Working at the School of Public Health

Following up the work on “The Iceberg” I had several other ideas in quick succession. The avuncular director of the School of Public Health came into my office one day, with an interesting question. The island of Tasmania with a population of about 350,000 at that time, had two cities, Hobart at the south end, Launceston at the north end; it was separated from the mainland of Australia by the usually rough sea of Bass Strait, and in those days air services were unreliable, often disrupted by poor weather. The question was this: How many neurosurgeons should there be in Tasmania? Was a single neurosurgical unit in Hobart enough, or should there be another in Launceston at the other end of the island? The two cities were several hours drive apart, and some people with severe head injuries would die in transit if they had to be taken by road from one end of the island to the other. I immediately wanted to answer a more general question: how many doctors of all kinds, in general practice and in every specialty, should there be? It was technically easier first to answer other questions: how many doctors were there? Where were they? Were they distributed equitably in the population? Were some specialties “over-serviced” and were the numbers in other specialties inadequate?  How could practicing doctors be identified and counted? There were several sources of information, all of them flawed. One immediate problem was that lists of licensed medical practitioners were separately maintained in each state, and significant numbers were licensed in more than one state. In some states, including my home state South Australia, it was possible to be licensed for life rather than renewing the license annually. I was licensed for life myself.   There was no easy way to deal with this problem other than to go laboriously through the printed lists of licensed medical practitioners in each state, strike out those with addresses outside that state, and count the totals, then adjust if possible for reduced activity by semi-retired and part-time practitioners, setting arbitrary ages or years since graduation, for retirement.. There were other sources of information: specialty societies had lists of their members. The pharmaceutical industry maintained up-to-date lists of doctors and basic facts about their practices, including useful information about the extent to which doctors were practising full-time, specialized, or focused on specific aspects of practice. They even had some figures for retired and part-time medical practitioners. This information enabled salesmen for the drug companies to concentrate their sales pitch on specific doctors and aspects of practice, and relevant drugs for this aspect when they talked to individual doctors. I recalled being asked by salesmen about my practice, and that the salesmen wrote down what I said. Very few doctors refused to see drug company salesmen, so this source of information was reasonably reliable. Even so, when my paper on “Medical manpower in Australia” was published, I commented on the shortcomings of my sources of information.  I looked also at ancillary professions such as optometry, podiatry, community nursing, physiotherapy and pharmacy, and glanced at the interactions and territorial disputes among them. These aspects of the sociology of professions were very interesting and had I stayed put in Australia I think it is likely that I would have explored this domain in greater depth.

Rebecca and David in inland Australia, 1963

While I was in the group practice in Adelaide I had published a descriptive article on the health problems I had observed among immigrant patients in my practice. This brought me to the attention of two social demographers at the Australian National University, Bill Borrie and Jerzy Zubrytsky. They asked me about my possible interest in becoming a research fellow in their group, but the salary they were offering was derisory, so nothing came of this. I’ve wondered sometimes how differently my career and our family’s lives might have evolved if it had been possible to respond positively to that inquiry.  I used to think wistfully about it in later years whenever Wendy and I returned to Canberra, sometimes to stay for a few weeks in the urbane ANU Residence in the increasingly attractive city of Canberra. It would have been a superb place to work and live…

"Where the dog sits on the tucker-box, five miles from Gundagai"

By the middle of 1963 I felt comfortable in my own skin, and that I was doing worthwhile work, carving out a niche that nobody else in Australia seemed concerned about.  In 1962-63 I wrote several original articles on these aspects of what we called ‘manpower’ in those days, now de-gendered and renamed  ‘human resources.’ These articles were published in small-circulation journals such as the Australian Journal of Social Issues and serial publications of Commonwealth and state health departments, mostly after we had left Australia again at the beginning of 1964. Home life was relaxed and very happy.

Family picnic, National Park, Adelaide Hills, 1963
L-R: Rob, David, Rebecca, Wendy, Vera Last; in front: Jenny, Kate, Peter - all of us except I who took the photo

An eminent semi-retired surgeon who was Director of the NSW Postgraduate Medical Foundation, asked me to evaluate continuing education programs for rural GPs. Data from the recently inaugurated Pharmaceutical Benefits Program had revealed upsurges in prescriptions for costly polypharmaceuticals after drug company salesmen’s visits to a district. Could I re-examine the data to find out whether educational programs aimed at discouraging use of such drugs were having any impact on prescribing habits of GPs? I did this, and wanted to expand the question. Medical insurance claims data could also be examined to explore other aspects of continuing medical education, for instance to discover whether qualified surgeons had better outcomes than GP-surgeons for frequently performed surgical procedures, appendectomy, hysterectomy, gall bladder surgery and inguinal hernia repair. In NSW in the late 1950s and early 1960s, surgeons with higher surgical qualifications performed about one third of appendectomies and inguinal hernia repairs, and two thirds of gall bladder surgery and hysterectomies. Surgical outcomes could be compared and measured by length of hospital stay, and incidence of complications such as postoperative infections and thrombosis.  All the data were available in medical insurance claims records.  I submitted a proposal to the Commonwealth National Health and Medical Research Council to conduct an analysis of records. I emphasized that such an analysis could be done discretely and without revealing any doctors’ identities; moreover it would cost very little. I submitted the proposal in the form of a letter to the secretary of the NH&MRC in Canberra.  Within a week or two, without any advance notice, two senior bureaucrats from the Commonwealth Department of Health came to my office. They stood at the corners of my desk while I sat behind it, and shouted at me, that I wasn’t ever again even to think thoughts such as those I had expressed in my letter to the Secretary of the NH&MRC. They made me give them the file copy of my letter and left, warning me that questions such as those I sought to answer were not scientific but “political” and were none of my business. I was virtually commanded never again even to think about investigating such a politically sensitive question. I found it very discouraging and frustrating to have my inquiring mind so aggressively deterred. I felt defeated, disconsolate, depressed. I described the experience in a letter to my friends in the Social Medicine Research Unit in London, telling them that Australians were not ready for this kind of health services research.

 Little Miss Twinkletoes and her partner, in our garden at 98 Grasmere Road, Cremorne, Sydney, about September 1963