In the year of the Queen’s coronation, my father had an industrial accident. He worked for the local farmer and, [there were] old binders which went on the back of tractors before the days of combine harvesters, and the blades would turn round and it got stuck, and he saw the piece of string along the spindle, so he put his hand in to pull the string out, and the arm was left in the field. And there followed about a month of being in hospital. And one does dwell on these things and I think that may have influenced my decision.
“University College took more women than other medical schools at the time… about one fifth of entrants…”
I went to University College and then subsequently the medical school. I think I may have been recommended this by my headmistress who said that they took more women than some of the other medical schools at the time. And indeed they had about one fifth of women entrants.
Beginnings in Anaesthesia
It was very difficult getting house jobs after graduating because in those days if you didn’t get a job at your hospital belonging to your medical school then you had to find yourself one. And it took quite a while to get my first house job. That was at the Bolingbroke Hospital.
The first one was medicine and then the second was surgery, and that was really good because the Guy’s surgeons would come to the Bolingbroke and they were quite high-profile people.
I was interested in anaesthesia was because I wanted to be able to do practical things. It’s no good prescribing when you’ve got a calamity on your hands. You’ve got to be able to do stuff.
“Over the next year or two, it was an issue of juggling family with training… that is much more difficult to do than you ever think”
I thought for a married person to do and bring up children, general practice would be even better. I was called the ‘dolly doctor’ on account of there were not many women GPs around. It was in Reigate in Surrey and lots of women would come to see you just to have a little chat, because their husbands went to London on the train, they had nothing better to do. If there was anything even faintly like an emergency, like delivering, with forceps, a child in the local cottage hospital, you got into trouble for leaving the laryngoscope open and the bulb going flat rather than congratulated for saving the baby’s life. I didn’t dislike but it wasn’t my favourite thing to do.
Over the next year or two, I think it was an issue then of juggling family with training. And that is much more difficult to do than you ever think, even with help, even with resident help. It is difficult because you have to apportion your time appropriately. And then came the decision about where to look for a consultant job and to move to Bristol was a big step. But I was immensely lucky to go to Frenchay where John Zorab and Peter Baskett, they were both immensely supportive.
Beginnings in Intensive Care
I think my interest in intensive care started while still at Kings when it became obvious that there was a big difference between the technology of ventilating people and maybe having them on inotropes, and looking after the whole patient who had a diagnosis and an illness. And anaesthetists were not trained for that. So there was multidisciplinary input from surgeon’s physicians and others, but actually gathering the whole thing together to get the patient better wasn’t really a concept that we were taught then.
“There was some resistance to the concept of looking after the whole patient”
King’s intensive care unit was already going because of the usual things like cardiac surgery, and of course it had the liver unit with Roger Williams. Out in Bristol, Frenchay was very much the neurosurgical centre, head injuries, so that had a significant focus on that aspect. But again there was some resistance to this concept of looking after the whole patient and all their illnesses.
“The Australians laughed at us and our backward approach…”
I think my first big step forward in intensive care probably was getting a bit of a feel for what was happening across the country, joining the Intensive Care Society, and then standing for their Council. And then we got to talk with other European countries and I think the biggest eye opener was from World Congresses, seeing how the Australians did it. And they laughed at us and our backward approach: they had a training plan and they were charge. You would call it a closed unit rather than an open unit when all of the consultants and physicians were in charge of their patients and you were just helping them out. We had no formal training programme. I think they laughed at our rather traditional ways. But it did make me think about the differences.
My particular research interest in intensive care, I think everyone comes to this at the end… It’s how you cure sepsis, because this is the big killer. We were focusing on all kinds of … tinkering at the edges really in those days, finding a way to cure endotoxemia… and there were some agents that could potentially be useful. The complexity of sepsis had really escaped us at the time and the agent that I was researching didn’t improve outcomes. Now, in retrospect, I’m not in the slightest bit surprised. But then we were very evangelical, it was definitely going to work.
“My particular interest was how you cure sepsis… the complexity of it really escaped us at the time”
I don’t think there is any particular publication that I’m very proud of- it would be not the research kind of stuff, that’s not ground breaking in any way, but it’s the sticking your neck out with an editorial in Intensive Care Medicine. And it was about training. I think, if I remember this rightly, started with, ‘A prophet is not without honour, save in his own country and in his own time’. Everywhere else in Europe, Australia and the States had got training underway and working, and we were really lagging behind, and it was to try and get this message across.
Training in Intensive Care
I became particularly interested in training in intensive care. Clearly the service was largely delivered by anaesthetists, 80% of practicing consultants in intensive care were anaesthetists. Cedric Prys-Roberts was very supportive of this concept of needing specific training separate from anaesthesia and the idea that all the colleges needed to be involved. So he was instrumental, with the other presidents, in helping to set up a group. It had various titles over its time like, ‘interfaculty’, ‘intercollegiate group on training’, so we developed a training programme and the concept and the content actually of a diploma in intensive care medicine and in the later committees we even looked at the concept of a faculty. But this was well before it was going to be accepted elsewhere. In fact I think it was emergency medicine that was setting up a faculty and so we got their Dean to come and talk about it. So there were people who were very clear about where things should go, but there were also those in anaesthesia who were rather reluctant to see that move forward.
“Only about 16% of trainees had any training whatsoever in intensive care”
They didn’t want to let go of intensive care and they were lobbied by those anaesthetists who preferred a fairly gentle life at the head of the table, and I might unkindly call them, ‘those who worked to live’ rather than ‘those who live to work’. But they didn’t want to go beyond that immediate perioperative period into looking after the sick ones longer term. Or even those who were not surgical at all. So there was a reluctance, a very considerable reluctance.
I think it probably was those people who were actually involved in the intensive care environment and knew their training could be better who were beginning to say, ‘Hang on, can’t we do better than this? Other countries are doing better than this.’ We did a survey and it transpired that only about 16% of trainees had any training whatsoever in the wider field of intensive care medicine. So, with other colleges wanting to be involved, and people doing intensive care, young consultants, realising and writing to say, ‘Actually we really do support this’, then there was a groundswell of positivity.
“My perception is trainees must have done this, this and this… Tick in box”
I think now, my perception is trainees must have done this, this and this. Skills based assessment in the workplace and so today we will pass an endotracheal tube in a difficult airway. Tick in box. That is not the same as the apprentice style that you and I grew up with, when we would listen to the consultant say, ‘Well there’s this and this way to do it, what do you think we should do?’ You gained a great deal more from this apprenticeship than I think the trainees do these days. You look at the problem with the consultant and you discuss all the ways of dealing with it. You learn a lot more from that.
It was a bit daunting, being an examiner for the College. And in the early stages, because I only examined for the then part two not the primary, the pass rate was quite low and it was of some concern that people would pitch up, often rather unprepared. So I think that fed into improvements in training. The unpreparedness of those who pitched up and… it was quite salutary how some of the candidates had not got a clue what to do with a patient. And people could fail part two up to 10 times. It shows there’s something wrong with the system.
“People could fail part two of the exam up to ten times”
I think the candidates underestimated the standard that was required. But we did change things to have people sitting in on the exam, and I think the pass rate has improved. I think those people sitting in went back and fed back to their departments or their areas what needed to be done. That was the concept. At the end of the day it is up to the individual to get the facts and the skills into their heads and hands but I think largely the candidates underestimated the standard.
I don’t think there was some particular area of the clinical that they were particularly bad at, although you could possibly make the case that in the olden days when the examining halls were in Queens Square, many of the patients used to come from the National Hospital for Nervous Diseases with all kinds of bizarre diseases that you would not necessarily expect those who were going for a career in anaesthesia to be about… It may have been that the examiners could have found a better source of patients.
I think I was an examiner for 12 years. Some trainees pop up now and again and say, ‘Do you remember me?’ And it was that I examined them, and then you think, ‘Did I pass them?’ because that was quite important!
Changes in Intensive Care
The lecture which was a bit scary was talking about futility and… trying to keep alive those persons in an intensive care environment when the chances of recovery were very, very small. They don’t use the word futility anymore; everyone is kept alive, largely because the family insists. And things have changed enormously… down to the rise in patient autonomy. All these patients in the intensive care environment that you’re talking about lack capacity. So it’s a bit of brave thing to talk about futility but it wasn’t seen to be that at the time. And one or two people came up afterwards and said they thought that was very interesting, slightly brave. In those days we felt we could go there. So is it a form of rationing if you can treat 100 patients for something acute in hospital rather than …
“It’s a bit fo a brave thing to talk about futility, but it wasn’t seen to be that at the time”
I would like us to go back to being able to have a sensible discussion where the intensivist is seen as someone who knows a little bit more about prognosis than the patient’s family, is trusted, perceived as knowledgeable, not riding roughshod over the family but coming to an agreement that it is useless, futile, dare I use the word, to persist. We’ve moved a long way from that. I think the internet has had some influence on that, because you dial what you want to see where you can get it. I don’t think it means that the internet is wrong… ‘If you want information, the internet is brilliant. If you want knowledge …’ It’s unevaluated information, isn’t it.
I think there are now so many people involved in the care of one critically ill person that the continuity is lost. And with working time directives and other issues that limit the period of time that people can work, then patients and their families don’t develop the right close relationship with, ideally, the team leader, so that they will be trusted.
I’ll always remember one guy who we had sorted out from about his fourth admission to an intensive care environment with chronic obstructive airways disease and ventilated, had bad emphysema, and he said, ‘I don’t want to be exposed to this again. I don’t want you to admit me again.’ And I think that kind of an exchange is really rare but you could only really have it if the whole unit has great confidence in the person who’s running it… you have to be immensely trusted. Those kinds of things would be great but I don’t think we’re going there. We share the responsibility with too many others. But that is a personal view.
I think the Chair I’m probably proudest of would be right back to the Intensive Care Society because these were such early days and the numbers of people who belonged to the society were very small, so we were very much feeling our way and very much perhaps behind other countries. So those were pioneering times and they were exciting times. And introducing things that the Association will probably think very simple like prizes for posters and things like that. It was quite innovative at the time.
I also had to review the confidential inquiry into maternal deaths. That was in the olden days when the Chief Medical Officer had advisors in all of the specialities, I was the one for anaesthesia. I think that was probably because of the Association of Anaesthetists. And I think it was probably people like John Zorab and Peter Baskett who were sitting round this Association of Anaesthetists Council table and tossing names into the system and they included mine, which was obviously from personal contacts but knowing that I was quite keen on this intensive care business.
I was never on the Council of the Association except as a co-opted person because of being CMO’s advisor. And it was immensely useful being there to take back stuff that was going to be relevant. You have to remember that CMO used to see his advisors in great lumps, but he would listen quite hard to stuff that was going on and things that were of concern, largely to working practices hence the Association had a far more useful voice and input into that than, say, the College.
General Medical Council
I worked with the GMC for a while. It was a good learning experience in how tedious lawyers can be and how long it takes them to cross examine and explore problems. Also the inherent difficulties with expert witnesses.
One of the most difficult ones came to me via Margaret Branthwaite. I had been asked to find someone to just take a look at this excessive number of deaths in an A&E department and there was a rogue healthcare professional there who liked to brandish neuromuscular blocking drugs and people would have arrests. ‘It’ll only take you a little while’, said she and nothing came for an awfully long time and then a Fed Ex man arrived with a bundle of files about this big. It was astonishing, quite astonishing.
I quite enjoyed some of it and I think making the right decisions on a fitness practice panel which was what it was called then, was a difficult job but a worthwhile job. And the one memory that always sticks out is a very, very sad case… due to be heard in three days. It was not completed, it was adjourned, and started again and we spent 56 days in all over that case… spread out over 13 months. He was found to require re-training, conditions put on his practice, and a month later he died of ischemic heart disease. He’d been swilling the Gaviscon throughout, which we all thought was stress and peptic ulceration. They stick in your memory a bit, especially when it goes on for so long.
Honours and Awards
I served on regional awards committee. I think it worked as well as it could within the constraints of how the system was set up… There will be some unfairness that creeps in. In the main I think the awards went to the best people but again it’s a huge task to be involved in that because you’ve got stacks and stacks of paper, and with the best will in the world, you can’t do it for more than a couple of hours at once and then come back. So to do a thorough job was very difficult. I served for four years and remember being medical vice chair for about the last two years with a lay chairman who I accidently knew because she was married to an anaesthetist. We got along very well but the task of actually going through the stuff was monumental.
I’ll be loath to say that we gave an award to the wrong people. You had to have your final visit to review the names that the region had chosen… but it would only be in about a very few percent that we changed our draft list. So there were some cases where we looked at awards nationally and shook our heads about some persons who we knew had been given an award for political activity. I don’t think it really happened in the Southwest, these were more the national things.
I was given an FRCP in 1998. I was very chuffed about that because I had my MRCP thinking that if you’re going to look after patients on an intensive care unit you need to know quite a lot of medicine. But then if you made a contribution to medical care and people noticed that you were actually doing it then you could be proposed for an FRCP by the RCP regional advisor. That was how I was suggested. But actually they award an awful lot of FRCPs. So when you go, it’s an annual exercise, and you sit in the library of the College of Physicians, you’re surrounded by probably 300 others. But still, no I was pleased.