Vancouver Institute Lectures

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

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4J0.c-)•0H.’HDH,0z>o0•*U,*1)CI)0•.0•0zCH4Jci)C.)Q)—Iwouldlike tobegin bythankingthe VancouverInstitutefor givingmean opportunityto sharesome thoughtswith youconcerningthe presentstatusand problemsrelatingto themedicalprofession.In attemptingtogivesomekind ofperspectiveto a difficultand rapidlychangingscene,Iwillhave todrawratherheavilyon myown experiencesand contactsasa physicianSHowever,we arepart ofall thatwe havemet,and Itake itto bemore orless. nevitablethat eachone of ususes hisown experienceas aguide tocontemporaryproblems.Thetitleof mytalk isthe titleof a remarkablebookpublishedin1938writtenby ArthurHertzler.We can, Ithink, atthis pointof timeidentifythe periodbetweenabout 1860and 1940as a periodin whichtheindividualpractitioner,who wasmore orless self-sufficient,reacheda veryhigh pointof development.ArthurHertzlerdescribesthe lifeof a countrypractitionerin themid-westof the UnitedStatespractisingalone.He wasremarkablyresourcefuland travelledto remotefarm housesunderappallingweatherconditions,and broughtsimpleremediesand homelywisdomto thecottagefireside.His bookopens witha descriptionof fivechildrenof a fatallyof eightdyingof diphtheria.He writes“the reignof terrorduringthe diphtheriaepidemicbringsout atrait commontothe entirehumanrace;when confrontedwith unknownperils,peopleseekaid fromsomesupremebeing.Prayersfor protectionliterallyfilledthe airin thosedays ofdoom.Therewas tic appealto thescienceofmedicinebecausetherewas none.No oneprayedthat thedoctorsmightfinda remedy--noone thoughtof thispossibility.”No oneknew betterthan thecountrydoctorof thisera howlimitedwas histherapeuticcapability.Morphine,digiLiiis,aspirin,rrtd inthe tropcnscuininecomprisedthe activepharmacopeia,and everythingelse heusedhas sincegone bythe wayside.Iwantedto beginwith thisconceptbecauseit wasthe onein whichI grewup. Myfatherwas oneof apartnershipof fourdoctorspractising30 milesfrom Londonin asemi-ruralarea. Hisconsultingroom hadapolishedcabinetcontaininglensesand therewere eyetestingcharts onthe wall.He hada primitiveanaestheticapparatuswitha nitrousoxidetap operatedby thephysician’sfoot;he hada smallsterilizer,butenoughto boilup somesurgicalinstruments.He andhis partnersran adispensarystaffedby a qualifieddispenser,and alltheir prescriptionswere filledthere.Veryearly inmy lifeI knewthe coloursof thedifferentmedicines,and beforeIwent tomedicalschool Iwas awarehowoften mixtureswere prescribedto actas a psychologicalprop forthepatient,ratherthan becausethey hadany veryspecificaction.Myfatherwas thephysicianin chargeof a 40beddedfever hospitalbuiltabout1880 andlocatedin themiddle ofan orchard.This wasfor thecare ofchildrenwith diphtheria,scarletfever,measlesand Germanmeasles.Over theyears thispracticehad developedlinkswith hospitalsand allof thephysicianswithinit hadsome responsibilityin a localhospitalsetting.When Icaine backfrom threeyears asan armydoctorin theFar East,in 1948, Ifound thatthe discussionsrelat:ingto a NationalHealth Service•-2-in Britainwere in full swing. At that timemy father was a localrepresentativeof the British Medical Association, and askinghimself thequestion ofhow to preserve the goodaspects of the well-trained familyphysician in themidst of radical administrative change.He never doubtedthat the patternof practice and of medicaladministration had to changeand in an attemptto look at differentmodels, he kept a keen interestinthe Peckham HealthCentre, which was a protorype communityhealth centre.I rememberhe tookme to visit it when I was inmedical school. His owntraining had not beenthe kind it is now fashionableto prescribe for afami).y physician. Draftedimmediately into World War I,he was one ofthree physicians who graduatedfrom his year. from UniversityCollegeHospital out of agraduating class of about 60,who survived the war. Hewas injured in France and,fter having been invalided athome, he spentthree years working with Sir ThomasLewis, then doing advancedcardiological research. After a briefperiod of training in surgery,he went intogeneral practice. His workwith Sir Thomas Lewis gave hima depth interestin cardiology which hemaintained for the rest of his life.He believedthat no family physician orgeneral practitioner could surviveintellectually unless he had, during histraining, acquired a really strongbasisin one or other aspectsof internal medicine, obstetrics,or paediatrics.•. I have dealt,at some length, with thispattern of practice becauseit seems to me thatmany of the problems itraises are those we are stillconsidering. In the presenttangle of health services,we can identifyfive different components,and one of these obviously isthe individualphysician and the professionalbodies which represent him. Asecond, isthe hospital, which mayeither be a large city hospitalor a sma2ler community hospital. The thirdis government; the fourthis he medical schoolwithin the university;and the fifth are theso-called paramedicalprofessions, namely nursing,physiotherapy, dentistry,and many others. Allof the individuals whowork in these different environmentsin differentways constitute the health professions--andI do not need toremind you thatthis is fast becoming oneof our major industries. Ibelieve that in two or• three years it is predicted thatthe health services as awhole will be thesecond largest industry” inthe United States.In discussing theinter-relationships betweenthese five components,I have to remind youthat there are some basicpropositions from which weall have to start. Weare in a society based upon an idealof freedom ofchoice. There are some whospeak as if one segment or anotherof societyinvolved in the health professionsshould be treated as if they weretroops. They argue thatdoctors should be compelled to practiceindifferent areas, overlookingthe fact that such compulsion is notcompatible with our present pattern ofsociety and its objectives. Occasionallythey speak as if one couldcompel a medical student to choosecertainprofessional careers forthemselves after they havegraduated. Admittingthat we may do something tosteer students and doctors intocertainchannels by making them especiallyattractive, neverthelesswe have toremember that we do not acceptan idea of a society run onsuch rigid andautocratic lines. The secondfeature we can identify is the obvious needfor planning in the presentworld to ensure high standardsof quality andeconomy of operation. Duringthe last ten years, 27 hospitalsaround-3-Bostonhave closed outtheir obstetricsservices. This is partly tobee>:plained bythe reduction oC work,but it was achieved withoutagovernmentdirective by collaborativeplanning amongst all theinstitutionsserving a largemetropolitan area. That kindof planning isclearlynecessary in the future. Thirdly,we must recognize that thereis a processof redefinition andevolution of roles withinthe healthscience professions.It was mypredecessor, Dr. Jack McCreary,whoplayed a leading part inCanada in arguingthat since after graduationwe requiredhealth professionals towork together, it wouldbe sensibleif we hadthis goai. In mind duringtheir education. As girlswith ahigher levelof intelligence and a muchbetter academic backgroundareattracted into nursing,the responsibilitiesand roles which can beaccepted by nurses willchange and expand. The familyphysician practising in the urban centrehardly needs to be familiarwith many of theacute medical and surgicalproblems that confrontedthe individualphysician in a rural areathirty years ago, and itwouldn’t make muchsense to train him as Ifhe was going to haveto operate on the kitchentable. We shouldn’t trainhim as a ‘Horse andBuggy Doctor’ until hehas chosen that rolefor himself. Fourthly,we can recognize that ourpresent society places agreat deal of stress on the criteriaof service•to people as the yardstickof success. Slowly,the objective ofpreservation of the environmentis taking precedenceover immediate gain, andslowly the concept of serviceto people is in mostof our minds becomingmore important than preservationof hospital autonomy;or defence of arigid bureaucracy; ora specialized pleaof academic self-interest.Fifthly, we can identifythe general point thatthe ucational process,whether it be of physiciansor nurses, mustbe adapted to what we believeto be the needs ofthe future physician and musttake as a prime tasktheprnviinn of continuing educationfor them and for all other healthprofessionals.With these generalconsiderations in mind let melook at each of thecomponents which 1have sketched, andtry and understand the problemstheyconfront and the effortsthey are making to adapt tothe future. Theprimary physician is certainlywaking a valiant effortto redefine hisrole in relation to otherhealth professionals,and to insist that heshould be the primaryreference point for mostmembers of the public. Heis confronted by the realitythat one man, alone andunaided, no longercontains the potentialfor maximal assistanceto any but a small groupofpatients. In my father’sday, a good physicianwho understood the correct useof digitalis and morphine,and possibly oxygen, coulddo as much for apatient who had hada coronary thrombosis,as could anyone else. Modernmedicine has made thisconcept outdated, justas It has swept away diphtheria and polio. Althoughthe needs of continuingeducation for suchphysicians are agreed by everyone,we have made little progress inunderstanding how to organizethis, since we do not know how totake physiciansOut of their practice, letus say for one year in everyten, and provideproper economic recompensefor them. We recognize that the problemsofphysicians in rural areas havea good deal to do with thedifficulty ofpersuading doctors with childrenthat their own dedication to thecommunity should take precedenceover their children’s need for highquality education. The primaryphysicians, and those who representthem,believe that medical schoolshave been training toomany specialists and-4-neglectingthe training ofprimary physicians; but theyoften forgetthat in afree society we allowpeople to choose what directiontheytake. Certainlythe medical schoolmust provide opportunityfor studentsto be part ofa family practice environmentduring their training,andour faculty at U.B.C.provides these opportunitiesin greatermeasurethan mostother faculties inCanada. However,we have to recognizetheproblem thatexposure of students toa deprived environment tooearly intheir liiieprovo.discouragingto them, since they willconclude thatthey can do littleto ameliorate thesocial problems whichthey confront.The large city hospitalhas problems all its own.. Ithas. been undertremendous pressure duringthe past few years for anumber of differentreasons, amongst whichare he fo.llowing.The public, perhapseducatedby Dr. Kildare andhis spectacularsuccesses in the emergencyroom area,have used the hospitalemergency departmentas a super sort offamilyphysician’s office,thereby putting tremendous strainon these facilities.Furthermore, medicinehas changed over thepast fifteen or twentyyearsand new techniquesare needed in the hospitalsetting. Suddenlythehospital has. had to findspace for such thingsas nuclear medicine,expauded laboratories,cardiac catheterizationrooms, pulmonaryfunctionlaboratories, etc.and has difficulty adaptingnineteen thirty space tonineteen seventyneeds. As if all thiswere not enough, the hospitalshave undergone a shiftfrom being nineteenth centurycharitable institu—tions, to beingmajor spenders of publicmoney. Shortlyafter the NationalHealth Service Actcame into power in Britain,my hospital in. Londonwasinvolved in a legal suit.Giving judgernent, LordJustic Denning remarkedthat the hospitals mustrealize that itwas no longer enough for themtogive a basic standard ofcare on the basis of charity.The tact that theyhad become major componentsin government administeredschemes, meantthatthe public was entitledto expect the highestpossible standard of contemporary professional care fromthem. Yet the hospitals •havebeen handicappedby inapposite financialstructures often based onyardsticks for financingmuch too crude for their newand changing roles.All too oftenthe politician has tended to lookupon them as if theywere the poor law institutionsthey are striving hardto adapt from. Imight also note in passingthatan additional problem hasbeen the compositionof the Boards of Trusteesestablished usually manyyears ago. The distinguishedlocal citizens whomake up these boards are generallyexpert in handling investmentsandlooking at balance sheets. Theyare far less well trained by theirbackground to judge whether the interfacebetween the hospital andthe publicis satisfactory, and theyare generally in no positionto judge whetherthe quality of the operationfor which they are responsible,reachesacceptable high standards. Asif all this were not enough,the increasingdemands of medical schoolsdependent on such hospitalsfor their educationalrole in clinical disciplineshas bean a complicatingfactor. Very oftenthe arrangements between theuniversity and the hospital havebeen poorlydefined. The responsibilitynow placed on medicalschools for the qualityof the education of graduatephysicians to which I willrefer later hasadded further stresses to thesystem.-Government has made an effortto meet the rising public expectationsrelating to health services.They inherited, however,several difficulties,—5--amongst which Iwould place in first positionthe problem of dealing witha civilservice which is unusedto public or community input into decisionmaking.One has a generalspectacle of the politician agreeingthatpublic participationin decisionmaking is necessary, and the civil servantstriving veryhard to prevent it being effective.Furthermore, the wholesystem has grownat such a rate that they have had tostructure largeorganizations involvingcomputer programes, etc. tohandle what has becomea majorcomponent of public spending.The medical school,which is responsible in the finalanalysis forthe quality ofphysicians and their graduate training,has also beenunder severestress. It has had to structureways for medical studentsto be educatedwithin the communityand by physicians miles away fromuniversity centres. Ithas •had to fight to preserve hard-won scientificand research excellenceon which all future progressdepends. Withoutthese advances continuing,we would be condemned to pratising the kindof medicine ourfathers practised. And, furthermore, itis the physicians w’no know where the frontiersof knowledge are, who are in thebestposition to introduce into hospitalsettings new techniques and newmethods of treatment. If youwere to visit the twenty or thirtylargestcommunity hospitals in Canada,and inquire when they introduced anewtechnique of value in the managementof patients, and. which physicianwasresponsible for introducing it intothe hospital, you would quicklydiscover that it wasthose physicians engaged in active medicalresearchwho brought these methods intothe hospital setting. Unlessyou areaware of what is going on in thegreater world of medicine, you are veryslow to adapt to change. Thesestresses and strains have been compoundedby serious questioningwithin the university communityas to whether theFaculty of Medicineshould exist at all, There aresome universityprofessors who regard the professional schoolsas somehow ancillary to themain purposes of a university, andthey spend much time urging thattheinvolvement of the university withthe community through these schoolsisabsorbing much too much of theuniversitys potential.The fifth component is t.he paramedicalorganizations and here therehave been major changes inthe midst of considerable difficulties.AsCharles Dickens recognized,elderly nurses are not the mostradical membersof society. Schools of nursingwith younger faculty keen tochange therole of the nurse and give her amuch sounder educational basis,have oftenbeen denied educational facilitiesin institutions whose nursingstaff isunsympathetic to such a radicalchange. I came across this when organizingthe medical intensive care unitat the Royal Victoria Hospital in Montreal14 years ago. As soonas we began to train nurses in managing respiratorsand tracheotomies and intreating patients who suffered a cardiacarrest,we found that the main oppositioncame from the well-entrenched seniornurses, who perhaps were jealousof so much responsibility and educationbeing given to their juniors.Yet as we review all these organizationsit should be apparent toall of us that the last ten yearshave seen major advances. In particular,the interface between the medical schooland the community has been traris-formed. I have only been in Vancouver forthree months, yet this is timeenough to see the interface betweenthe faculty and the community in some—6—det:ail. Notonly the programssuch as REACII, whichbring pacdiatriciansand studentsinto contact withan urban community of chiidren, but alsothe facultyinvolvementand leadership inestablishing programsfor thetreatment ofpatients with renalfailure both in the hospitalenvironmentand in theirhomes; thepioneer workrelating to the establishmentoffamily practiceunits and communitycare centres; and theresponsibilityaccepted bythe Departmentof Psychiatry underits new Chairman tointegrate and improveand encourage developmentof psychiatric workat everylevel withinthe community.These arebut three of many other examplesI mighthave chosen andthey illustrateadvances made in onesector.You will rememberthat it was C. P. Snowwho, in a famousessay,spoke of “two cultures”.He was portrayingthe growing divisionof outlook which existedbetween a scientificrand technologicallytrained personon the one handand someoneworking in the field ofthe humanities, on theother. Hisidea took fire,greatly to his surprise,because it correspondedto a public anxietyabout the discordantobjectives of thesetwo individuals.Medicine representsone of the maininterfaces between thesetwo culturesand indeed it wouldnot be too muchto describe it, in asense, as a thirdculture. One has onlyto look at theprogram of renal dialysis,for example,to see the intermeshingof modern technologicaladvance and machinery, withan understandingof the patient’sneeds and anxieties.I was encouragedlastweek to hear ProfessorDion of Laval University,who must be one of Canada’sgreatest politicalscientists,remark that it was in facultiesof medicinethat the universitywas doing its mostdistinguished work inrelation tothe community;and he saidthat, in his view,in Canada as a wholethefaculties of medicinehad made far greatercontributions inthis directionat this point oftime than had departmentsof sociology. Needlessto sayhis speech waswarmly applaudedby the representatives ofthe CanadianMedical Collegeswho were listeningto him.I wantto turn then fromthese immediate issues tosome more generalconsiderations.Eric Hoffer inhis book “Ordealof Change” has pointedout what Dostoievskystressed a hundredyears before. He writes“It is my impressionthat no one really likesthe new.We are afraidof it. We cannever be really prepa:edfor that whichis wholly new.We have to adjustourselves, and everyradical adjustment isa crisis inself-esteem. Thesimple factthat we can never befitand ready forthat which is whollynew has somepeculiar results. Itmeans that a populationundergoingdrastic changeis a populationof misfits, and misfitslive and breathein an atmosphereof passion. Thereis a close connectionbetween lack ofconfidence andthe passionatestate of mindPerhaps thisexplains the heatgenerated by discussionsrelating to thedispensation ofresources in thehealth fie.ldor its internal organization.All of the componentsat the present pointof time may be sufferingfrom alack of confidence.There is,however, no goingbackwards. In T .S . Eliot’swords ‘the railsslide togetherbehind you” andwe can recognize thatfewsolutions are tobe found by attemptingto return to aprevious era. Inrparticular,we must beverycautiousthat we donot dependon a romanticidealof the past,forgettingits moredesperate elementssuch asdiphtheria,as a patternfor thefuture. Neitherthe familydoctor myfather was,nor thesingle-handedrobust independentsurgeon needingnoassistancebut hisown resource;nor themedical scientistunconcernedwiththe interfacebetween hiswork andmankind;none of theseprovidepatternsaround whichwe canstructurethe future.You willhave noticedthat theseromanticideals donot containa romantic visionof a politician.Noneof us hasa rdmanticvision ofa politicianso perhaps Ican feeljustified inleaving thisone out.We have toassert,therefore,the necessityof change,and be strongenoughto welcomeit and toplan for.col].aborativedecisionmaking.Wehave towelcome strongexpresionsof pointsof view,but we haveto constructways inwhich decisionsare the outcomeof manyinputs.We can onlydo thissuccessfullyif we respectwho hasauthorityfor whatdecisionmaking, andnot attemptto denigratethe roleswhich othersare playing.For example,the. question,how many doctorsshould bebeing trainedin ourmedical school,is a questionon whichthe Ministerof Health shouldcertainlyhave input.How manyshould bebeingtrainedfor Canadaas a whole?How manyanaesthesiologistsshould bein trainingin our medicalschool?Into thislatter questionnationalbodies haveto have someinput advisingus whetheror not thereis a seriousshortagewithina specialty,which inturn shouldhave influenceon thenumbers ofresidentswe have intraining ina giventrainingprogram.If what Ihave saidhas been clearto you, itshould beevidentthat in thosekinds ofquestionneither theMinister,nor themedicalschool, northe. hospital,nor somebodylike theRoyal CollegeofPhysiciansof Canadaas a wholeshould determine.single-handedthe answersto questionssuch as that.The decisionmaking mustbe collaborative,andthe executivemeans toimplementthe policymust be inthe handsof thosewho are partyto, and agreewith,whatever decisionis taken.The problemsrelating toresidentphysiciansandsurgeons at thepresent timewellillustrate the.difficultieswhich weall confront.Governmentpays themthrough hospitalbudgets;and quitelegitimatelyfeels itshould determinehow many itis preparedto pay forHospitalsknow the serviceneeds forresidentsin all thespecialties,and are wellaware thatthe qualityofmedical workdone withinthe hospitalsis criticallydependenton thequality ofresidentswho apply towork there.The medicalschoolis heldaccountableby the RoyalCollegeof Physiciansand Surgeonsfor thequalityof the educationalprogram inwhich theresident isworking,and the medicalschool,by paying clinicalfaculty, determinesto some extentthose responsible forthe educationalcomponent.Any ofthese four bodies,Minister,hospital,medical facultyor RoyalCollege,can by unilateralaction interfere with thewhole structure.I haveobservedthat theeffect ofgovernmentlegislationin thehealth fieldis very oftennot foreseenat the timethe legislationisenacted. Forexample,the NationalHealth Actin Britainin 1948 ledtothe separationof practisingphysiciansfrom hospitals.This wasunforeseeneither bythe professionor by the governmentin 1948,and acareful restudyof issuesof the BritishMedico IJournal andthe Lancetof thatperiod, revealthat neitherparty foresawthe consequencesof thelegislationin this particularfield. Theseparationof the practising-8-physician fromhis Community hospita 1has undoubtedly been one of themajor reasons for emigrationof physicians from Britain and threeofmy contemporariesin medical school inLondon left general practicesin Britain forpractice in Canada becauseof t:his feature alone.In the spirit,therefore, that I havebeen trying to outiine inthis talk, Iwould like to outline someof the objectives of the Facultyof Medicine. Itsprime task has to dowith structuring the environmentfor the studentwhich will best enable himto adapt to the future, and tocontinue to educatehimself. It is all tooeasy for others, whetherhospitals or government,to structure Systems whichact as real impedimentsto learning. The facultyis first and foremost, a resourceof people. Ithas, in my opinion,already shown itself to beresponsive to the needs ofthe community, and to beadjusting itself to the future work oftheprofession. As a Facultywe are responsive to governmentnot just becauseit has the responsibilityof deciding proportionateexpenditures, butbecause collaboration andnot arbitrary decision—makingoffers us all theonly possibility ofadapting to inevitablechange. I have to point out,however, that the administrativestructure of our hospitals,and indeedthe established and praetisingprofession as a whole, maybe quite insensitive to the needs ofthe medical schooland the resources requiredfor usto meet better the challengesof the future. when allis said and clone,and admitting that the administrativeresponsibilities and structureswillchange over the nexttwenty years, it has tobe conceded that the qualityof medical care availableto all of us will criticallydepend on the qualityof student attracted into medicineand the quality of the educationhe isgiven. In addition,the physician hasto have every opportunityto keepup to date; and there has to beevery opportunity for flexibilitywithinthe system as a whole. Thereare societies which putfar more effort intoplanning the deliveryof health care thanthey do into the structuringoffirst class educationalopportunities for theirstudents. This is notsensible. Admittingthat it is easier toassess the physical state ofschool buildings thanit is to assess thequality of the teaching goingon within their walls,we must never confuse one withthe other. Ultimately,our success in meeting theneeds of the future willdepend on the qualityof the individualswe are training and ontheir dedication and expertise.Above all, we must enablethe medical school to he lookingforward to thefuture rather than insistingthat it protect thepast.I wouldlike to end by completingthe quotation of a line withwhichI began thistalk. It is from Tennyson:H1am part of all that Ihave metYet all experience isan arch where throughGleams that untravelledworld, whose marginfadesForever and foreverwhen I move.How dullIt is to pause, to make anend,To rest unburnishcd,not to shine in use.As though to breathewere lifeHDVglcd


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