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College history - Biographies

Professor Charles Bridges-Webb AO

My general practice career

My father and grandfather were both country general practitioners. in Victoria, but as a child I was not at all interested in following the family tradition.

In 1948 I changed schools. My father had attended Scotch College and wanted his son to do the same. I was quite happy at Ivanhoe Grammar School, doing well at my studies, and despite being rather a loner, fitting in well enough. However I submitted. Because of the distance from home I became a weekly boarder. I did not enjoy the next four years at Scotch College. The school was large and impersonal, and I felt daunted. As a weekly boarder I was neither one thing nor the other. I think my contemporaries felt also that I was "weakly", and probably with some justification; I was sensitive, not athletic, my mother was domineering, and I did not fit in well.

In my last term at school I received a letter from my father in which he informed me that he was going into hospital for an operation for cancer the following week. Dad's operation was long and difficult, but it was felt to be a possible cure, which in fact it turned out to be. Up until then I had no career plans other than that I was not going to be a doctor like my father and grandfather, probably for no other reason than that I felt that it was expected. My wish to become a farmer was discouraged by my mother, since she could see no way for me to have a farm of my own immediately, and anything less was not to be thought of; my mother could not see her son as a farm labourer. Forestry was an outdoor career which was considered more receptively, and so became my refuge when asked the inevitable question, "What do you want to do?" Dad's illness was probably a factor in my decision to turn my thoughts to medicine as a career. If l could not be a farmer, then I would be a country doctor.

I followed my father's footsteps at the University of Melbourne, as I had at school, by going into residence in Ormond College. A wonderful world of learning and fellowship opened up. I was studious by nature and quite liked learning, and I loved my university days. I could not understand those of my colleagues who seemed not to enjoy the present, but were always looking forward to a future time, usually after graduation, at which they seemed to think that life would really begin. I enjoyed the present and had a plan for the future, country general practice, which was unusual in that few of my medical contemporaries had any plan, and when they did, general practice was certainly not part of it. But I was also intent on exploring and living life to the full; and that meant having other interests too.

In 1954 my father had a minor stroke. This led him to resign his position as Honorary Anaesthetist at the Royal Melbourne Hospital, a position which he regarded as a high honour. He was devastated not to be able to continue long enough to teach anaesthetics to his son.

A special event in fourth year influenced my career in a positive way. During a lecture on infectious hepatitis in microbiology Professor Rubbo mentioned a book, Epidemiology in A Country Practice, by an English general practitioner, William Pickles, in which be reported on work he had done in tracing epidemics of infectious diseases through the isolated villages in his part of Yorkshire in the 1930s. I did not get the book reference clearly, so after the lecture I went down and asked for it, intending to get it out of the library. "I'll do better than that", the professor said, "Come to my office and I'll lend you my copy." This I did. After enjoining me to read the book and return it within a fortnight, he added "And don't just leave it in my office. Make an appointment to see me, and tell me what you think of it." It was a challenge, but not an unkind one; he was a friendly and encouraging man, and a wonderful teacher. I was captivated by the book, and more or less there and then decided that as well as being a general practitioner I wanted to do epidemiological research.

At the end of fifth year l went to Broken Hill for a month. The hospital there took senior students each January. We were given free accommodation and expected to assist in the wards, pleased to have the opportunity to be useful as well as gain experience. There was plenty of free time, and I used it not only for socialising but for reading and writing. It was probably because of these activities, and the amount of time I spent in the hospital library, that, foreshadowing the future, I was dubbed "The Professor". Broken Hill was another experience that helped confirm my desire to live in the country.

At the end of 1957 my long hours of study were rewarded. I had a good medical degree and a position as Junior Resident Medical Officer at the Royal Melbourne Hospital. My first patient was a middle-aged man with a heart attack. I painstakingly took his medical history, and then proceeded to examine him; pulse, blood pressure, head, chest, abdomen, all the routine I had been taught. Then I sat him up to listen to the back of his chest. "Breath deeply" I asked, and he did. Then as I listened he suddenly slumped and fell back. I quickly ascertained that he had died. Dead! My first patient! While I was talking to him! Those were the days before cardiac resuscitation. I was devastated.

I remember little of what followed, but the wonderful thing was that the Medical Registrar took care of me. He arrived, assessed the situation, took me to a side room, refused to let me go and tell the man's relatives of the death, but did it himself, came back and talked me through the evening's events. I have since realised that I was exceptionally fortunate to have been backed up by a kind and sensitive doctor.

That was the start of what I found to be a difficult year. The hours were long, the work demanding, and the back-up for newly qualified doctors often minimal. The great camaraderie developed amongst the junior medical staff helped a lot, but even so, I nearly resigned in despair halfway through the year. An empathetic medical superintendent managed to encourage me to continue.

A more important event happened during my final term in the medical ward. The Honorary Medical Officer in charge was Dr John Bolton, a short rotund cheerful man whom I quickly learnt to like and admire. One day during a ward round I asked if patients who had had a long history of anginal heart pain did better after suffering a heart attack (myocardial infarct) than those who did not have such a history, reasoning that those with angina might have had a better chance of collateral circulation opening up and preventing some of the damage resulting from the blocked artery. Dr Bolton professed not to know the answer, but suggested that I could find out by a small research project using the hospital records to study 100 patients. This he helped me to do. Shock in Myocardial Infarction was my first research paper, published in the Royal Melbourne Hospital Clinical Reports early the next year.

The next year I went overseas to see the world, not to do any further training, though I did a few GP locums in Britain to help pay my way. Just before I left I met Anne and we became officially engaged the day after I arrived back. We were definitely planning to live in the country,and I was looking for an opportunity to join a country group practice. It was Dad who found what we wanted, almost before we began to look. He was working with a dental surgeon who mentioned that his son in Traralgon was seeking a fourth partner for their practice. Anne and I went _down there one Sunday to see the place and meet the doctors and their families. We got on well, it was just what we wanted, and apparently they felt the same. The deal was sealed immediately, and we never looked at another practice. With the benefit of hindsight I am surprised that it was so easy; most of my friends and colleagues agonised over their choices.

Anne and I married early in 1960 and moved to Traralgon immediately after our honeymoon. I had found the loves of my life, both personally and professionally.

My life as a general practitioner started as dramatically as had my life as a doctor. On my second day as a country general practitioner, a train hit a school bus on a level crossing in the town. The bus driver and six children were killed;23 children were injured. The hospital set in motion a disaster plan that I had not known existed, and doctors from towns for miles around converged upon it, thankfully a couple of specialist surgeons among them. I was sent up to the children's ward and worked there. The four most seriously injured were unconscious and unidentified at that stage, so we gave them numbers until we learnt of their names. I spent some hours suturing the multiple lacerations and plastering the broken leg of one boy, who with his bruised sister, became my patients.

The boy in the bed beside the door of the children's ward was still unconscious when l came back from dinner to reassess his condition. Darkness had fallen outside and the ward was quiet and dim, but nevertheless humming with activity around spots of light centred on beds. The boy was worse, his breathing obstructed from the swelling worsening around his terrible head and facial injuries, and I knew he needed a tracheostomy to allow him to continue to breath. As one of the other more experienced general practitioners passed by I said to him, "He needs a tracheostomy". "Well, do it," he said. "But I've never done one." "Well there is no one else free, so you'll have to do your first," he said.  Fortunately a new colleague came to my aid, and with wonderfully supportive nursing staff we managed it together. It had to be done in the bed in the ward, since the operating theatres were fully occupied for hours with more important operations. Sadly the child died next day.

General practice did not continue as drama, but I loved the people and the routine. There were occasional highlights. In 1961 I diagnosed two possible cases of polio and sent them down to the Fairfield Infectious Diseases Hospital, among the last cases of this disease to occur in Australia,.four years after the introduction of the Salk vaccine. One thirteen-year-old girl's father was very upset that he had not allowed her to be immunised; fortunately she recovered, with only a slight limp as a reminder. Another dramatic day of practice started at 4.30 am with a Caesarean section, and finished with a patient whom I knew well shooting his wife dead outside the children's home where the couple's child was in care. This tragic event arose out of a sad and difficult situation for which it was hard to see any satisfactory solution, but the home staff accusingly felt that either I or the police should somehow have prevented the violent outcome. Would that we could have done so! Later I had to go to Melbourne to give evidence in the man's trial for murder.

Death featured more kindly for a middle aged man dying of cancer. He knew well what was happening, but supported by a devoted family, and his strong Roman Catholic religious faith, he chose to remain at home. He was very interested in the Apollo space mission s,d decided hat he was not going to die until a man had landed on the moon. This seemed medically very unlikely of achievement, but he enlisted my help against all odds. He attended to everything that was published in the newspapers or broadcast on radio and television about the Apollo moon mission, and discussed it with any who would participate, ignoring the shrinking of his body in the excitement of the challenge. On 21st July 1969 he watched on television as Neil Armstrong took "one small step for a man, one giant leap for mankind"; he was then ready for his own giant leap. He bad achieved his goal. Two days later be died peacefully.

There were successes. In the early 1970s there was considerable controversy about the role of frequent prescribing of barbiturate sedatives in the high rates of suicide. A patient of mine greeted me after my return from one holiday with a written note."As you know", she wrote, "I have been dependent on some drug for over 20 years. When you suggested that I give up all tablets I did not know how I would manage but was determined to try. The first month was the worst. I still have some nights when I lie awake all night, but I do not worry... I will never go back to being dependent in any way on tablets; my mind is more alert, my memory is better and I fed healthier in every way."

I sat the new exam for Fellowship of the RACGP in 1971. I felt that I was an experienced general practitioner and that it would be easy. I was somewhat dismayed to find the exam testing and difficult, and hoped that my results would be alright. To my relief they were, and later Wes Fabb told me to my surprise that I had done particularly well.

I had not forgotten my idea of incorporating research into my professional career. I joined the Australian College of General Practitioners (it was many years later that it became "Royal") within months of beginning practice in 1960, and they helped direct me to educational and research materials. I was particularly stimulated by reading of research as "organised curiosity".a wonderful description by Tev Eimerl, an English general practitioner. Organising my curiosity described exactly what I wanted to do. Eimerl had also written other wise words: "A system that attracts enthusiasts only is probably not as effective finally as one that embraces less study and effort and encourages a larger number to take part" I could identify with that.

I started right from the beginning by keeping records of all the conditions I treated, asking such questions as: What is most common? How is it treated? Keeping the practice index and reading about the general practice surveys based on such methods which had 'been undertaken in England, led me to participate in the initiation of the first National Morbidity Survey in Australia, a joint venture between the Australian College of General Practitioners, the National Health and Medical Research Council, and the Commonwealth Bureau of Census and Statistics. For three months from February 1961 I kept records about 1000 patients on the first version of the special cards produced for the Survey. These were subsequently modified and further tested twice before the final card was approved and the full survey began in 1962. However I did not participate in that, as I was by then very busy in the practice and already committed to other research Projects.

My first research based on the practice index was to find out what were the most common conditions I treated. Far and away the most frequent were acute respiratory infections, as they are almost universally in general practice. I analysed the 1644 episodes I saw between May 1960 and April 1963. I presented these results at the 1963 Annual Convention of the Australian College of General Practitioners in Sydney and they were well received. I was pleased that my presentation was received well and commented upon in some newspaper accounts of the convention.

l was befriended by John Radford, then the Chairman of the College's national Research Committee of Council, with whom I had been corresponding. He took a great interest in the newcomer on the scene, and encouraged me to continue my research activities with the support of the Victorian Research Committee of the College, which l joined as soon as I returned home, and thereafter travelled up regularly from Traralgon to meetings.

Since I was interested in anaesthetics, and giving quite a few, I soon developed a record card for recording details of these in a systematic way and recorded all my anaesthetics on them. It gave me great satisfaction and led to my first publication in a refereed medical journal, when in 1963 the Medical Journal of Australia published an account of 300 consecutive anaesthetics I had given. The article provoked some correspondence in subsequent issues of the journal, mainly around the theme of whether the method of open ether anaesthesia should continue to be taught, or whether it was outmoded, general practitioners taking the former view, specialist anaesthetists the latter.

The Australian College of General Practitioners took up my record card and promoted its use for general practitioner anaesthetics. It also became the basis of a wider survey of general practice anaesthesia that I undertook through the College Research Committee in Victoria over the next two years. This involved 96 general practitioners recording information about 2821 anaesthetics over a three month period. That was a large pile of edge-marked cards to manipulate as I struggled with the analysis and the statistics. The advent of an electronic calculator the size of a small typewriter which could actually multiply and divide as well as add and subtract was a major factor in making it manageable. though it cost the enormous sum of $500!

I presented the results at the 1966 Convention of the College. They confirmed my own experience. I made a number of points in conclusion, including that there is little place for the occasional anaesthetist who gives fewer than 10 anaesthetics per month. That was most controversial among many of my general practitioner colleagues!Anaesthetics proved to be but a passing research interest, overtaken by other questions. When I found I was giving more and more anaesthetics I decided that I preferred my patients conscious, and made a deliberate decision not to go on and become a general practitioner anaesthetist.

A new research direction arose out of a football match, surely an unlikely event to influence medical research. I was watching the Traralgon team play another town in a local derby. l was with a number of friends, most of whom had colds of varying degrees of severity, coughing and spluttering amidst the cheering for our team. I hoped they were not going to infect me. During the following week some of the friends with colds who were also my patients, came in for a consultation. However it was not necessarily those who had seemed most sick who came in; some who were much worse battled on without medical help. It set me wondering, why? What made sick people seek medical attention? It also made me aware that my researches were biased towards those for which the patient sought attention. Were the others different?

Thus was the direction of my future research initiated. But I realised that first I needed to learn more about research in research in general practice. Since I had study leave due to me after five years in the practice, l used it to go to England in 1966 to meet people who were doing the sort of research I now wanted to do. During my four months in England I did four main things to further my professional career: undertook some locum work in general practice; contacted many of those doing research in general practice; sought out those doing research on upper respiratory infections;and learnt more about paediatrics. I visited as many as possible of those people I knew of already, and they recommended many others.

As I became settled in the practice I began hosting medical students from time to time during their fortnight's general practice experience. Then we hosted an intern, under the auspices of the Melbourne Medical Postgraduate Committee. That was the start of my involvement with medical education, well before any education for general practice became formally instituted. I was greatly influenced by Michael Balint's The Doctor, His Patient and the Illness, which described the effects of "the drug 'doctor"' on both patients and the doctor himself, particularly the undesirable and unwanted side effects. His ideas fitted in with my own experience of practice and he acknowledged the great burden of responsibility in medical practice.

Other changes came to our practice. We began an early involvement with computers. The hospital decided accepted resident medical officers for the first time, responsible to us. Our opposition practice built new premises, and we were so busy that we hoped they would attract more patients.

When I returned from my trip to England in 1966 I reflected ruefully that some of the incisive and critical comments about my own research and ideas had been a little deflating, but that the depth of concern shown for a fellow researcher was encouraging. I was ready to go on. This was greatly helped by my being awarded the first RACGP Research Fellowship in 1967, after which I had some paid research time and a research assistant. The next year I became Honorary Secretary to the RACGP Research Committee of Council. That group was a wonderfully stimulating and stable collection of GPs with whom we formed many personal and family friendships over the next 20 years, our annual meetings exciting and much looked forward to opportunities for professional and social interaction.

My own main research project, funded by the RACGP Fellowship, involved 56 families with children, including my own, who were to keep a daily health diary for each family member for a year, and were willing to allow me to access details of all medical attention which they received during that time. I was thus able to learn about all illnesses, particularly respiratory infections, including those for which no medical attention was sought. The families' cooperation throughout the year was outstanding.

In 1968 I met Basil Hetzel, newly arrived in Melbourne as Professor of Social and Preventive Medicine at Monash University. He was most interested in the research I was doing in Traralgon, and extremely supportive. I thrived on the intellectual challenge against the comfortable background of practice in a wonderful professional and community setting where personal relationships were valued above all else. It was Basil Hetzel who suggested that I could write up my studies in Traralgon as a doctoral thesis, a thought that had previously never occurred to me. He also arranged for me to be appointed as an Honorary Research Associate to the university, and encouraged me to apply for a National Health and Medical Research Council grant to undertake further studies.

In 1969 the RACGP Research Committee of Council was preparing for a second national morbidity survey, lead by the energetic Martin Hutchinson of Tasmania, who refused to give up even in the face of great obstacles, the main one being lack of funding. When research funding proved unobtainable, a joint venture between the RACGP and Intercontinental Medical Statistics was arranged. This firm had a market for selling information on prescribing to drug companies, and we were pleased to have the opportunity to include prescribing in the survey and be able to relate it to morbidity, which had not previously been done. It enabled the survey to be done, and continued over six years from 1969 to 1974, though there were always difficulties in reconciling the different priorities of market research and a scientific epidemiological approach.

I got the NH&MRC research grant for 1970 for which I applied. and was again eligible for study leave from the practice. I took it two days per week in order to finish writing up my previous research and start the new project, though often frustrated by the need also to care for patients, particularly midwifery ones, on my research days. I was, however, willing to go to great lengths to maintain the personal continuity of care by which we set much store in the practice. Anne joined in by learning typing at evening classes at the Technical School in order to help me and share in my research.

My new project, the Traralgon Health and Illness Survey (TIDS), was a major undertaking, building on but much more representative of the community and more sophisticated than my previous studies. It preceded and in many ways foreshadowed the later triennial Australian Health Surveys undertaken now by the Australian Bureau of Statistics, for at that time there was relatively little information about community health status. This time a group of 81 families from our own practice were recruited to keep a daily health diary record for a year. During the same year an interview questionnaire survey of a random sample of 371 families in the town was conducted. Information about health problems requiring attention came from general practitioners, from the hospital and from surveys of the problems underlying the work of the ambulance service, infant welfare sisters, district nurses, chemists, home help and meals on wheels, social welfare, Lifeline, marriage guidance, and clergy. The overall community response to the survey was one of enthusiastic acceptance. While the main publications were in an overseas journal,my first in the international arena, there was plenty of comment in Australia.

Partly as a result of my research findings about the status of health in Traralgon, a Traralgon Health and Welfare Group was formed in 1974 comprising members of all health, social and welfare services. This did much to improve liaison and coordination. An application was submitted to the new National Hospitals and Health Services Commission, for money. for a community nursing service. It was granted, and the service was an enormous success. I was finding this application of knowledge gained by my research very interesting, but it took time!

Another government initiative was the introduction in 1973 of funding for the RACGP to establish the Family Medicine Programme, a vocational training program for general practitioners. I became Area Coordinator for the program for West Gippsland on a sessional basis. Our first trainee joined the practice towards the end of 1974.

Anne and I went to a five day national seminar for new RACGP Family Medicine Program educators held at Marysville. It was an interesting meeting, notable as much for the friendliness of all participants, as for the challenging and stimulating discussions. While there, and in the course of discussions not directly related to the seminar, I was introduced to an important book. The Structure of Scientific Revolutions by Thomas Kuhn took my attention both for its main ideas, and for its reference to religion, oblique though this is. Kuhn makes the case that science and its paradigms of scientific authority change by revolution rather than by evolution, and he says that "this most clearly distinguishes it from every other creative pursuit except perhaps theology... The competition between paradigms is not the sort of battle that can be resolved by proofs. The transference of allegiance from paradigm to paradigm is a conversion experience that cannot be forced... A decision of that kind can only be made on faith."

When advertisements appeared for Chairs of General Practice or Community Medicine for a number of medical schools, I found the idea irresistible, though regretting that it would mean a move to a city. I was going to miss the generosity of a country community, the garden, the space and such things as having fresh milk from a friend's cow while she had agistment in our back paddock.        

l applied for Melbourne and Monash, my alma maters, and Hobart and Newcastle because they were small cities. I did not get them, but was approached by Sydney, and ended up with the job there in 1975. A move from country to city, from one state to another where we had no connections, and from private practice to an academic job, seemed full of hazard. We hoped that we were doing the right thing.

I found my University work interesting and exciting. I had the great advantage that I was starting up a new department from scratch. I wanted to advance slowly and build a solid foundation rather than quickly erect an impressive structure. I liked being part of a larger organisation than my own small practice, though it had its frustrations. I wanted the department to have a clinical emphasis. I was able to persuade the university to buy and amalgamate a couple of practices near our headquarters at Western Suburbs Hospital where I was able to continue my clinical work. It was near home so that I could provide continuity of care, which I regarded as very important, to a small number of families.

By the end of 1978 we had enough staff associated with the Department to have a Christmas Party for staff and families at our home. I was doing my best to meld us all into a department family, with roles as people rather than just as professionals.

I started to explore New South Wales outside Sydney, getting to know some of the doctors and other health personnel with a view to arranging for student attachments. I maintained my connection with the RACGP Research Committee of Council, and the good fellowship with colleagues from round Australia which its relatively stable membership promoted. Now we were in Sydney we had the chance to repay some of the wonderful hospitality that was the hallmark of the friendships that had developed over the years.

When I became an academic one of my pleasant anticipations was increased international travel but neither time nor money presented itself in any obvious way during my initial years in Sydney. However. having acquired staff and settled the department into its teaching role, l could plan to attend the 8th World Conference on General Practice in Montreux, Switzerland in May 1978 and the associated meeting of the World Organisation of Family Doctors (WONCA)'s Classification Committee, of which I had been a member for some years. There I met many of the members face-to-face for the first time. From then on I managed to attend most of the meetings of this group, and travelled overseas once or twice most years. Friendships grew out of this just as much as in Australian meetings.

My main research activity during my first year in Sydney was to edit for publication a major report of the general practice morbidity and prescribing survey that had been undertaken by the RACGP Research Committee from 1969 to 1974. Editing was a new venture, which brought me into contact with the editorial staff of the Medical Journal of Australia, whose offices were conveniently just across the road from the University, and in particular with Dr Laurel Thomas, their medical editor. Her knowledge, understanding, helpful cooperation and enthusiasm in planning and implementing the Supplement to the journal which was eventually published in October 1976 gave me a revealing and exciting insight into yet another world.

The survey had been large and comprehensive. During its six years information was obtained about more than one million disease episodes from more than 7000 weeks of recording by over 1200 different general practitioners. The biggest challenge of the report was to get the balance right between oversimplification and loss of information in masses of data.

One of the books I was asked to review in 1978 became the catalyst for an important international contact and adventure. The Healers Art: a New Approach to the Doctor-Patient Relationship by Eric Cassell was an unassuming Pelican book. By the time I had read the first page of the prologue I was alert; here was someone whose ideas were not only congenial, but beautifully expressed, and they stretched my own similar ideas considerably. As I read further I was enthralled. Over the next few years I met and got to know Eric, a New York physician, and his anthropologist wife Joan. I wanted to get him to visit us in Australia. As I was unable to get funds from the university, I persuaded the RACGP to invite him as the first Visiting Professor to the NSW Faculty in 1982. During his six-week stay he participated in seminars and workshops in many parts of the state.

I became a member of the RACGP working party on medical manpower, and we sought evidence not only to justify an appropriate ratio of general practitioners to population, but also to identify the criteria for making such a judgement. In our publication in AFP in 1981 we noted that "since perception of illness is so common and present utilisation arises from only a minor proportion of it, there is obviously very great scope for increased use of medical care ... (Yet) the reduction of the financial barrier with the introduction of Medibank in 1975 did not have a dramatic effect on utilisation of general practitioner services which increased by less than 10%". We concluded that an appropriate ratio of general practitioners to population in metropolitan Australia for the 1980s was in the range of 1 to 900-1300, with lower populations for country general practitioners.

A project to find out what part general practitioners played in managing medical emergencies was undertaken in collaboration with the RACGP Research Committee in 1979, and 230 general practitioners from all parts of Australia recorded all 1940 emergency calls in which they participated for a one month period.

Country general practitioners dealt with more emergencies than their city counterparts, as is still the case, but at that time even in the cities general practitioners were seeing more than six emergencies per month. The commonest presentations were injuries, severe pain, including chest pain, and respiratory difficulties. We were particularly interested in chest pain, the cause of which was acute heart attack in one third of patients, of whom 13% died within a fortnight. That was still a markedly better outcome than I had noted in my hospital survey twenty years earlier.

In 1982 I became a member of the National Health and Medical Research Council as representative of the Royal Australian College of General Practitioners and found this an exciting challenge, attending meetings in most state capitals over the next few years. But I soon found that the routine meetings became a bore.

In the department by 1985 I was beginning to hope that our computer medical record summary, which we were using most effectively in the practice, might just be marketable with a medical accounting system. I was also starting to gather support for a new national general practice morbidity survey. Both were slow processes.

When I began at the university in 1975 I expected that it would take ten years to establish a sound department of general practice. To me the essence of academic life was asking questions. If someone else knew the answer, then education was required. If no one knew the answer then research was needed. Education and research were the opposite sides of the one coin. By 1985 I could take stock and believe that we had achieved much of what we had tried to do. We had a sound undergraduate teaching program. We were a small cohesive department in which friendship flowered alongside professional support. We had some research achievements, without having made a major impact anywhere. That was our next objective, and I expected it to take another five years.

With Neville Anderson and Alan Chancellor I wrote and edited a book, General Practice in Australia, that was published in 1986. This represented a consolidation of practical experience, learning and research about our profession. While it was mainly a compilation of factual material, there was still an element of creativity and challenge in putting it together, and that was important to me.

In 1986 the Commonwealth Health Department established a Bicentenary campaign to increase immunisation and eradicate measles from Australia. We were very pleased to be approached about doing a survey of the extent to which children were being immunised against measles prior to the campaign. The Childhood Immunisation and Infectious Diseases Survey that eventuated soon became known appropriately as CIIDS, pronounced "kids", and was our first major project.

Our teaching load was light in 1989 so we planned to include further emphasis on doctor/patient communication and clinical skills in our teaching in the new course, and to write a textbook of general practice from the teaching materials we used. We made good progress with the first, but the textbook did not get past being produced in house for our students.

I had begun teaching with the RACGP Family Medicine Program by spending half days sitting-in and providing feedback to trainees in their practices, enjoying a different teaching role with postgraduates. Sometimes this meant going to the country, an opportunity I seized with relish. Anne usually came with me. She also started doing a bit of relieving work as receptionist in the practice, enjoying the opportunity to work with me.

The Australian Association for Academic General Practice, which I had christened A3GP, had never been a strong organisation. I was an enthusiastic member. When it met in Melbourne in 1989 l became president, and hoped to make it more active.

Government initiatives begun in 1989 were resulting in major changes for general practice. Vocational registration was implemented, with financial incentives for general practitioners to become registered. This also required an ongoing commitment to continuing education and quality assurance, the newest buzzword. It was a controversial requirement.

Quality assurance activities had been begun earlier by the RACGP in 1987 with the establishment of a committee to develop and promote a program to general practitioners. I became a committee member, and later chairman for three years. We tried to establish a program not to be defensive, but to demonstrate to politicians and the public how good general practice is. We established a cycle and publicised it with the mnemonics of popular beverages: the aim was BEER, best ever end results, and the process ALE, assessment, learning and evaluation.

The views expressed by the authors of these articles are their own and not necessarily those of the publisher or the editorial staff and must not be quoted as such. Every care is taken to reproduce articles accurately, but the publisher accepts no responsibility for errors, omissions or inaccuracies contained therein or for the consequences of any action taken by any person as a result of anything contained in this publication.

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