Dr Linda Hawker’s recent blog post: “Changes in family medicine—baby boomers look back” gives an insightful and quasi-tearful overview of 45 years’ worth of changes that have emerged in medicine since she graduated from the University of Alberta Medical School in 1977. Her recently retired family-doctor classmates described feeling “devalued, disengaged, sad, and frustrated” in the last number of years, in startling contrast to how they described their experiences in the earlier years of their practices: “satisfied, enjoyed, fun, rewarding.”
I spent my first 10 years in medicine (1956 to 1966) in general practice. Reading Dr Hawker’s post, I am trying to recall what made me move away from general practice.
I graduated from the University of British Columbia medical school in 1955. After a year of internship, I was offered a junior partnership with one of the pioneer doctors on the North Shore of Vancouver, Dr Clarence McNeill. I was the eighteenth doctor on the North Shore with privileges at North Vancouver General Hospital, a 110-bed establishment with open wards of 10 beds each, built in 1929; the precursor to Lions Gate Hospital. The old hospital served the 10 000 to 12 000 residents of North Vancouver and West Vancouver.
In 1956, five of us were general practitioners with hospital privileges. Three of the specialists were general surgeons, two were obstetricians, four were internal medicine doctors, one was a urologist, one was a radiologist, and one was a pathologist. In that year there was only one certified anesthetist but a couple of the general practitioners, like my senior partner, did anesthesia as well. The chief of staff was the legendary Dr Carson Graham, a general practitioner and one of the first doctors on the North Shore way back since 1924. He also had a strong influence on the hospital’s manager and the governing board. As an administrative principle, patients were admitted under their general practitioner’s name. This made us general practitioners feel like it was our hospital with consultant specialists. This was not the reality, but we felt very loyal to our hospital.
When I started my medical practice in 1956 I had very few patients initially, so the Public Health Unit hired me to do the smallpox vaccination of virtually all eligible school children on the North Shore. I also did most of the weekend, evening, and night calls for my senior partner. As time went by, I became quite busy, and I settled into a pattern. Usually I had five or six adult patients, a couple of kids, and one or two maternity cases in the hospital to look after, most of the patients without a specialist being involved. I usually had at least one house call to make in the morning before getting to the hospital to see my patients there, and then after office hours but before dinner I usually had another one or two calls to make. I was out in the middle of the night two to three times per week, including maternity cases. At night I would carry an electric kettle and a big umbrella in my car; many of the night calls were to visit a small child in a respiratory distress. I set up my equipment, generating steam, gave some medication, and sat with the parents for an hour or so, as the child settled down. The next morning I was probably holding a retractor while the surgeon did an appendectomy on one of my patients. I did most of the assisting at surgery for my own patients. I learned to take out tonsils, and in those days I did that by the score. There was only one operating room, and adjacent to it a makeshift dressing room for surgeons. We used to have coffee there in the morning, sometimes peeping over the door to see who was operating. I learned a great deal at those brief coffee times. It was a bit of continuing education. I heard what bug was infecting the community, what unusual symptoms were presented by patients to my colleagues, and what the last pharmacy rep was trying to push. Our patients stayed in hospital for several days or weeks in those days. Each morning I called the families to report on their family member’s condition.
There was no emergency department in the hospital, but there was a room set aside to receive patients arriving by ambulance. There were no doctors staying in the hospital; the injured person’s doctor was called, so occasionally I had to leave my office and stich up one of my patients. In a way, everything went a bit slow: X-ray technicians, lab persons, and even ECG technicians had to be called in when needed in the evenings. It was a major event for the surgeons to assemble the operating room staff for an urgent operation during the night, with one of us general practitioners staying up with the patient and holding the retractors in the operation, then calling the family to explain how things went.
I usually got to my office for the first appointment at 10 a.m., had a quick lunch at home (there were no dining facilities in the hospital), and then back in the office. I usually left after 5 p.m. to do a couple of house calls. As time went on, I saw about 20 patients in my office on a busy day. Other general practitioners saw 30 or 40 patients, many of whom had walked in. Not having the universal health care system yet, an office visit was $3 to $4, a house call $6, and I seem to remember a night call was $6 to $8, depending on the complexity. Some patients paid cash, others had private insurance with MSA or CU&C, companies insuring mostly members of union groups, like telephone workers, shipyard workers, or teachers. There was also separate billing for social welfare recipients.
We had two office staff members: my senior partner’s nurse also looked after the billing. My nurse was a practical nurse whom I hired away from the hospital. She was with me for over 6 years, she knew our every patient, and the patients loved her. She brought me news of how some of our patients were doing; she often came across them in our small community. There was good communication between general practitioners and specialists; we often stopped the specialist while in the hospital, explaining our need for help and making the referral or the specialist getting hold of us to explain his findings and recommendations. The radiologist usually explained his findings in person too, teaching us a bit about what to look for on an X-ray film. I cannot remember being bothered with much paperwork. Patient histories in the office were on cards, often with abbreviated data and minimal entries.
Our offices looked different from today’s set ups. I had a consulting room with a big desk for myself, a sofa for family members, and an easy chair for the principal patient. Often parents, husbands, or wives sat on the sofa during history taking. Then the patient was shown into a nice, warm examining room. Yearly exams were a fashion in those days, and we did many head-to-toe plus internal exams. We also did some of the simpler lab tests in the office.
The small medical staff at the hospital had a family feeling. We saw each other in the hospital every day and we got along well. The doctors’ wives all knew each other and had their charitable organizations. We had three or four lively smorgasbord dinners during the year. At medical staff meetings, the hospital board’s appointed chief of staff presented the board’s issues and the elected president of the medical staff stood up for the doctors.
My family life revolved around my medical practice. I met my future wife in my last year of medical school while I had a brief elective assignment at North Vancouver General. She was one of the telephone operators in the hospital. It helped me greatly that she understood my preoccupations and my daily and nightly comings and goings. We tried to make sure to have breakfast and dinner together with our children but I missed most if my son’s school soccer games and my daughter’s ballet lessons. There was no TV in those days, and going to a movie was a bit of a pain for me; what if I had an urgent call? We did have a telephone answering service. Sometimes I had three or four calls waiting for me when we got home from some activity.
Things began to change for general practitioners around 1962 when planning for Lions Gate Hospital finished and the new hospital opened. The change was primarily felt in the hospital environment, not in doctors’ private offices. We still did house calls—I still remember one very foggy evening when my wife was walking ahead of my car to find the right address for my visit. But now we had a shiny new emergency department, fully staffed, and many of our patients found their way there by themselves. We had many new doctors and several new departments—cardiology, orthopaedics, psychiatry, more complex surgery, advanced lab facilities. New and complex admission procedures were introduced, along with impersonal administrative staff, quite a few unfamiliar new doctors, and new regulations. Our world changed. I did not feel devalued or disengaged or sad or frustrated, but for me the highly satisfying, very personal hands-on style of general medical practice diminished. I even missed the house calls, which used to bring me closer to my patients and often helped me understand their underlying problems. With the new specialities and technologies I became more of a traffic director than a healer. As president of the medical staff of Lions Gate Hospital in 1965, I learned and saw that with all the great advances in medicine the new hospital had to serve the needs of the various specialties.
In 1966 I received an offer I could not refuse; as a tenured member of the UBC Faculty of Medicine I was given an opportunity to teach and explore previously unexplored medical territories in the context of academia. This I did with great satisfaction for the next 30 years.
—George Szasz, CM, MD
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