Medical practice in Adelaide 1954-59

When I met Wendy in September 1955 I’d been working in the Western Clinic, for about 15 months. This was a suburban group medical practice of ten doctors in partnership. I was a salaried assistant with a chance of becoming a partner. By the latter part of 1955 I felt increasingly competent and confident. My years of hospital experience had paid off. I made several diagnoses that impressed my colleagues. I detected a chorion-epithelioma, a rare and deadly malignancy that resembles pregnancy, identified several other cancers that none of my colleagues had detected, identified patients with tuberculosis and syphilis, correctly diagnosed diabetes in a youngish man (mid 40s) who complained of inability to perform sexually, and recognized an unusual presentation of ringworm, among much else. Several young women selected me to watch over the progress of their pregnancies and assist at the birth of their babies.

I demonstrated convincingly that I could manage difficult patients competently. I acquired quite a large following of the elderly chronic sick and infirm, almost all of whom I saw in their own homes. I loved those house calls: seeing patients in their natural everyday habitat was a far better way to get to know them and to understand the dimensions of their problems, than seeing them in the unnatural surroundings of my office.

Having recognized the interesting ethnic and linguistic diversity of the people we served I began taking lessons in Italian and brushed up my German, making it possible for me to communicate in their own language with many of the ‘New Australians’ who attended the Western Clinic.  This was greatly appreciated by these immigrant families and some of them gravitated to me from other doctors in the group.  I’d have liked to tackle Greek too, but although we had many Greek-speaking patients, the different alphabet and linguistic distance from familiar western European languages were deterrents. I decided to postpone learning Greek for the time being. Nevertheless the fact that I had visited Greece – I’d back-packed there in the summer of 1952 – attracted some Greek families to me.

But I wasn’t happily settling back into Adelaide. After living for three years at the epicentre of western civilization, I felt considerable culture shock. Adelaide in 1954 was a small-minded, dull little city. Conversations in Mary Martin’s book shop provided almost the only breath of the culture that I craved. My medical school classmates and other friends were all married, almost all with small children and I felt very much an outsider, a lonely onlooker. At that time there were no resident theatres, no interesting restaurants, no night life in Adelaide.

After a few failed attempts to connect with one of the rare available young women, including a few who were friends or relations of patients, I met and began dating a young woman who was a cousin of my cousin David Judell’s wife. It was a relationship born of desperation and was never emotionally, culturally or intellectually satisfying to me, nor I suspect, to her, even though we did establish a tolerably satisfying sex life. That young woman was a bore; she was interested in gossip about movie stars but very little else. I think she found me boring too. After that magical day when I met and began to fall in love with Wendy, I dropped her like yesterday’s newspaper. My excuse, a true one, was my decision to turn my attention to further medical studies, aiming, for want of anything else that was credible, towards a specialist qualification in internal medicine.

In December 1955, after being told there was no immediate prospect of a partnership, nor any likelihood in the foreseeable future, I left the Western Clinic and took a position as senior registrar (senior resident) at the Royal Adelaide Hospital. I began this phase of my career at Northfield Infectious Diseases Hospital, where I spent almost 6 months from November 1955 until early winter 1956.

My timing was very good. As well as a wide range of all the common infectious diseases, I saw many patients with viral encephalitis, a serious mosquito-borne infection, and as that epidemic subsided, we were hit by a nasty epidemic of paralytic poliomyelitis – the last ever epidemic in South Australia as it turned out, because the following year the Salk vaccine became available. The 1955-56 polio epidemic hit young adults particularly hard; moreover, it was a seemingly more aggressive strain of poliovirus than usual, and often attacked the nerves in the upper region of the spinal cord and the base of the brain. When nerve roots in these regions are attacked, respiratory muscles and muscles involved in swallowing are knocked out. Case fatality rates are very high and the epidemic becomes much more dangerous than usual. Before long I had about 30 patients in ‘iron lungs’ – the large, cumbersome respirators we used in those days to maintain respiration. Only about half the patients in iron lungs ultimately survived, and even smaller proportions of those whose swallowing muscles were affected. In the 1950s we were still uncertain about the precise mode of transmission of the polio virus. We know now that it is transmitted by the fecal-oral route, that the virus must be ingested, not inhaled, spread by droplets or transmitted directly from person to person. I was seriously afraid that I might be infected by the patients I was treating; but I did what I had to do, I treated them because it was my duty to do so. The thought of keeping my distance from them never even entered my head.  Of course we observed “universal precautions” – we wore gowns, gloves, masks, washed hands and changed gloves, gowns and masks between each patient.  About 50 years later in 2006, I led a discussion with final year medical students in Ottawa and described what I had done and my fear of being infected and perhaps dying of bulbar poliomyelitis. Some of the students thought I’d been daft. They claimed they would never put their own lives at risk as I had done; they said their first duty was to look after their own families and therefore look after themselves, do whatever they had to do to avoid placing themselves at risk, for example the risk of exposure to HIV infection. My discussion with students about the duty to care for patients even at grave personal risk involved the entire class of 84 students. It was an animated, at times almost vituperative argument in which virtually the entire class participated. About two fifths of the class took the view that they would put their own safety first, asserting that they owed this duty to their families. The remainder, the majority, adhered to conventional Hippocratic ethics, in which physicians treat the sick even if they risk infection and possible harm to themselves. It saddened me to discover such a high proportion of senior medical students with this self-centered view of their role in caring for the sick. Nonetheless I vividly recall that argument as an excellent example of medical education at its best. At the end of it, perhaps a few of the self-centered students had been won over, and every one of the students who put care of their patients first, had been consolidated in their values and beliefs.

After almost 6 months at the Northfield Infectious Diseases Hospital in 1955-56, I moved into the Royal Adelaide Hospital as medical registrar (chief resident in north American terminology) to one of the ‘honorary’ visiting physicians, Ken Hetzel, father of Basil Hetzel who some years later became a good friend of mine when he switched career from internal medicine to epidemiology. I enjoyed the work but found it less challenging, less stimulating than in the London hospitals where I’d worked in 1951-54: the Adelaide specialists were much less intellectually curious than those with whom I’d worked in London.

At about this time, the doctors in the Western Clinic were finding that I was much missed. The fact that I would soon be getting married made me a more attractive proposition than I had been as an unattached bachelor. I had been at the Western Clinic long enough to bond with enough patients who asked the other doctors what had become of me, was I ever coming back. I was invited to come back to join them as a partner in the practice, and did so in September 1956, during the early months of the ‘hands-on’ phase of courtship in which Wendy and I were getting to know each other’s bodies just as our prolific exchange of letters had enabled us to get to know each other’s minds. Looking back on it over 50 years later I am sure that first getting to know each other’s minds and only then getting to know each other’s bodies was an ideal sequence, at any rate for Wendy and me. I think that this sequence would suit many others who manage – unsuccessfully, as often as not – with the reverse. Rates of marital breakdown would, I feel sure, be lower. It’s too bad that this hypothesis can’t be tested in a randomized controlled trial! 

Our courtship, marriage, family formation and early married life were crowded with memorable events described in other chapters of these memoirs.  Here I’ll focus on my professional and intellectual life.

An immensely important ‘self-improvement’ activity was a course in speed reading that I took at the School of Mines, Adelaide’s equivalent of a community college.  This ran for about 12 weeks. It worked by conditioning the retina to absorb information from a progressively larger field of vision. When I started the course my reading speed was about 350-400 words per minute, which was well above the average of 250-300 words/minute.  When I started the course I was already reading groups of words or phrases, sometimes entire short sentences, at a single glance. At the end of the course I was reading 1300-1400 words per minute, usually taking in whole paragraphs at a glance.  Tests showed great improvement in my comprehension and retention of information as well. I continued on my own for the following year or so, as advised by the teacher who ran the course, and although I rarely timed myself, I estimate that my reading speed with ‘light’ reading like newspapers, popular novels and intellectually undemanding material in medical journals, maintained or increased my speed to well over 2000 words per minute. By then I was absorbing a page at a glance when reading novels, as Oscar Wilde was reputedly able to do. I tested myself when Wendy and I had been married for about 18 months, with a popular best-seller, Neville Shute’s well known novel, A Town Like Alice, which I finished in just under an hour. Wendy had read and admired this book. She watched me taking in a page at a time, turning over pages every 1-2 seconds. She tested my comprehension and was satisfied that I’d really read the book, not just skimmed it. She was very impressed, and about 14 years later, she and David took a similar speed reading course in Ottawa, with similar benefits. At that speed, the brain is totally occupied absorbing what is on the printed page; there is no spare brain capacity to get distracted, and retention of written material is much more efficient. This had a dramatic impact on my intellectual life, as it did later on Wendy’s and David’s. Over the following few years, my intellectual life exploded into a most satisfying period of research productivity that was the basis of my academic success. Ability to read at high speed and to comprehend and retain the information is an almost essential prerequisite to academic success.  Years later when I became an editor of journals and books, proof-reading slowed me down and I think my habitual reading speed has slowed, although I can still read light fiction very fast, a 300-page paperback novel in an hour or so. This can be a disadvantage at times, for instance on intercontinental flights when I was obliged to take half a dozen paperbacks, all of which I would have read between London or Paris and Ottawa. Electronic tablets – Kindle, Kobo, etc. – were just coming into vogue when my frequent intercontinental air travel ended. David uses them on his frequent travels and they have become indispensible to him.

During my remaining years in general practice in 1957, ‘58 and ‘59, I was reading widely and deeply: scholarly monographs in sociology, anthropology, psychology, as well as several weekly and monthly medical journals. I was exploring several fields, not yet sure which interested me most, which mattered most. It would have been impossible to accomplish even a small portion of all this without boosting my reading speed and comprehension.  I was drawn more and more to the notion that a scholarly academic life was where I really belonged. About this time I re-established friendship with Bob Culver, a classmate in Brighton Public School days. I met him again when his mother was a patient of mine and told me her son Bob was keen to get together with me.  He was a senior lecturer in engineering at the University of Adelaide and his description of how he passed his time filled me with envy. Everything he told me about academic life made it seem irresistibly attractive (probably he didn’t mention the time wasted by academic committees). I was very happy in general practice, but not with its greedy consumption of my leisure time, leaving me no time for reflection and thought. Also, I was unhappy ideologically with the fact that my income in fee-for-service practice came in large part from people who were in a distressing life crisis.

Several research-oriented questions intrigued me. These were mainly in the unexplored borderland between clinical medicine and social and behavioural sciences. Some profoundly sick patients seemingly were untroubled by their plight, whereas others who were often less sick suffered greatly. I thought at least some of this difference in illness behavior related to their cultural origin, especially if they were immigrants from Holland or Germany on the one hand, or from Italy or Greece on the other, the latter wearing their emotions closer to the surface. Sickness behavior seemed to have some sort of relationship to culture and ethnicity. I discussed this at meetings of the recently established College of General Practitioners, and with Norrie Robson, newly appointed first professor of medicine at the medical school. Did it make any difference, I wondered, to the ultimate outcome of their clinical condition? I had a hunch that usually it didn’t. At one of the meetings of the College of General Practitioners, I asked a related question: “Why do some people get sick, and others not?” Someone wrote the question down and we discussed it for a while. About 25 years later, this question turned up as the title of a book that became famous. I asked one of the co-authors of that book where they’d got the idea for the title, but he didn’t know. I’ve sometimes wondered if it could have been traced back to my question at that meeting.  

In my final 2½ years at the Western Clinic I entered an aspect of the work and life of the Adelaide medical school. I was appointed to the outpatient staff of the Adelaide Children’s Hospital. For 2 mornings a week I saw patients – infants and small children brought in by parents (usually the mother) with various ailments. This carried with it an opportunity to attend and take part in academic activities such as clinical-pathological conferences and lectures by distinguished visitors, further widening my intellectual horizons. At one meeting I ruffled a few feathers when I remarked that I was more interested in ways to preserve and improve the health of infants and children than in exploring the minute details of rare and strange diseases that affected one in 1,000 or fewer of the population. Everyone else in the room seemed to regard this sentiment as close to blasphemous. The medical superintendent of the hospital, a pompous self-important man for whom I had limited time and less respect, clearly regarded my comment as a personal insult.  

After the pandemic of Asian influenza in 1958, I realized during my convalescence from the near-fatal attack of pneumonia that followed shortly after the Asian influenza pandemic subsided, that what I really wanted to do was to find ways to keep people healthy, rather than wait for them to get sick and treat them one at a time. This was a philosophical conversion to the notion that it’s better to find ways to keep the population healthy than to wait for individuals in that population to get sick or injured. Along with my ideological aversion to collecting a fee each time I saw a sick person, this philosophy of medical care unfitted me for life as a family doctor in those days when the emphasis was almost entirely on treating the sick. Yet family doctors cared for pregnant women and immunized their babies against common infectious diseases, activities that were aimed at protecting good health. All I sought was to expand, enhance and emphasize that part of the family doctor’s role, to maximize the emphasis on preserving good health. Ideally I would have liked to combine general practice and a scholarly academic life. In the late 1950s that would not have been feasible in Australia.

In 1959 I tried to discuss with Clarrie Rieger, a thoughtful surgeon and a medical politician (past president of the British Medical Association in Australia) who was the senior partner in the Western Clinic, a scenario in which I would work about 80% time in the clinic, and devote the rest of my time to research. By then the College of General Practitioners had not only been established, it was flourishing to the extent that there were possibilities to get funds for research. I had become very active in the College of General Practitioners, serving on committees, developing ideas for research.  Clarrie had said that he saw me as a successor to him as a medical politician, actively engaged in advancing the interests of the medical profession in its negotiations with the government. I had zero interest in this. I wanted to explore public health sciences, epidemiology, medical sociology, and anthropology. I don’t think Clarrie Rieger grasped what I was trying to describe and explain to him, but insofar as he did, he was unsympathetic, said forthrightly that there was no way the partners in the Western Clinic would tolerate a situation in which the youngest, presumably most energetic partner in the group, worked only part time in the clinic.  I didn’t know my putative field well enough, was not articulate enough, to explain my inchoate ideas effectively.

About then I met several times with Norrie Robson, the new professor of medicine, to discuss with him possible ways for members of the College of General Practitioners to collaborate with the medical school’s department of medicine. At these meetings I was the designated representative of the College of General Practitioners, and as well I had a strong self-interest: I was seeking career advice, seeking ways I could blend my evolving interest in research questions with my career as a general practitioner in a large group practice within a 15-minute drive from the medical school. Norrie Robson was very helpful and supportive. He was an Edinburgh graduate and was already thinking of ways to establish in Adelaide a general practice teaching program, along similar lines to the recently established General Practice Teaching Unit at the University of Edinburgh. I volunteered myself and my practice to accept medical students, and recruited two or three friends to do likewise (not partners in the Western Clinic but GPs in other parts of the metropolitan area). We found that because of the crowded curriculum and absence of suitable time slots, the logistics were more complex than we had anticipated: it was hard to find suitable blocks of time other than holidays. In the end I managed to take two students under my wing, one each in two successive holiday periods when they were able to accompany me on home visits and observe, occasionally help me deal with patients in the office.

At those meetings with Norrie Robson I got some wise career advice. He emphasized that I would need academic credibility, which I could enhance by research, publications, higher qualifications than my basic graduating degree. I was working on a simple paper, describing a few of my observations of illness among ‘New Australian’ patients. This paper, “The health of immigrants; some observations from general practice,” was published in the Medical Journal of Australia January 30, 1960 – a month after I had left the Western Clinic with Norrie Robson’s advice to begin training in epidemiology and public health at the School of Public Health and Tropical Medicine at the University of Sydney, the only place where such training was available in Australia.

I had realized that Wendy and I and our two little toddlers would have to move on, start a new life, a new career.  It was a bold, almost deviant thought, a reckless, irresponsible action, to give up a secure position where my family’s lifetime prosperity was guaranteed, to leap into the unknown where future work prospects were unknown but precarious, and failure would have dire consequences. An important consideration was that our move meant we would have to leave Adelaide, perhaps for the rest of my working lifetime. I felt close to my extended family, and regarded the ties to my mother, my aunts and uncles and cousins, as very important. We would be moving away from all of them, cutting the strands of a fragile yet sturdy support network.  Wendy and I talked about all of this, albeit rather vaguely, superficially. She was preoccupied caring for our two little children, left the decision almost entirely to me – unlike other life-changing decisions later that we made jointly.  We set off to begin this new life at the end of 1959, when I left the Western Clinic. Early in 1960, we loaded our station wagon with some of our possessions, space-occupying kids’ paraphernalia, as many of my books as the car’s springs would tolerate, and set off for Sydney, where I spent the academic year as a private student at the School of Public Health and Tropical Medicine. I was beginning a new life with no idea at all where this would lead us.

Picnic lunch en route Adelaide to Sydney, early 1960