Why and how I became a General Practitioner
Thanks to my parent's sacrifices I was privileged to attend as a boarder one of England's oldest public schools - Ely.
It was founded by St. Etheldreda in 670 A.D. on a high hill just north of Cambridge overlooking miles of flat fenland country.
St. Etheldreda's name became shortened to St Audrey; hence the word 'tawdry' from the cheap bric a brac which was sold at the local fair. And it was probably a tawdry assortment of boys who entered school in my year of 1934, to emerge into Adolf Hitler's war in 1940 as well disciplined bright young atheletes - ideal for 'officer-like qualities', fodder for the blitzkreig at the time when our enemy, better equipped, was winning.
Perhaps one of the saddest moments of my life was, after the war, the unveiling of the memorial at school. It read, thank Goodness with some exceptions, like my class register; together with a smattering of the names of some of the masters who had taught us. Yes, they were called masters, not teachers, in those days; and discipline was strict but fair to all.
Struck by the beauty of the Cathedral and the sanctity of its surroundings my earliest adolescent ambition was for the priesthood. But later in the fifth and sixth forms this was replaced. Under the influence of my uncle and with much talk of impending war, my mind was "irrevocably" changed: to become a regular naval officer. A visit to Dartmouth sealed the issue, and perhaps that was just as well. My distinctions were in mathematics, physics, and chemistry; to my detrimental attainment of only weak pass in Latin and the humanities - hardly satisfactory embryonic material for a priest.
Then war struck and there was the youthful excitement of "Hanging up the washing on the Siegfried Line", and "What a surprise for Il Duce" and all that. It seemed that our enemy was providing me an ideal opportunity of a naval career; but not so the British Government. Hoare Belisha (of Belisha Beacon fame) was now Minister for War, and the policy was: "no commissions except through the ranks". The Navy therefore offered me a second best opportunity to train as a Fleet Air Arm pilot and short service (hostilities only) R.N.V.R. commission. Disappointed, I accepted this, setting the scene, assuming survival, for the opportunity at war's end to leave the Navy for "something really worthwhile".
The Navy taught me leadership, concluding at 23 years of age in command of a squadron of 14 assorted aircraft - a kind of general practice - with ten officers, sixty naval ratings and fifty Wrens (W.R.N.S.), bless them. Quite a family, with all its little day to day problems. It also taught me survival and rapid decision making.
A deck landing on an escort carrier (commonly termed "Woolworths") in an Atlantic gale with a delicate aircraft like the Seafire (Sea Spitfire) is a daunting business. The wingspan was 32 feet, the flight deck 50 feet wide. On one occasion I ended in the Atlantic, rather than on the carrier, and that led to my first real acquaitance with the medical profession, at the receiving end in hospital.
There were other occasions too: an appendicectomy, and nasal surgery to "fix" my sinuses. On the last of these times I met her. She was a naval nurse called Betty and eight months later we were married. London was in the grip of Vl "buzz bombs" and V2 rockets at the time; and her Father was a general practitioner in the western suburbs.
It was a delight to accompany him on rounds, and his patients enjoyed being introduced to a young man with such a nice uniform and pilot's wings.
Almost abruptly the war ended, and we suddenly found ourselves with the stark reality that civil life had no need for any crash hot people whose only qualification was flying and looking after the Wrens. And with my nursing wife and medical father in law, the decision was none too difficult. But as a mature age student with family responsibilities with the arrival of an infant boy, the prospect of descending from the lofty responsibilities of officer rank to the lowest form of life -a first year medical student - required considerable adjustment.
Ours was an interesting year at Bristol. With so many university places being saved for ex-service people, the other twenty five percent seemed very young, but were ever so bright.
Unlike the usual blast cell type of medical student we deliberately trained ourselves as undergraduates for general practice. On graduation I was thirty years of age, and with a family; and just no time, in spite of distinctions in finals, to hang around hospitals on the pittance which residents were paid in those days: 4 pounds per week with 3:5:0 deducted for ones' keep left only fifteen shillings for the family! General practice it had to be. So during our undergraduate years we learned the important things, and sought keenly as much practical experience as possible. In sixth year we even dressed to look like doctors and I still possess the leather bag in which I carried my own instruments. Very impressive in finals!
But again the British Government got in our way. The National Health Service was in full swing, and it meant that our generation could get a job as a poorly paid sweated assistant, but you got sacked if you dared to mention a partnership to your employer. So as effectively as the last century's transportation of criminals populated Australia, the British Health Service sent us in droves to this country. I was one of the first of my year to arrive, raw and green; and of the 26 people who graduated with me, I have seen sixteen in Melbourne. And a number of these are suburban GPs like myself.
Circumstances just threw us in at the deep end of general practice. Before leaving England I did a locum, shocked to find sixty patients in the morning surgery, a string of calls for trivia, and another sixty in the afternoon. But it was simpler. Most of the patients needed to come for some technical reason like a prescription or certificate and the British Health system positively encouraged referral to hospital of anyone with significant problems.
After those stresses, it was a rest cure for me to work my way here as a ship's surgeon on one of Vesty's Blue Star vessels. Had it been 1987 when contracts are less viable, I would have stayed in Perth with its relaxed beauty, rather than fulfilling my obligation to come to Melbourne. And the deal in Melbourne fell through anyway. But they wanted someone for two weeks in Brunswick, and I took the job and they invited me to stay. That was thirty five years ago. On 30th November 1987 I "retire" and for reasons later apparent, we return to Perth to live.
So, in the days before FMP and Chairs of Community Medicine, what did one do about learning general practice and continuing medical education. And especially when you find yourself in a strange country where they don't quite speak the same language!
There are many different pathways one could take. Some did not bother. Others became too busy where doctors were in short supply, to do other than learn by experience. Of course one must concede that experience is the most important component of CME; but it should never be the only factor.
Caring, honesty, and an attitude of service, when added to experience have multiplying effects towards good practice. The opposite is also true. Those who do not care, or are obsessed with reward have little chance of achieving quality of care.
Assuming experience and correct attitude, my own recipe for continuing education is now described, together with some other details of my history which have influenced this process.
Membership of a good, well motivated group is almost an essential element of continuing education when one is lacking experience. My thanks are due to my senior partners, the late Ken Ratten, and my good friend Keith Smyth for providing so many "corridor consultations" and so much helpful advice and resource on clinical problems. And don't the patients appreciate it, when extra interest is shown in their problem. A group should be organised to allow for conference time in a relaxed atmosphere when issues may be discussed in depth.
By a natural process, not in a similar manner to Alec Guiness in his film, "Kind Hearts and Coronets", I became senior partner twelve years ago. It has been my privilege to try to accord to the other five, who will soon be without me, the same kind of patient management guidance which I received. And it will be with much sorrow that I depart from this happy association.
The formula of equality and democracy in a partnership is not always easy to achieve. It depends on the personalities involved; and on a willingness by all to put in just a little more than they take out. This applies also to practice staff, and gentleness and quietness will enable the patients to feel relaxed and welcome in a family setting. In the same way as a placid well adjusted mother will generally have a happy child; patients will react favourably to absence of stress and harmony within a group. This harmonious and caring situation will naturally lead to continuation and updating of professional education.
The fostering of correct relationships with consultants and patients. To use every referral as an exercise in CME is easy and of great benefit to both the GP and his patient. To present the case, as it were, as a repeat of case reports in medical finals; and to read the consultants report with critical objectivity, is valuable. Occasionally we should take the trouble and have courage to phone the consultant if there is anything in the report which is not understood or with which one disagrees. It keeps them on their toes too! I nearly always involve patients in this process of summarising, by reading to them the report, and inviting discussion. It is their life, they have a right to know.
It is my habit never to read an x-ray report without looking at the films first. This is generally done in the patient's presence and a useful opportunity can be taken to demonstrate to the patient both the normal anatomy and their problem. It is surprising that one often finds something not in the report. It must be awfully trying for radiologists to pore over thousands of films without knowing where the patient feels the pain. They are bound to make the occasional omission.
The care with which one answers the patient's questions is also a useful exercise in CME, and good practice management. I arrived in Australia as a dedicated explaining doctor to a scene when it seemed that no one told anyone anything! Even the pill bottle was labelled "The Tablets" and the patients had no way of knowing whether they were taking my digoxin and that prescribed at the Royal Melbourne Hospital concurrently. Thank Goodness this has changed and that patients are accustomed to questioning. But sometimes they get too worried about the answers.
Ones own library gets too easily out of date; and the publishers say that GPs don't buy books. Perhaps they go to the medical library; and we are very lucky to have so many good free journals in Australia. The pharmaceutical industry deserves some credit, so long as we maintain a critical and watchful attitude to the material which is presented. Fortunately the computer age is now bringing to isolated doctors efficiency in educational resources.
The honorary system
In the days before Medibank (Mark 1) everyone bulk billed their pensioners for services limited to home visits or surgery consultations. There was no recourse for pensioners to special investigation except through the public hospital. For reasons of further education and to provide that service direct to my patients I joined medical outpatients at the Royal Melbourne Hospital. Teaching combined with patient investigation was advantageous to the patient, the hospital (for they got our services at no cost) and ourselves. It meant sacrifice of otherwise free time or of earning capacity. It meant, too, together with the very long hours of practice work, effectively there was a "widow" at home caring for one's children. Ten or eleven p.m., after the children are asleep, is too late to arrive home, when this becomes a daily habit. Conscientious GPs of my earlier days made inadequate fathers.
It was also interesting to note that some patients preferred a continuing attendance at hospital out-patients where you were a specialist and wore a white coat; rather than seeing the ordinary "run of the mill" GP that you were at the surgery!
In the late sixties Betty became ill and ultimately died from bronchogenic carcinoma. I left the Royal Melbourne Hospital to provide greater care for my boys; and, until I met Iris I became miserably lonely.
Iris and I found that we had exactly parallel histories. She had joined the Wrens soon after I joined the navy. She was married to a naval officer when I married a naval nurse. On post-war demobilisation both husbands had undertaken medical training in U.K. Both families had migrated to Australia. She to Perth; and both of us were left alone. It didn't take very long to marry her! But we were left with our conjoint left ventricles in Perth, whilst physically residing and working in Melbourne.
It was amazing to hear of the change which my patients observed in me. I hadn't noticed any difference in my standard of care but they had. "How wonderful I looked", was the usual remark, and this points up the lesson to all that a happy and supportive home life is an essential ingredient to the good doctor. We must study our family relationships, and ensure that there is a budget of time between one's work, one's academic activity and one's home. Thank Goodness times have changed for today's young professionals. But then they have a different set of pressures and problems.
Lastly the College
Two things happened to me on the same day early in 1972. Iris was involved with the Organising Committee for the Fifth World Conference (WONCA) in Melbourne; and she asked me to organise private dinner parties. I did, and I wrote a report and Monty was delighted, and one thing led to another, and there seemed to be a hundred and one different things to organise, and I did, and I found myself appointed as Honorary Secretary to the conference.
Like so many others in the Faculty we worked our proverbial butts off for months; because we couldn't afford to engage professional organisers. And it was fun anyway. But every time I see Monty Kent Hughes' portrait staring directly at me in Trawalla I remember taking him home at 4:00 a.m. because he was just too tired to drive, and then doubling back to snatch a couple of hours sleep before getting to the Masonic Centre to start things going at around 7:30. Thank Goodness our conjoint family was old enough to care for itself and that Iris and I could get on with the Conference, and all its overseas visitors.
The other thing which happened is that I answered a call for "New Blood" for the Victoria Faculty Practice Management Committee. I turned up to the building in Albert Street to find empty darkness; and I was just about to leave when Wes Fabb arrived having forgotten his keys. Together we burgled the place, and I found that the two of us constituted the meeting! A more satisfactory quorum exists today. I found too, that Wes was on his way to do other very important things which have revolutionised the quality of training for General Practice. So I found myself Chairman of a one-man band in Victoria, but ipso facto membership of a group: The Practice Management Committee of Council of the College.
It is really amazing what happens in Australia when you get together for a week-end with like minded people from every other State. The dynamic energy created by such a combination is difficult to believe. The worst thing that the College should do if it is short of funds is to restrict the meetings of its productive Committees of Council. Much may be done by efficient correspondence through an active chairperson. But as the Health Insurance Commission in its wisdom disallows benefits for any medical service which does not involve face to face contact between doctor and patient; the eyeball to eyeball meeting with one's trusted inter-state colleagues is vital to the success of the College.
So from 1972, I have devoted a portion of my time to design, to writing, to teaching, and creation with my colleagues of systems of care. In this privileged role one learns much, and it is a delight to puzzle out systems of practice management including preventive programmes, flexible enough to be used in the vast majority of situations.
The College is to be thanked for allowing me this privilege; and my partners deserve my gratitude for being available to try things at a draft stage. Particularly I would like to mention Selwyn Carson of Christchurch, New Zealand for the years we have spent together with others in work on the Manual for General Practice which has now been copied and used throughout many parts of the World. And we must not forget the many other colleagues from overseas. The opportunity to share experience at international conferences is an important component in CME and one can always learn a better way to do things at visits to other practices. How often do we visit the people from across the road or invite them over for a cup of coffee?
Lastly Iris is to be thanked for all her work for the College; and for helping with all my work; having been instrumental in starting much of it.
Edward C. Gawthorn - October 1987
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.