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Recollections and Reflections on the Medical Life, Student and Doctor, 1954 to 2000

2002; Lippincott Williams & Wilkins; Volume: 34; Linguagem: Inglês

10.1097/00005176-200205001-00017

1536-4801

J A Walker‐Smith,

Primary Care and Health Outcomes

In these personal recollections and reflections, I shall deal in some detail with the years before I settled in Britain, but I shall also range briefly over the past 45 years as a student and a doctor. In March 1954, I began my medical career as a first-year undergraduate student of medicine at the University of Sydney (founded in 1850)(1) (Fig. 1). At that time, medicine was a 6-year course of study, still largely modeled on the curriculum of the University of Edinburgh. Most of the founding fathers of Sydney Medical School had hailed from Scotland, and Edinburgh in particular. The most notable was Sir Thomas Anderson Stuart, founding professor and first professor of physiology (2). In first-year medicine, we studied zoology, botany, physics, and chemistry. More than 300 students began that first year, and the failure rate was more than 50%.FIG. 1.: Great Tower, University of Sydney, 1954.Most of us lived at home, apart from the privileged ones who lived in one of the four residential colleges, all denominational in foundation: St. Paul's for the Church of England, St. Andrew's for the Presbyterians, Wesley College for the Methodists, and St. John's for the Roman Catholics. I had indeed come from a church school, Sydney Church of England Grammar School, usually known as “Shore” (3) (Fig. 2). The school is one of those schools in Sydney described as a “great public school,” that is, a private school, in contrast to the free government schools described as “public” in New South Wales. The school was closely linked with Shrewsbury School in England, whose motto was “Manners Makyth Man.” Jimmy Burrell, one of the masters at school whom I best remember, frequently reminded his class of this motto and the vital importance of good manners, including raising one's boater to a master when encountered outside the school grounds (Fig. 3). Our motto at Shore was “Vitai Lampada Tradunt” (they hand on the torch of life). At the heart of school life was the chapel, which was built to commemorate “old boys” of the school who had died in the First World War. The architecture was modeled on Eton Chapel, that is, the congregation faced a central aisle. Every morning from 1945 to 1953, I attended morning chapel for 20 minutes at 8:40 AM, and every morning a prefect turned a page in the “Book of Remembrance,” which listed the names of those boys who had died in one of the world wars (231 in total). A total of 2,270 old boys of Shore served in the Second World War (4). However it was Gallipoli and the Western Front that were all too familiar from history lessons.FIG. 2.: Chapel and School House (on left), Sydney Church of England Grammar School.FIG. 3.: John Walker-Smith and Garth Setchell as sixth formers at Shore in 1953.When I was a schoolboy, my family assumed that I would study medicine. My father was a consultant urology surgeon at the Royal Prince Alfred Hospital (RPAH) (5), and my maternal and paternal uncles (Roy Trindall and Hugh Walker-Smith) were general practitioners. My paternal grandfather, Dr. John Walker-Smith, was a Glasgow general practitioner who emigrated to Australia in 1883, and my maternal grandfather, Dr. Richard Barzillai Trindall was one of the earliest Sydney graduates (6). I was the third generation of my family to enter the University of Sydney. Furthermore, my mother (Alexandra [Alix] Buckingham Walker-Smith) was one of the first female graduates with a Bachelor of Arts from the Sydney University. My son, James, is the fourth generation of our family to attend university. He is studying politics in Bristol. I did consider briefly the idea of studying archaeology. My mother insisted that this was really a hobby, although I did visit the magnificent Nicholson Museum of Archaeology at the University. Reflecting now on the decision between medicine and archaeology, I see how my interest in the history of medicine has lead me back to archaeology. While on holiday in Crete last month, we visited the archaeological site of Knossos. I was delighted to come across a video on sale in Rethymnon, Medicine in Minoan Civilisation, which I have been able to use as a teaching aid in the Royal Free History of Medicine Special Teaching Module for students. I also came upon a remarkable scientific exhibition that analyzed the food content of cooking vessels in the Minoan period, giving insights into the nutrition of more than 3,000 years ago (7). I also toyed with the idea of the diplomatic service. However, everyone in the family assumed John would “do medicine,” so medicine it was. Although I did not have much personal choice, it was my own decision, and in the end I have not regretted it. Today many young people agonize about the right career, perhaps because of too many choices. After this preamble, I return to 1954. How did I feel as I started medicine? Apprehensive, scared even, is the answer. I had led a somewhat quiet life in a happy home and had attended a strict school with a large emphasis on sport (in which I had never excelled to my father's disappointment). While attending the Annual Army Cadet Camp in Singleton (first as a private, then as a corporal, and finally as a cadet-under-officer) for 3 years, I became painfully aware of another harsher world “out there.” One of the great things for me about university life was the friendships I made. Many of these have stood the test of time and are friendships for life. During second- and third-year medicine, friendships were made especially among those who dissected the same “bod” (cadaver) for a full year. Incidentally, the term bod that students used at that time bore no disrespect for the dead but was one way of coping with an experience that was far from pleasant. When one looks back, our grim dissecting room provided a rather horrifying scene. I remember feeling my stomach heave when we first entered the vast gothic room with the sickly sweet formaldehyde stench emanating from row upon row of cadavers. The extraordinarily gothic environment with little groups of white-clad students gathered around the cadavers and poring over their Cunningham Anatomy texts, which were protected by plastic covers, makes an unforgettable and not pleasant memory. Influenced by the architectural tastes of Anderson Stuart, our medical school had been built in Scottish Tudor Gothic style, reflected in the dissecting room (Fig. 4). The building was always cold, even on the hottest of Sydney days. Its long corridors with busts of famous figures from medical history such as Sir James Young Simpson (of Edinburgh, discoverer of chloroform anaesthesia) and its eponymously named lecture theaters (Vesalian, Hunterian, and Anderson Stuart) were redolent of the distant past and northern climes. This was in complete contrast to the hot southern environment in which the building actually stood. Yet it did give us students the powerful message that we were engaged in an ancient, distinguished, and, indeed, noble profession. The dissecting room seemed sometimes like a temple of arcane mysteries, but we experienced a very tough and vigorous teaching program in anatomy, including detailed knowledge of the skull and the skeleton.FIG. 4.: Entrance to the Old Medical School with the dissecting room to the left on the first floor, 1955.Several of us, who had dissected together, remained together in our clinical group when we at last began hospital work in fourth-year medicine at RPAH. My father was still a consultant urology surgeon there, in fact, he was an honorary surgeon. Medical families at the same institutions were quite common at that time in Sydney, and the family feeling of Sydney's medical community was strong. In part this remains true even today. As clinical students, we proudly wore our short, white coats, as do students at the Royal Free today. This clearly identified our lowly status in the medical hierarchy. This dress was compulsory. Our clinical tutor was a formidable, albeit young, physician, Dr. Dick Harris. However, he was of the old school. For the first time, he taught us to say “abd-O−-men” rather than “abdomen.” He abjured us never to have our hands in our pockets on a ward round. He said with subtle humor that this was his prerogative alone. He gave us classic instruction in the basics of the clinical art. This has served me well all my life. Formal lectures were given in the New Medical School, the Rockefeller building. Then in fifth year, we began the “specials” as well as medicine and surgery. These specials included obstetrics; ear, nose, and throat; ophthalmology; and psychiatry. In psychiatry, we were privileged to have Professor Ian Trethowan, recently arrived in Sydney from England to reform New South Wale's archaic psychiatry laws and to abolish inter alia such titles as “Master in Lunacy.” His lectures were exciting, almost thrilling. However, for me, the pièce de résistance was pediatrics because we left Prince Alfred to go to the marvellous Royal Alexandra Hospital for Children (RAHC), “the kids,” a 10-minute walk to Camperdown. “The kids” was a fantastic place to go, and we had a charismatic professor of child health, Sir Lorimer Dodds, a truly inspirational lecturer. I can remember as yesterday his clinical demonstrations/lectures on pink disease and tuberculous meningitis. I can see to this day that little baby with that fell malady who was later, tragically, to die. I left the children's hospital feeling what a challenge pediatrics was and how much remained to be done for sick children. In this fifth year, I began my lifetime interest in the history of medicine, which came to fruition in 1993 in my sabbatical studying the history of medicine at the Wellcome Institute. I was one of the student founders of the Medico-Historical Club (8). It met three times a year, sometimes with famous international speakers. I spoke once on John Snow of cholera fame. Notable events in the fifth year included the Queen Mother's opening of a new unit for infants and mothers, and a visit by Billy Graham. We were all allowed to cut short a lecture to hear him. The final year followed with intense teaching in medicine, surgery, and obstetrics and gynecology. There was very little time for social activities. The finals in the midst of a very hot summer were a grueling ordeal. The joy of passing the exams just before Christmas could not be confined. We enjoyed a particularly fine summer holiday, surfing at Newport Beach just north of Sydney. (Pausing here to reflect on the sea and the beach in the Australian psyche, if I were asked when I feel most Australian, it would be on Christmas holidays at the beach, which are the most evocative magic of Australia for me—a surfing beach framed by Norfolk pines. The opening ceremony of the recent Olympic Games celebrated this glorious link that most Australians have with the sea.) The graduation ceremony occurred in the gothic splendor of the university's Great Hall on a very, very hot day in January, after our life as junior doctors had already began on 1 January 1960. Looking back on the 6 years at the University of Sydney, what do I think now of the quality of the education we received? It was remarkably broad and comprehensive, with a very strong scientific base. Much time was spent studying physiology, biochemistry, and so on, and certainly too much time was spent studying botany and zoology in the first year. But all this made me realize so clearly that medicine is rooted in science. How good were the teachers? Many were outstanding, and perhaps I remember most of all Professor Ruthven Blackburn of medicine, with his enquiring approach into all and everything. My medical life as a doctor began at RPAH. I had been lucky enough to be appointed there as a houseman, known as junior resident medical officer. This involved rotating through a number of firms. In my case, first came medicine, with that doyen of Sydney physicians Sir William Morrow (a gastroenterologist), then surgery with Mr. Lovell, followed by neurosurgery, obstetrics with pediatrics, casualty, blood bank, and finally urology (by then my father had retired). We all were now completely dressed in white, trousers and short coats. The following year, I was appointed as a senior resident medical officer (long white coat) at RPAH with a junior resident medical officer beneath me, a registrar above, and then the consultant team (consultants rarely wore white coats). I again had a term in general medicine, but this time, I also had terms in cardiology, in which my future brother-in-law (Dr. Howard Peak) was my registrar. I also had more obstetrics training at King George V Hospital, performing countless dilatations and curettages after miscarriages, exchange transfusions for Rh disease of the newborn, and even one caesarean section under supervision. I also had a surgical term in which I performed several appendicectomies. However, despite my father's example, I had no vocation for surgery, and I resolved to become a physician. When I started at RPAH, the honorary system inherited from Britain was still in place. In this system, most consultants were visiting and called honorary surgeons or physicians. My father was one of these, and he worked in this system throughout his career until he retired from RPAH in 1960, aged 60 years, then the age of retirement for public hospitals. He was also an honorary surgeon at Manly District Hospital and Mater Misericordiae Hospital. He did operating sessions, three outpatients and related ward rounds. Under this system, consultants did all their work in public hospitals free of charge. He earned his living during weekends and evenings in the private sector. His dedication and devotion was and remains a great inspiration to me. From my earliest time as a student, I had always wanted to train in England. My father before me had trained mostly in London but also in Edinburgh and Yorkshire and had inspired me with the quality of British medicine. I applied to the Hammersmith Course in Medicine and was accepted for autumn 1962. However, to extend my training, I first went for 6 months to the RAHC as a junior resident medical officer. At that time, spending at least 6 months caring for children was considered good experience for a physician in training. The time at RAHC was marvellous. Although I did not realize it at that time, this move changed my life. Throughout this 2 and a half years (at RPAH and RAHC), I lived in the hospital residences. I worked often on alternate nights, many times without sleep, especially during obstetrics. Little social life was possible, and often on the weekends that I spent back home with my family, I slept a good deal of the time. Perhaps we did work too hard, but it provided a fantastic experience. It provided a broad medical experience, obtained firsthand, including direct surgical and obstetric experience and laboratory responsibility in the blood bank. However, holidays were good, when one could get away from it all. Returning to my plans to continue training in England, I simply could not afford the cost of travel to England for the Hammersmith course. Therefore, as my father before me had done, I elected to travel to England as ship's surgeon. I was appointed surgeon to the MV Aramaic of the Shaw Saville line, a cargo ship with a ship's company of about 40 souls. This was a marvelous adventure. However, as I flew from Sydney to Adelaide to begin the voyage, I had never felt more immature and inexperienced in the ways of the world. We traveled from Adelaide to Aden. There I went ashore, in some style, in a colonial barge and stepped for the first time in my life on foreign soil. Despite my 26 years, I had never been outside Australia and I had only rarely been outside Sydney. I was accompanied ashore by the ship's wireless operator, nicknamed “the vicar,” which describe the opposite of his personal behavior. The scenes ashore were like something out of the story of Aladdin's lamp, but the presence of abject beggars, often with gross deformities, showed a darker side. We sailed on through the Suez Canal, where I climbed the mast for a fantastic view. My medical duties proved somewhat limited and mainly involved accompanying the skipper on ship's inspections, but also learning to spot malingerers. Then came my first, wonderful, port of call in Europe, Genoa. Then we sailed around Spain, past Gibraltar, up the Bay of Biscay, and to the English Channel. There, with some emotion, I had my first glimpse of England and the white cliffs of Dover. Then we sailed on to Dunkirk, down the Elbe to Hamburg, and finally back up to the Channel and to Liverpool, where I made my first landfall in the old country. At last, I set foot on British soil, the land of my forebears, the country my mother always called home even though she had never been there. In London, like so many Australians, I stayed briefly in Earls Court, and then I went with my sister on a kind of pilgrimage around Scotland, the land from whence all my paternal ancestors had come. Then I traveled back to London where I had the good fortune to stay at London House, a residence hall for postgraduate students from the Commonwealth and from the United States of America. At London House, I also established lifetime friendships, not only with doctors. I traveled daily to the Hammersmith Hospital to begin that wonderful postgraduate course with so many giants as teachers (including Sir John McMichael and J. G. Scadding). At the end of the course, we could apply for house jobs. I applied to work for Professor Chris Booth, who was an inspirational teacher of gastroenterology, and I was lucky enough to be appointed (Fig. 5). This changed my life. I realized that gastroenterology, and the small intestine in particular, was my life's vocation. This opportunity also consolidated my desire to become a physician. To extend my training, I applied to work at the Brompton Hospital. I was so fortunate to be SHO to Professor J. G. Scadding, a great teacher. There I also met Jack Pepys who aroused my interest in allergy, which was later to bear fruit in my work in gastrointestinal food allergy, and with whom I made another lifetime friendship.FIG. 5.: The “Firm,” Hammersmith Hospital 1963. Right to left: Gilbert Thompson, David Mollin, Jimmy Stewart, Chris Booth, Michael Brain, and John Walker-Smith.I passed the membership in both Edinburgh (for nostalgic reasons) and London (at Bart's, Dr. Cullinan, Dr. W. W. Brooks, and Sir Ronald Bodley Scott). By now, my planned 2 years in England were approaching their end, so I made plans to return to Prince Alfred. I was appointed as a clinical research fellow in gastroenterology in the A. W. Morrow Unit, led by my mentor Sir William Morrow. My field of study was protein-losing enteropathy, but I also had training in hepatology (with Steve Mistilis) and in rigid endoscopy. I developed an animal model for cholangitis. I was well on my way to becoming a gastroenterologist when John Yu asked me to give a talk at RAHC, which kindled my interest in gastroenterology in children, a field then in its infancy. This interest developed when I went to Melbourne to an international meeting that Dr. Charlotte Anderson had arranged. She is one of the great pioneers in pediatric gastroenterology. At the meeting, I met Professor Prader and I asked him whether I could be trained in his unit in Zurich. After my memorable 2 years in England, I was keen to return to Europe for further training. Eventually, after 1 year as a professorial registrar at RAHC with Professor Tom Stapleton, I went to the Kinderspital in Zurich for 6 months. There I received the only formal training I have ever had in pediatric gastroenterology, from Professor David Shmerling; otherwise, I am afraid I am self-taught. On the way to Zurich, I had the immense good fortune to see something of the developing world when I visited Harare Hospital as the guest of Dr. George Soutter, whom I had met at London House (Fig. 6).FIG. 6.: John Walker-Smith at Harare Hospital, Salisbury, Rhodesia (now Zimbabwe) in 1966.I returned in 1967 to RAHC as a student supervisor and Wellcome clinical research fellow. I was appointed as honorary associate physician (consultant) in 1967 and then staff physician in 1972. I passed my MD in 1971, in Dissecting microscope appearances of the small intestine in childhood: a postmortem study. One day in 1972, I was sitting in my office in the Institute of Child Health at RAHC when I opened the Lancet and saw a senior lecturer/consultant pediatrician post advertised at St. Bartholomew's Hospital (Bart's) and Queen Elizabeth Hospital for Children (Queens). I applied because I was very familiar with Bart's and with the work of Tony Dawson in adult gastroenterology. I was short-listed; therefore, I flew to London at my own expense, with my wife Liz's blessing (we had married in 1969), and was appointed in September 1972 as a senior lecturer—this was some 28 years ago. I have been on the academic staff of the University of London ever since. What a decision, what a move—I, Liz, and my 2-year-old daughter, Louise, made the great journey to England by sea through the Panama Canal to Southampton. Why did I move? Well at that time, it seemed the opportunities for developing pediatric specialities were far greater in London. The BPA document by Donald Court entitled “Paediatrics in the Seventies” influenced this decision (9). Furthermore, I had so enjoyed life in London in the past, and in part nostalgia for the past, as epitomized by Bart's, drew me to London. A pediatric gastroenterology service and research group was consolidated on the two sites, Bart's and Queens, ultimately establishing the Academic Department of Paediatric Gastroenterology in 1988. I made exciting links with Europe through the European Society for Paediatric Gastroenterology and Nutrition (ESPGAN), including hosting with John Harries the ESPGAN London meeting of 1979 and attending council meetings in Vevey. The British association (BSPGN) was founded in 1986, and the first council meeting was held at Bart's (Fig. 7).FIG. 7.: The first council meeting of the British Society of Paediatric Gastroenterology in the Guild Room at St. Bartholomew's Hospital, London. From right to left: Chris Rolles, Ian Sanderson, Bob Nelson, John Walker-Smith, James Dickson, and Ian Booth.In 1995, we enthusiastically celebrated the 125th anniversary of Queens (10). The future, up to my retirement, seemed clear and I anticipated consolidation and expansion. Then the axe fell. The Tomlinson Report recommended closing all that I believed in, the two hospitals, Bart's and Queens, and the department I had created, the Academic Department of Paediatric Gastroenterology (11). Bart's has been saved in part, but tragically Queens closed in September 1998. In 1993, I had received a very warm invitation from Andy Wakefield to transfer my unit to the Royal Free, but I held out hoping Bart's and Queens could be saved. The invitation was reaffirmed by Professor Zuckerman (dean of the Medical College) and Mr. Martin Else (the chief executive of the Trust) in 1994. On 10 March 1995, I accepted their invitation to transfer the Academic Department of Paediatric Gastroenterology to the Royal Free to become the University Department of Paediatric Gastroenterology. This occurred on 1 September 1995. The move included two senior colleagues, Dr. Simon Murch and Dr. Alan Phillips. The latter had been with me for 20 years. This second great move was not so far as the move from Sydney to London, but the journey from Hackney to Hampstead had its contrasts, too. Looking back now on my whole career, I think about my mentors. While a junior doctor, these were clearly Sir William Morrow in Sydney, Sir Christopher Booth in London, and Professor David Shmerling in Zurich. As a consultant, I was mentored by Sir Anthony Dawson. Who inspired me? My colleagues at home and abroad. At home, these included two scientists, Alan Phillips and Tom MacDonald. More recent inspiration came from my clinical colleagues Simon Murch and Mike Thomson, who have carried forward the momentum at the Royal Free. One colleague I must mention is Martin Savage and the joint “growth–inflammatory bowel disease” clinic. On the inspiration that came from abroad, first and foremost, I must mention the sage advice of Allan Walker from Boston, a peer and good friend with whom I have closely collaboration during the past 5 years that we have served together as editors of the Journal of Pediatric Gastroenterology and Nutrition (Fig. 8). His example as a promoter of pediatric gastroenterology has been an inspiration. Friends in Europe whom I've met in association with ESPGHAN have played a big role in my life. Jacques Schmitz is a particular example. My friends in the Commonwealth whom I met through the Commonwealth Association of Paediatric Gastroenterology and Nutrition and my friends in Asia whom I met through the Asian and Pan-Pacific Society of Paediatric Gastroenterology and Nutrition have been very important. Maintaining the RAHC connection through an exchange rotation of lecturers with Sydney also has been important. The South American connection (Chile, Brazil, and Argentina) has been important too. Sometimes I feel as if I belong to another country, the world of pediatric gastroenterology, where I have so many friends. I must also include all my trainees in pediatric gastroenterology and in pediatrics (Fig. 9). I cannot mention them by name because there are too many, but they remain a continuing inspiration. The qualities I most admire in them are their zeal and loyalty. Loyalty is of course a two-way street!FIG. 8.: John Walker-Smith and Alan Walker at Boston Children's Hospital.FIG. 9.: International Group at Queen Elizabeth Hospital for Children. From right to left: Uhli Agnaarson (Iceland), Arriego Barabini (Italy), an unidentified visitor, Ms. J. Obosi, Mamoun Shahrier (Bangladesh), John Walker-Smith, Charlie Charlton, Satoru Nagata (Japan), Arvind Shah, Alan Phillips, and Eric Newman.For them, the international connections have been concrete, with the trainee exchange program: first, the long-standing, yearlong rotation mentioned above between my lecturer, first at Queens and now at the Royal Free, and a registrar from RAHC in Sydney. This has been very successful academically. The exchange program also involved the rotation for research fellows, a short, 1-month exchange between Boston Children's Hospital and my department. For two research fellows, Ian Sanderson and Rob Heuschkel, the exchange led to much longer and highly successful training periods in Boston and were of much value to pediatric gastroenterology in the United Kingdom. In my medical life, I have seen great changes. First, within the field of pediatrics, recognition has come for the pediatric specialities and gastroenterology in particular. The BPA, in its prophetic document “Paediatrics in the Seventies,” foresaw these vital developments (9). In 1962 at RAHC in Camperdown, pediatric gastroenterology as a specialty was quite unknown, but by 1972 it was in the vanguard of staff appointments (I was the first staff physician in any discipline to be appointed). This salaried staff system was to gradually replace the old honorary voluntary system inherited from Britain, now only an historic memory. In the seventies, the first appointments in pediatric gastroenterology in the United Kingdom began. At first, the appointments were all academic. The discipline began to flourish. The British Paediatric Gastroenterology Group was established in 1974 in Birmingham, and later in 1986 it became the BSPGN. Now the concept that children deserve specialized care just as adults do is becoming widely recognized, albeit still not everywhere. Second, we now have the ability to use a variety of sophisticated techniques to safely and effectively diagnose children who have gastrointestinal disorders. Now accurate diagnosis is possible in most cases. In 1968, the advent of parenteral nutrition for children (12) made it possible for us to keep many children, especially infants, alive, who in former times would have died. This has allowed description of new diseases such as microvillous atrophy and autoimmune enteropathy, which may in time be curable. Small intestinal transplantation, unbelievable in the past, is now becoming a reality. Third, I have seen a changing pattern of disease, with the welcome decline in infectious diseases but the unexpected increase in chronic inflammatory bowel disease and food allergy and, in the developing world, of pediatric AIDS. Fourth, the development of oral rehydration therapy has saved many lives in the developing world. The continuing challenges of gastroenterologic disease in the developing world are greater than ever. My experience at Queens with large numbers of pediatric patients from Bangladeshi families who had recently immigrated, and my own interest in developing countries, especially in the Commonwealth, has led me to these diseases are major challenges for us in the developed world, too. The Commonwealth connection has meant a lot to me and came to a climax recently when, as a representative of CAPGAN, I attended the Commonwealth Health Ministers meeting in Geneva. Fifth, I have witnessed the sad closure of institutions, with mergers and so on. I have not observed bigger to be better in any shape or form. I mourn the passing of Queens and the reduction of activity at Bart's. As Coleridge stated, there is a great problem in reconciling the forces of “progress and permanence.” For me, Bart's uniquely achieved such reconciliation. In a written tribute that I paid to Ba