal dialysis, for example, to see the intermeshing of modern technological advance and machinery, with I was encouraged last an understanding of the patient’s needs and anxieties. be one of Canada’s who must week to hear Professor Dion of Laval University, was in faculties of medicine greatest political scientists, remark that it that the university was doing its most distinguished work in relation to the community; and he said that, in his view, in Canada as a whole the faculties of medicine had made far greater contributions in this direction Needless to say at this point of time than had departments of sociology. the Canadian of es the representativ by his speech was warmly applauded him. to g Medical Colleges who were listenin I want to turn then from these immediate issues to some more general considerations. Eric Hoffer in his book “Ordeal of Change” has pointed He writes out what Dostoievsky stressed a hundred years before. “It is my impression that no one really likes the new. We are afraid of it. We can never be really prepa:ed We have to adjust for that which is wholly new. ourselves, and every radical adjustment is a crisis in The simple fact that we can never be fit self-esteem. that which is wholly new has some for ready and . It means that a population undergoing results peculiar a population of misfits, and misfits is drastic change There live and breathe in an atmosphere of passion. and confidence is a close connection between lack of the passionate state of mind Perhaps this explains the heat generated by discussions relating to the dispensation of resources in the health fie.ld or its internal organization. All of the components at the present point of time may be suffering from a In T .S Eliot’s There is, however, no going backwards. lack of confidence. that few recognize we can and words ‘the rails slide together behind you” era. In previous solutions are to be found by attempting to return to a .  r  that we do not depend on a romantic particular, we must be very cautious desperate elements such as ideal of the past, forgetting its more Neither the family doctor my e. diphtheria, as a pattern for the futur pendent surgeon needing no father was, nor the single-handed robust inde ical scientist unconcerned med the nor assistance but his own resource; none of these provide mankind; with the interface between his work and You will have noticed e. futur patterns around which we can structure the ain a romantic vision of a politician. that these romantic ideals do not cont ician so perhaps I can feel None of us has a rdmantic vision of a polit  justified in leaving this one out.  change, and be strong We have to assert, therefore, the necessity of ion making. We decis ative abor enough to welcome it and to plan for. col]. we have to construct but of view, have to welcome strong expresions of points can only do this We many inputs. ways in which decisions are the outcome of making, and ion for what decis successfully if we respect who has authority rs are playing. For example, not attempt to denigrate the roles which othe being trained in our medical school, the. question, how many doctors should be should certainly have input. is a question on which the Minister of Health a whole? How many as How many should be being trained for Canada our medical school? Into this anaesthesiologists should be in training in some input advising us whether latter question national bodies have to have a specialty, which in turn should or not there is a serious shortage within we have in training in a given have influence on the numbers of residents it should be If what I have said has been clear to you, training program. neither the Minister, nor the evident that in those kinds of question ody like the Royal College of medical school, nor the. hospital, nor someb ine. single-handed the answers Physicians of Canada as a whole should determ g must be collaborative, and to questions such as that. The decision makin must be in the hands of those the executive means to implement the policy ion is taken. The problems who are party to, and agree with, whatever decis present time well relating to resident physiciansand surgeons at the Government pays them ront. conf illustrate the. difficulties which we all it should determine feels ely through hospital budgets; and quite legitimat service needs for the Hospitals know how many it is prepared to pay for aware that the quality of residents in all the specialties, and are well ally dependent on the medical work done within the hospitals is critic medical school is held quality of residents who apply to work there. The Surgeons for the quality accountable by the Royal College of Physicians and is working, and the medical of the educational program in which the resident some extent those respon to s school, by paying clinical faculty, determine four bodies, Minister, sible for the educational component. Any of these by unilateral action inter hospital, medical faculty or Royal College, can fere with the whole structure. legislation in the I have observed that the effect of government the legislation is time the at health field is very often not foreseen in in 1948 led to Brita in For example, the National Health Act enacted. This was . itals the separation of practising physicians from hosp government in 1948, and a unforeseen either by the profession or by the o I Journal and the Lancet careful restudy of issues of the British Medic the consequences of the of that period, reveal that neither party foresaw The separation of the practising legislation in this particular field.  -8-  physician from his Community hospita 1 has undoubtedly been one of the major reasons for emigration of physicians from Britain and three of my contemporaries in medical school in London left general practices in Britain for practice in Canada because of t:his feature alone. In the spirit, therefore, that I have been trying to outiine in this talk, I would like to outline some of the objectives of the Faculty of Medicine. Its prime task has to do with structuring the environment for the student which will best enable him to adapt to the future, and to It is all too easy for others, whether continue to educate himself. hospitals or government, to structure Systems which act as real impediments It to learning. The faculty is first and foremost, a resource of people. has, in my opinion, already shown itself to be responsive to the needs of the community, and to be adjusting itself to the future work of the profession. As a Faculty we are responsive to government not just because it has the responsibility of deciding proportionate expenditures, but because collaboration and not arbitrary decision—making offers us all the only possibility of adapting to inevitable change. I have to point out, however, that the administrative structure of our hospitals, and indeed the established and praetising profession as a whole, may be quite insensi tive to the needs of the medical school and the resources required for us to meet better the challenges of the future. when all is said and clone, and admitting that the administrative responsibilities and structures will change over the next twenty years, it has to be conceded that the quality of medical care available to all of us will critically depend on the quality of student attracted into medicine and the quality of the education he is given. In addition, the physician has to have every opportunity to keep up to date; and there has to be every opportunity for flexibility within the system as a whole. There are societies which put far more effort into planning the delivery of health care than they do into the structuring of first class educational opportunities for their students. This is not sensible. Admitting that it is easier to assess the physical state of school buildings than it is to assess the quality of the teaching going on within their walls, we must never confuse one with the other. Ultimately, our success in meeting the needs of the future will depend on the quality of the individuals we are training and on their dedication and expertise. Above all, we must enable the medical school to he looking forward to the future rather than insisting that it protect the past. I would like to end by completing the quotation of a line with which this talk. It is from Tennyson: began I am part of all that I have met Yet all experience is an arch where through Gleams that untravelled world, whose margin fades Forever and forever when I move. How dull It is to pause, to make an end, To rest unburnishcd, not to shine in use. H As though to breathe were life 1 H  DV g lcd  

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