Dr Stanley Jeffs is a retired GP who has made regular contributions to the College Journal. He is now 90 years old. His first article, An Epidemic of Lumbago, was published in 1961. You can download and read it from our archives here. He has suggested this contribution will be his last offering to the BJGP. It gives a fascinating glimpse into the history of general practice as well as much for us to consider for the future.
THE CHANGING FACE OF GENERAL PRACTICE IN THE 20th CENTURY
By Dr S. G. Jeffs (a personal opinion based on doctors I knew)
Dr Joseph Porter
By my calculations Dr Porter must have been born about 1890. Certainly he was a medical officer in the First World War when his personal transport was a horse. Tall and with a slightly mischievous look on his face even in his old age, I first knew him in the late 1950s in Levenshulme, a district of South Manchester, where, at that time, there were eight doctors in practice, all within a thumbprint on the map. There were two partnerships of two and four single handed doctors. Three of the single-handed doctors lived above the surgery premises. The NHS had been going for a decade.
Dr Porter and I, both single handed, stood in for each other occasionally for emergency on-call, which, in truth, was not very often, quite rare in fact. The law at that time, required each doctor to be responsible for his patients’ care at all times all year round. Our trade union, the BMA, struck a really bad deal for general practitioners, and for junior house doctors too. So, if I wanted to go to the cinema for instance, I would arrange with the manager of the cinema to give his telephone number as my emergency contact number and he would provide an end seat for me in the auditorium. In that way, should an emergency arise, the usherette could find me easily without disturbing anyone else.
It was only a few years after I came to Levenshulme, about 1957, that Dr Porter took ill and he sent for me. I was not his physician and I regarded it as a privilege that another doctor wanted my opinion, an inexperienced youngster in his late twenties. At that time Dr Porter must have been nearing 70 so I was less than half his age. The diagnosis was easy. He was in congestive cardiac failure.
“I will have to admit you,” I said. “wherever I can find a bed. Would you like me to try Manchester Royal Infirmary first or Withington Hospital?”
Withington Hospital had been built originally as a workhouse and to many patients it still bore the stigma.
“It doesn’t matter to me,” he replied. Then taking my hand in his he said, “Will you look after my patients for me?”
“Of course I will,” I said.
There was a sort of unspoken brotherhood, an ethic that, regrettably, was dying with Dr Porter’s generation.
There was no question of money or how much extra work I would have to do. There was still at that time, a feeling among many doctors, but not all, of a sort of unspoken brotherhood, an ethic that, regrettably, was dying with Dr Porter’s generation. But I had had ethics rammed down my throat in medical school from the dissecting room to finals in medicine and considered it the right and decent thing to do to look after another doctor’s patients when he was sick.
Dr Porter was in hospital for three weeks and even when he was discharged he was too ill to continue in single-handed practice. It seemed natural at the time though I can’t remember now precisely how it came about, but we joined in partnership which, sadly, was to last only a few years. I can picture now, when Dr Porter died, one of his patients standing in the entrance hall of the practice, a man of about 50, his hat in his hand, a look of total dejection on his face, a man lost and alone in the world as if he had been one of the Children of Israel in the Sinai desert when Moses died, saying to me, and these are his exact words which I shall remember for ever: “The doctor’s dead. What shall I do?”
I don’t know how Dr Porter saw himself as a doctor but if I can put words into his mouth, perhaps he saw himself as a shepherd tending his flock. I shall never really know, but, together with his patients, I saw him as a deeply caring, godly man. He did his best to keep up with modem advances in medicine, and mostly succeeded, but the driving force within him was his devotion to his fellow man and his ability to help others through his medical training. Before the NHS, when all practice was private, his patients told me that, when they couldn’t afford to pay him, Dr Porter would smile, put his fingers in his waistcoat pocket, extract a two shilling piece or a half crown coin, and, giving it to the patient would say “I think you need this more than I do”.
Dr Porter did with words what I tried to do with Valium and he was far more successful than I was.
Many of his patients told me that, if one member of a family had a serious illness, like pneumonia, Dr Porter would summon the family together and, by the bedside, they would all go down on their knees and pray – pray that on the fifth day of the illness, when there would be a crisis, the good Lord would see fit to deliver him back to the fold of his family. And if the patient did die, Dr Porter would be there at the funeral to help and console the family. Dr Porter did with words what I tried to do with Valium and he was far more successful than I was. He gave his patients the will to strive to get better, not to sit back and complain and demand attention and blame others It was this very personal approach to each patients inner strength that made Dr Porter so loved.
Dr Alan Guthrie
I joined Dr Guthrie in 1973 in Chester. I was the third doctor in that practice that century. The first doctor practiced from about 1900 to the 1930s. Then Dr Guthrie till the 1970s. Then me. I stayed with him for three years while he prepared for retirement. As a GP, Dr Guthrie was quite different from Dr Porter – and from myself. I gained the impression that Dr Guthrie saw himself as a medical sorting house. His job was to look after a section of the community, 4,500 patients at one period but just over 2,500 when I joined him. Roughly, I would say, for practical purposes, in his mind he divided his patients into 2 groups – those who had serious illnesses or long term conditions that could become serious if unattended -and all the rest. The first group comprised all patients with cancer, suspicious lumps, serious disease of any organ, hypertension, diabetes, and so on. All these patients were sent to hospital for diagnosis and long term treatment.
Dr Guthrie never worked with any other professional. He left messages for the nurse but did now know her.
Dr Guthrie did not do any laboratory or X-ray investigations of his own, not even follow up. That was hospital work. All the rest of the patients, the second group so to speak, comprised every day illnesses and complaints. He was not as personal a doctor as Dr Porter who came before him, or as advanced in diagnosis and treatment as I had been taught to be, but nevertheless, I never found a carcinoma he had missed, nor any serious condition undiagnosed and untreated. He never worked with any other professional. He left messages for the nurse but didn’t know her. He did know the midwife but never worked with her. He refused to accept the need for a health visitor. “I am the health visitor,” he said when I queried him.
He knew all his patients he said, and he knew what was happening to them all the time. If he got a house call to a patient in St Ann Street, while he was there, he would knock on the door of every one of his patients in that street to know how they were getting on -even shout through the letter box. “It’s the doctor, are you alright?”. If the answer was “Yes thank you,” as it usually was, he’d go on to the next house, and so on. But, if the answer was “I’m not very well today, doctor,” or some similar reply, he’d stay and attend to that patients’ needs. In this way he’d do 40 “visits” a day. As I say, he kept an eye on his “flock” in a totally different way from Dr Porter. Dr Guthrie was not a personal doctor. He saw it as his job to look after the medical requirements of a section of the community, and by his standards he did it very well indeed.
I was a medical student from 1944 to 1950. It was a singular time in the history of medical education for three main reasons which shaped the outlook of those students who would become the future practitioners. Firstly, the profession was changing from being predominately an art form to becoming a blend of art and science. Secondly, the discovery of new drugs, particularly the antibiotics penicillin, sulphonamides, streptomycin, chloromycetin, revolutionised the treatment of bacterial illnesses. And thirdly, and possibly most importantly, the revulsion and abhorrence of the German and Japanese wartime crimes, produced a national, in fact an international, attitude of moral questioning – how could it have happened, what kind of animal was homo sapiens, what kind of world did we now want to build? This moral questioning went through the whole of society – including the undergraduate medical education.
Ethics was rammed down our throats from the dissecting room to finals in medicine. The cadavers we dissected, we were reminded, were once living human beings who loved and laughed and prayed to God and we should respect them. One student was failed in finals for not showing due care and consideration to his patient, even though his diagnoses and treatments in major and minor cases were correct. Not surprisingly the doctors who graduated at that time were to become creators of new, different and hopefully better things, pioneers in their field.
It was our generation which fought to create a College of General Practitioners with their own academic journal full of original contributions.
But the GPs of my generation were inheritors of a lowly position in the medical hierarchy. We were the dregs of the profession! Lord Moran PRCP called GPs – doctors who had fallen off the consultant ladder, not thinking that many of us, even the cleverest in my year, never wanted to be consultants in the first place. To be a consultant you had to have post-graduate training and pass further exams whereas GPs just went straight into practice and, theoretically, need never open another textbook or journal. Not surprisingly then it was our generation which fought to create a College of General Practitioners, to establish University departments of General Practice with their own lecturers and professors, their own academic journal full of original contributions in academic, community and social aspects of general practice.
I can only speak with direct knowledge for Manchester University but I have no reason to doubt that my experiences reflected national feelings and aspirations, and not only in Britain but also throughout Europe and beyond. The aim of our medical school at the time I was a student, through its pyramidal system of education (which in my opinion has never been bettered), was to produce a complete and highly competent, highly ethical doctor, with an enviable ability of bedside diagnosis and capable upon graduation, of looking after a section of the community in all its requirements including midwifery.
And so, as an illustration, in my first job, which was advertised simply as House Physician. I was expected to run a casualty department, to suture wounds down to the deep fascia, to take and interpret my own X-rays and plaster fractured upper limbs, and generally do everything a Casualty Officer needed to do short of specialised therapies. On other nights, I was expected to stand in as the doctor in charge of medical admissions in which role, in the hospital laboratory, I had to measure patient’s blood sugars and ureas, set up my own drips, and initiate whatever treatment was necessary. I was also asked once to anaesthetise for the gynae list when an anaesthetist failed to turn up. I was competent with gas, oxygen and ether – and happily all the patients lived and none got pneumonia!
Other doctors, who, on graduation, did not want to work in hospitals, were able to go straight into the community, deliver their patients babies and perform minor surgery in the local cottage hospitals. All this was possible because our teachers had aimed at producing graduates of wide ranging abilities with a strong ethical background. It was an exciting time. It was also the time of the birth of the NHS.
The science of medicine is what you do for the patient. The art is how you do it.
So when I joined Dr Guthrie in 1973 to look after 2,500 patients, not surprisingly, he was horrified at the changes I made. From there being just him and no-one else, suddenly there were two doctors plus a trainee (post-graduate student), a practice manager, a receptionist, a filing clerk, a nurse and her bath lady, a health visitor, and a midwife with her pupils, plus visiting other professionals from the community. At that time I saw myself as primarily a family doctor who practiced medicine half as an art and half a science. The science of medicine is what you do for the patient. The art is how you do it. The bedside manner of old is, for example, part of the “art.” I also saw myself and my contemporaries as the new general physicians who would, in time, replace hospital general physicians. Comprehensive specialties were breaking down into smaller more highly specialised units. No matter how much I pleaded with him, Dr Guthrie refused to allow my post-graduate students to sit in with him. He dido’t want any young whipper-snappers criticising him. I was sorry about that. They would have learnt so much from him. My generation then, were ethical revolutionaries with their feet finnly placed in the past but with their sights on a new future.
The Modern Graduate
We must be careful not to sacrifice the bedside for the laboratory, for then we will lose more than we will gain.
By the end of the 20th century the medical graduate has become primarily a scientist. To enter medical school (s)he must have the highest grades in physics, chemistry and biology, and graduate with, among some traditional learning, an enviable knowledge of human biochemistry. So how will future generations think of the modern doctor? I used to teach my trainees that, in every age, there were some good things and some bad ones, and that they should try to keep the good which our predecessors established, like the trust and deep caring of Dr Porter’s time, and add to it the best of modern medicine. But, we must be careful not to sacrifice the bedside for the laboratory, for then we will lose more than we will gain.
Every doctor must be judged against the background of the times in which he lived. Did he, as a representative of the profession, serve his patients, and society, well? By creating an academic College and teaching programmes to help our juniors into their professional careers, I think we made a worthwhile contribution to society. From the point of view of the individual doctor and his professional relationship with his patient, Dr Porter’s generation produced outstanding physicians. Indeed, if I was ill, I would like to be cared for by someone like Dr Joseph Porter.